Surgeons who practise in rural areas or in relatively isolated small hospitals sometimes have to undertake emergency operations that are complex and relatively unfamiliar. In these circumstances, the surgeon will not be held to the Standard of Care of a surgical subspecialist in a teaching hospital.
However, when surgery is undertaken electively, outcomes should be no different than those at a tertiary or quaternary care centre.
At Examination for Discovery of such a Defendant surgeon in a medical malpractice Action, certain elements of training, experience and disclosure should be routinely addressed1.
Practice PointElements of surgical training for assessment at Examinations for Discovery:
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National and international specialty and subspecialty surgical associations frequently prescribe minimum numbers of surgical procedures at which the training surgeon should observe and assist.
Following observation and assistance, surgical associations also recommend minimum numbers of operations that are observed and assisted by experienced mentors before the surgeon undertakes a procedure with an inexperienced assistant1.
As a further stage of surgical training, first "solo" procedures should be performed on patients whose condition and anatomy is relatively uncomplicated by previous surgery and co-morbidity2.
In granting operating privileges, a hospital has a responsibility to review the surgeon's training and experience for each procedure for which privileges are requested3. Although the surgeon is generally in self-employed contract status, the hospital's failure to observe due diligence may be found to be negligent.
Practice PointConsider joining the Hospital for incompetent credentialing |
Even when an adverse outcome is within the range documented within the clinical research literature, its occurrence might have been materially less likely in the hands of a more experienced surgeon. Informed consent dictates that the range of possible outcomes be disclosed for both the consulting surgeon and centres of excellence.
Thus, the surgeon should disclose his own experience of the procedure, particularly if that experience is limited, and that he is still under the supervision of a preceptor if that is the case4.
For certain relatively common but complex surgical procedures, a minimum number of procedures annually is required to significantly reduce complication rates. Operations for which better outcome has been demonstrated for high-volume surgeons include laparoscopic cholecystectomy 5, carotid endarterectomy 6, and cancer surgery on the lung 7 [full-text], esophagus 8, stomach 9, and pancreas 8.
Surgical volume is a better predictor of outcome following Coronary Artery Bypass Grafting than the surgeon's reputation among other physicians10.
Practice PointSurgeons should disclose their own limited experience and to what degree risks would be lower in more experienced hands |
As noted by in a study11 on patient safety by Health Canada,
Evidence-Based Hospital Referral: Elective treatment should be guided by providers to hospitals and clinical teams with superior outcomes, when valid comparative outcome measurement systems exist.
Where outcome comparisons do not exist, such guidance should be based on scientific evidence of volume outcome relationships.
For many treatments, the scientific literature documents significantly superior patient outcomes in hospitals with higher volumes or with teaching programs
The Leapfrog group have established12 evidence-based minimum thresholds for certain surgical and invasive procedures - Coronary Artery Bypass Grafting (500/year), coronary angioplasty (400/year), abdominal aortic aneurysm repair (30/year), carotid endarterectomy (100/year), esophageal cancer surgery (7/year).
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