Wednesday, January 4, 2017

The occasional surgeon

On the Forbes website, Dr. Robert Pearl writes

"When I was selected to become CEO of The Permanente Medical Group, the Permanente half of Kaiser Permanente, the time required for my responsibilities forced me to give up doing surgery on a regular basis. But every year since then, during the week between Christmas and New Year’s Day, I have returned to the operating room. The timing works, as the leadership demands become minimal and it’s unlikely I’ll suddenly be needed to fly to another part of the country. It’s a magical time for me, contrasting dramatically with my world as CEO. For several hours each day, my focus is not on millions of Kaiser Permanente members—or, for that matter, on all the complexities of healthcare policy, politics and strategy—but, rather, on a single patient at a time."

Dr. Pearl is a Yale medical school graduate who trained at Stanford and has been board-certified in plastic surgery since 1979. The American Board of Plastic Surgery did not start requiring maintenance of certification every 10 years until 1995.

We do not know what specific surgical procedures he does during his magical time. Is he removing moles, performing reconstructive surgery, or doing facelifts and nose jobs? Do his patients know that he only operates a few days per year? What happens if a wound complication requiring revision surgery arises? Who follows up his patients?

How does he maintain his skills if he only operates one week per year?

The literature does not address Dr. Pearl's unique situation.

A database mining paper claimed cardiac surgeon performance deteriorated after even one day of not doing surgery. I blogged that I didn’t believe it citing many concerns including that a number of unmeasured confounders could have accounted for the small differences in outcomes.

A report prepared for the UK's General Medical Council referenced “return to practice guidelines” from the Academy of Royal Medical Colleges which found few studies about how quickly and why medical skills decline and concluded that an absence of less than three months from practice was probably not significant.

In 2014, Braun et al published a survey of deployed US Army pediatricians, half of whom were away for 6 months or more during which they "infrequently practiced the full range of their pediatric skills." Such deployments led to "a significant decline in perceived comfort with both routine and acute pediatric care."

From the UK GMC report: "Regarding surgical and clinical skills, the disparate evidence on specific skills shows that the majority of subjects assessed for retention of learned skills did not totally [emphasis added] lose the new skill after a set time period."

Notwithstanding the cardiac surgery study mentioned above, surgical skills probably do not fade after a few days or even a few months of inactivity. But operating only one week per year for several years? Quite possible.

When I was a chief of surgery, I would not have given privileges to a surgeon who operates 1.9% of every year.

Would you want the occasional surgeon to perform your operation?


Anonymous said...

I agree that this guy is utterly irresponsible.

The effects of lack of practice can be even higher for some procedures. According to one study, ERCP skills atrophy when a practitioner does less than one procedure per week.

Skeptical Scalpel said...

I had not heard that about ERCP. Do you have a link to that study?

Korhomme said...

No, he's not operating on me; manual skills need regular practice.

Sounds like ego polishing combined with a major lack of insight.

Korhomme said...

Concert musicians practice daily. The violinist Jascha Heifetz said:

If I don't practice one day, I know it; two days, the critics know it; three days, the public knows it.

Macha said...

Surgery is not something in which to dabble.

Anonymous said...

I am trying to figure out how he keeps his license under the state medical board.

Anonymous said...

I doubt the surgeon is going to volunteer such information to the patient. So,I'm wondering how we should question the doctor to find out his operating volume. It seems kind of impertenent to ask how many and date of the last operation. Or is it?

William Reichert said...

This guy is the CEO of his hospital. He is the leader. He sets the standards. What kind of standards is he setting?

Skeptical Scalpel said...
This comment has been removed by the author.
Skeptical Scalpel said...

William, he is the CEO of the Permanente Medical Group--that is, all of the doctors who work in the 38 Permanente hospitals across the country.

Korhomme and Macha, good points.

State licensing boards do not seem to care how busy doctors are as long as they pay for their licenses.

There is no way for a patient to know for sure how many cases a surgeon has done. Hospitals have the data, but it is not a matter of public record.

Anon said...

Well, normally his focus is on "millions of Kaiser Permanente members" so focusing on just one patient requires such an infinitesimally small use of his prodigious intellect that it's really not a problem.

Skeptical Scalpel said...

Anon, thanks for your insight. You may be right.

Oldfoolrn said...

I have not scrubbed on a case in 9 years, but would like to offer my services to the good doctor. We would go together like tweedle dee and tweedle dum.

Anonymous said...

I'm Anonymous #1. I read this factoid about ERCP in a paper about suppurative cholangitis. Unfortunately this was more than 2 years ago and I think I no longer have the paper. I'll try to locate it though.

The same paper mentioned that some European countries have tried to concentrate ERCP procedures in reference centers to pool resources and ensure operators get enough "papillotome time."

Skeptical Scalpel said...

Old, you'd probably do OK except maybe with the robot.

Anon, don't worry about it. I can do without it.

Unknown said...

"Data on success (24) and complication (14,30,33,34) rates suggest that to maintain their skills in ERCP, endoscopists should perform an average of one or more procedures per week."

Springer J, Enns R, Romagnuolo J, Ponich T, Barkun AN, Armstrong D. Canadian credentialing guidelines for endoscopic retrograde cholangiopancreatography. Canadian Journal of Gastroenterology. 2008;22(6):547-551.

Anonymous said...

I wonder: would Dr. Pearl support credentialing another surgeon to operate in one of his organization's hospitals if that surgeon operated only one week each year _and_ (presumably) had no other clinical medical activities for the remainder of the year?

I recall reading a profile (IIRC, in The New York Times Sunday Magazine) some years ago when Bill Frist was Senate Majority Leader. Apparently he would return to his home state each week to operate on Fridays. I wondered: who was responsible for covering his patients on Saturday? Would you want a cardiac surgeon who operated only once/week performing your procedure? If he was only in practice for one day / week, when did he see pre-operative consultations and post-operative visits?

While it may well be true that surgical skills do not deteriorate in just one week, I suspect (without studies to back this up) that a one week layout (or a month layoff) for a surgeon who otherwise operates daily the rest of the year is far less of an impact than a week layout that happens every week. I also suspect that a cardiac surgeon (in Frist's case) doing 300 cases / year who takes a month off is going to be far better than a surgeon doing perhaps 50-100 cases / year total (assuming 1-2 cases each Friday) operating only one day / year.

Medicine may be able to be practiced "part time," but I doubt it is practiced well on an itinerant basis.

artiger said...

I'd call this a couple of things, perhaps something like a "Hollywood Syndrome", along with some hero worship. For some patients, it's a badge of honor, even a bragging point at social events, to say that the Permanente CEO, a US Senator, Oz, or [insert over-glamoured physician name here] was their surgeon. Risking their health is only a mild gamble when the rewards of such celebrity association are so attainable.

Skeptical Scalpel said...

Ian, thanks for the reference.

Anon, I agree with your comments. Thanks.

Artiger, That's an excellent point. I would bet that some patients do just what you said.

Vamsi Aribindi said...

I think that we have to extend some trust to a fellow doctor- and read a little between the lines of this story.

Many doctors who are elderly or hold leadership roles can't practice full time and keep up their skills. But the overwhelming majority can safely take roles such as performing insurance physicals or seeing low acuity patients in the free clinic with medical students and residents.

The key is for these doctors to know their own limits- something we have trusted doctors to do for ages, mostly for good, sometimes for ill.

I personally know of an elderly cardiac surgeon who serves the department in which he holds a leadership role by walking interns and 2nd years through creating AV fistula grafts once a week. It's all he does, though he technically is fully boarded in cardiothoracic and general surgery, and he does it quite safely.

I would like to trust that Dr. Pearl returns to the OR on those weeks perhaps to watch over a senior resident as they perform a trigger finger release or carpal tunnel procedures, or as they repair facial lacs- low acuity procedures that he can safely do despite his low volume per year. But of course specifying this would have taken some of the luster of the piece...

Vamsi Aribindi

Skeptical Scalpel said...

Vamsi, thanks for your comments and your optimistic outlook on this subject.

However, Dr. Pearl practices at Kaiser Permanente Santa Clara Medical Center. I can find no evidence that it has a residency in either general or plastic surgery, nor can I find evidence that it is affiliated with any programs in those disciplines.

He made no mention of residents in his essay either.

Anonymous said...

Its reasons like this that we can't trust doctors. That and a ton of evidence I have of doctors acting like patients in terms of "antics". That means porn, stealing, hurting patients. I believe Medscape had a recent article or two on more docs believing it is ok to cover up a mistake and more docs saying it is ok to have relationships with patients.

The more I think on it, the more I change I my tune to saying this really should not be allowed. I don't want laws, but if you can't get people to comply with patients wishes (yes, tell them you haven't operated in a year and see how they react), what are you going to do?

artiger said...

Anon above, I'm with you, but for reasons I stated above, I'll bet that Dr. Pearl would be able to find a week's worth of patients who would be more than willing to have him as their surgeon. He might have to comb through a few cocktail parties, or take a discerning look at some of his secretaries and VP's, but he'd be able to fill up a surgical schedule for a week. I mean, do you think the guy is going to operate more than 6 or 8 hours a day, or on Saturday or Sunday, during that week?

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