An Orthopedic Surgeon on Surgeon Peer Credentialing
Healthcare consumerism is forcing surgical patients to have to master the idea of surgical quality. This is a problem because surgical quality is hard to measure. In practical terms, our present limitations mean that for a patient it is hard to pick a surgeon.
That said, we do know that in some areas, most notably bariatric surgery, there is an empirical basis for believing that surgeon quality, as an important component of surgical quality, can be subjectively and validly peer assessed.
How generalizable is the validation of surgeon peer credentialing? In which lines of service can surgeon peer credentialing reliably guide a patient to qualified surgeons?
To the best of our knowledge, there are no good studies of surgeon peer credentialing in lines outside bariatrics. Still, there are clues that peer credentialing may be a valid, useful means of getting at surgical quality outside bariatrics. For example, Dean Knoll, one of our reconstructive urological surgeons, recently quipped that he can tell if a surgeon is any good within two minutes of skin incision. He should know because he's been teaching surgeons penile implant surgery and implantation of artificial urinary sphincter for many years and he has seen all kinds of them come and go.
We put the question of surgeon qualification to Surgeo surgeon Dr. Amir Jamali, an orthopedic surgeon who specializes in hip and knee surgery. Dr. Jamali is a two-time joint fellowship trained surgeon who has considerable experience in hip arthroscopy. He has taught other surgeons at Harvard University, Stanford University, and the University of California, as well as in the People's Republic of China. In other words, he has seen many surgeons and many levels of ability. You can see what he said about surgeon peer credentialing by watching the video below; a transcript follows.
You can also click here to hear a consumer oriented conversation about surgical quality.
Dr. Krongrad: We’re back with Amir Jamali, to talk about quality. Amir, here’s the question, here’s the issue: everybody wants quality, nobody knows really how to define it – or at least, let’s say that everybody has a different definition. In many cases there are public, online tools where people are measuring quality as defined by the number of parking spaces and how long you waited in the waiting room, most surgeons would reject that as a definition of quality. Surgeons look at things like blood loss, bowel perforations, wound infections, and things of that nature. Not to mention, success in surgery. Given that there are no objective tools for the kinds of things I just cited. There are tools that would help us to say you’re a better surgeon than the guy down the street in terms of infections, blood loss, or true clinical things. The question is, are there any other tools other than the objective ones. I want to reference with you a study that was done in Michigan. This was done by the Michigan Bariatric Collaborative where they took video tapes of surgeons and gave them to other surgeons and asked them to score their colleagues. The observation was really interesting. That is when surgeons look at their colleagues work on videotape, and gave them scores ranging from one to five. Those subjective scores correlated beautifully with objectively measured clinical outcomes like hospital readmissions, reoperations, duration of surgery. What about surgeons allows them to know things subjectively and immediately that nobody else really does? And, if you agree this is a generally phenomenon, I want you to talk about orthopedics and whether or not it applies there too.
Dr. Jamali: I do agree that surgeons will always strive to do better. I think we all see our own cases and have a repository of information about what’s constituted a successful surgery or a successful technical exercise. Also through our experience and our training, we’ve seen the evolution of our own skills. So I’m not surprised that surgeons looking at videos of bariatric surgery could tell which ones are going to be more likely to have had a good outcome. In may come to certain things such as the efficiency, the technical exercise of preparing certain sites within the bariatric surgery, or repeating the same steps or simply the delicacy of the technical skills the surgeon has. I’m not surprised by that at all. I think your second question is whether that would apply to orthopedics?
Dr. Krongrad: More specifically you’ve operated with other surgeons, you’ve stepped in and watched them operate. Can you tell if they’re a good surgeon just by looking at them? Can you tell if their patients can generally do well just by watching them?
Dr. Jamali: Yes, what I’ve realized is there is a lot to the surgery, especially in orthopedics. We have a lot of dependence on equipment. The first thing about a successful surgery is the thought process that got the patient and the surgeon to the operating room in the first place. So, when the surgeon has done a lot of planning ahead of time. Then, almost everything usually goes well during the surgery. There is a lot of brain power that’s required to getting to the OR. As far as once you are there, there are other things that also depend on the team, having the team that’s integrated well with the surgeon. That is another second part that is external to the skills of the surgeon. IF we put those things aside. There’s definitely things that we see in our colleagues that reflect that they are thoughtful, delicate in the way they handle the tissues, delicate in the way they handle the power tools we often have to use. They don’t dig themselves holes that they have to dig themselves out of. These are all things that are very, very quickly recognizable when you see a colleague or if you were to look at a video of a surgery.
Dr. Krongrad: One of the urologists we’re working with – a guy who has taught a few hundred surgeons from Korea to Brazil in reconstructive urology, said “I can tell a good surgeon within two minutes based on how he does his skin incision and goes from there. Does that make sense to you?
Dr. Jamali: I would agree with that, I would even take it further and say that I can know a good surgeon by how they prepped their patients. If you start contaminating before you’ve even prepped the patient, then I don’t think the surgeon is going to go very well.
Dr. Krongrad: Thanks very much for your thoughts.
Dr. Jamali: Absolutely.