Should doctors say how many?

Dr. Ramona Bates is a plastic surgeon in Little Rock, Ark., who writes regularly at Suture for a Living.

More from Suture for a Living

Monday the WSJ Health Blog posted “Should Doctors Say How Often They’ve Performed a Procedure?” written by Jacob Goldstein.

It references another guest post by Adam Wolfberg, M.D — “Test Poses Challenge for OB-GYNs”

Dr. Wolfberg writes: “None of the published studies of CVS pitted seasoned physicians against novices; what patient would agree to be randomly assigned to an inexperienced doctor holding a long needle? But several reports from individual hospitals demonstrate that the miscarriage rate declined over time as the hospital’s staff became more experienced.

“These reports point to a dilemma: CVS mavens got that way by practicing, so their present-day patients benefit at the expense of previous patients.”

When I first began my solo practice 19 years ago, patients often asked how long I had been in practice. They ask less often these days. I have never failed to answer.

Patients sometimes asks how many times I have done a procedure, but not often. Early in my practice, and sometimes even now, if it is a procedure I feel a bit uneasy with or haven’t done in a while I will bring the subject up without being asked. After all, some procedures you just don’t do every day or even every month. Some diseases you don’t see every month or even every year.

In my mind, many of the procedures I do are built on basic surgical principles. I withdrew my privileges for microvascular procedures more than 10 years ago. I didn’t get enough patients referred to me to feel that my skills were kept sharp. In private practice, unlike at a university, there are no labs to go do practice work in to maintain those rarely used skills. I have no doubt that I could regain them given the chance, but at what cost (financially or complications).

Because I gave up my privileges for microvascular procedures, it means I have limited my repertoire of reconstructive procedures important in hand, breast, and other work. I tell my patients about them. If a breast reconstruction patient wants a free TRAM flap, then she is referred to someone who does it. If she wants to keep me as her surgeon, is there the possibility she is short changing herself on the outcome? I suppose, but I try (TRY) to be upfront and fair to each patient.

The question asked “should doctors say how often they’ve performed a procedure?” may seem an easy one to answer. If asked, yes. If not asked, should it be part of the consent form? I’m not sure it should for most procedures, but for extremely complex ones, maybe.

What if I did 100 of one type of procedure, but my last one was over a year ago? What if I have done 50 of a second procedure that is closely related in skill-set? What if that number is only 15? What if I have never done one and don’t wish to now, but the patient needs the procedure and is not willing to travel to another hospital? Is it okay that I have “informed” them, but they want to take the risk? How do I define that risk for them?

How many of which procedure is enough to become proficient? How often does it need to be done to remain proficient? Who gets to define proficient? Who gets to define the “magic” number of how many is enough to be proficient? Who get to define how often the procedure needs to be done to remain “proficient”?

As Dr Wolfberg noted