Should high-volume surgeons have surgical privileges?

In school they told me “Practice makes perfect.” And then they told me "Nobody's perfect," so then I stopped practicing.          -Steven Wright

As a youngster growing up in New Jersey, I had parents who would say things like: “If you work hard, you can accomplish anything you put your mind to.” Foolishly, I believed them.

So, like any normal boy, I set my mind to becoming a star player in the NBA. My models were Julius “Dr. J” Erving (forward for the New Jersey Nets) and Larry Bird (forward for the Boston Celtics).

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Taking to heart the parental wisdom that hard work was important, I practiced for hours every day-especially during the summers when I was not in school or working my summer job flipping hamburgers on the boardwalk. In practice time, I spent hour after hour taking shot after shot from the right or left side of the court, with the idea that eventually my field goal percentage would approach 100%.

The practice paid off in that my game definitely improved, but there were certain painfully apparent differences between my on-court performance and that of my role models.

Like Erving and Bird, I usually played the position of forward. But, as the saying goes, I made up for my relative lack of size and leaping ability by being slow. Eventually, it became clear that a career on the hardwood courts of the NBA was not in the cards, so I gravitated toward the second-most glamorous career (ophthalmologist).

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But the lesson of how repetition leads to improved performance was not lost on yours truly. While practice may not always make perfect (at least in this life), it definitely does “make better” not only in sports, but also in the operating room. In cardiac, orthopedic, and gastrointestinal surgery, higher-surgical volumes for physicians and hospitals are associated with better outcomes, including lower mortality rates.

Next: Adverse envent, volume link

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Adverse event, volume link

In eye surgery, the relationship seems to hold as well. In Ontario, Canada, for example, the adverse event rate varied with the number of patients operated on by the surgeons in a year:

            Cataract surgeries per year                      Adverse event rate

                        50 to 250                                           0.8%

                        251 to 500                                         0.4%

                        501 to 1,000                                      0.2%

                        >1,000                                               0.1%

The logical consequence of this relationship, to people like John Birkmeyer, MD, of Dartmouth-Hitchcock Medical Center, is to allow only the higher-volume surgeons to operate.

“If low-volume surgery were a drug, the FDA would have banned it long ago,” he says.

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Not everyone is on board with only allowing high-volume surgeons to have surgical privileges, however.

Some believe that limiting the number of physicians performing certain procedures will make it harder for patients who live in areas with smaller populations and fewer high-volume subspecialists. Others are concerned about emergency call situations, where an on-call surgeon might need to perform a procedure fairly urgently for a patient.

How good a job would that surgeon do if he/she was not allowed to perform it at all during the rest of the year because he/she did not meet the volume threshold? Does anyone know what would be the practical result of only permitting ophthalmologists who perform at least 1,000 phacoemulsification procedures annually to continue being cataract surgeons?

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There is one area in which we can all agree: People who don’t author editorials at least once every other week should not be allowed to write any.

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References

1. Surgeons push back against minimum volume standards. June 23, 2015. U.S. News and World Report.

2. Surgeon volumes and selected patient outcomes in cataract surgery: A population-based analysis. Ophthalmology. 2007;114:405-440.

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