Outcomes

[MilesDavisTheDoctor]

A lot is made out of the fact that orthopedics generally has patients with great outcomes and on the other hand, there are fields like neurosurgery where the opposite is often the case. I was wondering which surgical subspecialties have the best outcomes.

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[DoctwoB]

The variance within a field is usually larger then the variations between fields. In urology for example, you can take care of infertility, stones, bph, etc where patients do well and complications are rare, or do oncology and do cystectomies which have a 50-60% complication rate. Likewise in general surgery you can do trauma, HPB, surg onc, etc and deal with sick folks or Breast/colorectal and have a more outpatient practice with better outcomes. On average Urology, ENT, and Ortho will have less sick patients then gensurg, vascular, CT, or neurosurgery, but again there’s plenty of sick H&N or bladder cancer patients and healthy hernia/choley/appy/early breast CA/spine surgery patients. Most fields will give you a range that you can choose to specialize in.

Except vascular, they’re all sick AF.

 

[LucidSplash]

Except vascular, they’re all sick AF.

Damn straight. Somehow all the other fields can avoid a lot of operations by saying “not a candidate for surgery.” Usually a few days before I have to take them to the OR.

 

[MilesDavisTheDoctor]

That intra-field variance is something I've noticed, for example, even neurosurgery can focus on functional/epilepsy or spine, but still, they will probably have to take some amount of trauma call which will have extremely sick patients. Is this a normal consideration a lot of people have when choosing a field? I went into medical school initially wanting to go into neurosurgery but after a little more exposure to the field and seeing how devastated a lot of the patients were after surgeries I was a little turned off.

 

[slowthai]

That intra-field variance is something I've noticed, for example, even neurosurgery can focus on functional/epilepsy or spine, but still, they will probably have to take some amount of trauma call which will have extremely sick patients. Is this a normal consideration a lot of people have when choosing a field? I went into medical school initially wanting to go into neurosurgery but after a little more exposure to the field and seeing how devastated a lot of the patients were after surgeries I was a little turned off.

Not to derail, but this is exactly why I switched from nsx as well. I was neurosurg or die for the longest time, but when I found out about their outcomes, I was done. I can't be giving my all in the OR just for people to die on the table or leave worse than they came. The emotional rollercoaster killed it for me too. I wanted to pursue a field with relatively good outcomes. That was ENT for a while, but then the 20th conversation about snorting Flonase got to me. Enter ortho. Hope the bone breakers let me join the club.

 

[longhaul3]

This is a really common question and is always a point of emphasis for people deciding between neuro and ortho especially. But I think it's the wrong question to ask because it doesn't take into account the "incomes" i.e. what the patient comes in with and what the natural history of the pathology is. Yes, someone with a ruptured aneurysm and a blown pupil is probably going to have a bad outcome, but your job as the neurosurgeon is to save a life. On the other hand, if the aneurysm had been detected before it ruptured, you could have cured the patient with zero morbidity. People with tumors in eloquent areas or giant skull base tumors can have bad outcomes from surgery, but the natural history of the disease is progressive paralysis and/or herniation and death. The impact you make in resecting that huge skull base tumor is literally to reverse the natural history of the disease and save this person's life.

In ortho, someone comes in with knee pain and the possible outcomes are worsening knee pain or less knee pain. Or someone comes in with a terrible comminuted fracture and the worst possible surgical outcome is amputation. I get that these problems impact quality of life, but quality of life and presence of life are different ballgames. I don't mean this pedantically or condescendingly at all—it's just a matter of perspective that when people talk about outcomes, they tend to ignore the substrate you have to work with.

For that reason I like the "sick vs. not sick" question better. And there have been a couple of good posts about how each specialty has its own variety of sick and not sick.

 

[AnatomyGrey12]

That intra-field variance is something I've noticed, for example, even neurosurgery can focus on functional/epilepsy or spine, but still, they will probably have to take some amount of trauma call which will have extremely sick patients. Is this a normal consideration a lot of people have when choosing a field? I went into medical school initially wanting to go into neurosurgery but after a little more exposure to the field and seeing how devastated a lot of the patients were after surgeries I was a little turned off.

I'm just an M3 who will be applying to a surgical field this year, but I'll say I definitely took this into account when choosing. I like working with sick patients and all the complicated pathology that can come with them, but I found I needed it balanced out with patients that I could genuinely fix and see walk out of the hospital/clinic free of the pain or issue they came in with. In my experience NS has a lot of longitudinal management and often never truly "cures" their patients and instead has to take gratification in seeing patients take baby steps of progress, possibly never reaching where they were before the surgery, trauma, tumor, stroke, what have you. Obviously spine is a little different, but also comes with its own set of challenges. NS is an awesome field, but I personally could never do what they do and greatly respect those that can.

I agree with the above, sick vs. not sick is probably a better way to look at it instead of just outcomes. All fields have a varying balance between those two. It looks like you are a pre-med about to start in the fall. Your questions are good and honestly better than the questions I asked when I was about to start. As you go along you'll start to see some of the variance between surgical fields that makes them each unique from each other, get some shadowing experiences if you can. Keep asking questions and getting exposure and eventually you'll find where you fit and what you want to do. Good luck

 

[slowthai]

This is a really common question and is always a point of emphasis for people deciding between neuro and ortho especially. But I think it's the wrong question to ask because it doesn't take into account the "incomes" i.e. what the patient comes in with and what the natural history of the pathology is. Yes, someone with a ruptured aneurysm and a blown pupil is probably going to have a bad outcome, but your job as the neurosurgeon is to save a life. On the other hand, if the aneurysm had been detected before it ruptured, you could have cured the patient with zero morbidity. People with tumors in eloquent areas or giant skull base tumors can have bad outcomes from surgery, but the natural history of the disease is progressive paralysis and/or herniation and death. The impact you make in resecting that huge skull base tumor is literally to reverse the natural history of the disease and save this person's life.

In ortho, someone comes in with knee pain and the possible outcomes are worsening knee pain or less knee pain. Or someone comes in with a terrible comminuted fracture and the worst possible surgical outcome is amputation. I get that these problems impact quality of life, but quality of life and presence of life are different ballgames. I don't mean this pedantically or condescendingly at all—it's just a matter of perspective that when people talk about outcomes, they tend to ignore the substrate you have to work with.

For that reason I like the "sick vs. not sick" question better. And there have been a couple of good posts about how each specialty has its own variety of sick and not sick.

With this in mind, bad outcomes are unavoidable in every field. I have heard that even in ortho, even benign complications can be devastating from the surgeon perspective, to the point where it's almost too much to handle and they seriously consider throwing in the towel. This makes 100% sense to me, because just the thought of being responsible for a patient that you personally cut into, even for a routine case is almost overwhelming, even as a lowly med student. I mean, you put your heart and soul into this, all for the sake of the patient, and something goes wrong? It's like an assault on your identity, almost. I can easily see how it can make someone go nuts. How much more so in a field with a relatively high morbidity and mortality?

 

[MilesDavisTheDoctor]

This is a really common question and is always a point of emphasis for people deciding between neuro and ortho especially. But I think it's the wrong question to ask because it doesn't take into account the "incomes" i.e. what the patient comes in with and what the natural history of the pathology is. Yes, someone with a ruptured aneurysm and a blown pupil is probably going to have a bad outcome, but your job as the neurosurgeon is to save a life. On the other hand, if the aneurysm had been detected before it ruptured, you could have cured the patient with zero morbidity. People with tumors in eloquent areas or giant skull base tumors can have bad outcomes from surgery, but the natural history of the disease is progressive paralysis and/or herniation and death. The impact you make in resecting that huge skull base tumor is literally to reverse the natural history of the disease and save this person's life.

In ortho, someone comes in with knee pain and the possible outcomes are worsening knee pain or less knee pain. Or someone comes in with a terrible comminuted fracture and the worst possible surgical outcome is amputation. I get that these problems impact quality of life, but quality of life and presence of life are different ballgames. I don't mean this pedantically or condescendingly at all—it's just a matter of perspective that when people talk about outcomes, they tend to ignore the substrate you have to work with.

For that reason, I like the "sick vs. not sick" question better. And there have been a couple of good posts about how each specialty has its own variety of sick and not sick.

This is an interesting framework to think about this issue rather than just outcomes. Are you a neurosurgeon?

Even though the "incomes" for orthopedics and neurosurgery are quite different, and that is what in large part explains the "outcomes", it's hard to get around the fact that at the end of the day as a neurosurgeon it seems like you're giving a lot more bad news to families than as an orthopedic surgeon. The highs (curing someone's brain cancer) might be higher, but the lows (take out too much tumor and now the patient is in a coma) are much lower. It seems to me like to be successful as a neurosurgeon you have to be emotionally hardwired in a way to be able to let those high highs get you through those extremely low lows and I'm not sure that will work for me.

 

[longhaul3]

With this in mind, bad outcomes are unavoidable in every field. I have heard that even in ortho, even benign complications can be devastating from the surgeon perspective, to the point where it's almost too much to handle and they seriously consider throwing in the towel. This makes 100% sense to me, because just the thought of being responsible for a patient that you personally cut into, even for a routine case is almost overwhelming, even as a lowly med student. I mean, you put your heart and soul into this, all for the sake of the patient, and something goes wrong? It's like an assault on your identity, almost. I can easily see how it can make someone go nuts. How much more so in a field with a relatively high morbidity and mortality?

This is the other side of the coin. Bad outcomes from elective surgeries are a thousand times worse. If your substrate is a healthy person with a knee issue and something goes wrong, the patient would have been better off if he had never met you, and that's devastating.

Surgery is all about the benefits of surgery outweighing the risks. Knee scopes happen because the potential benefit to quality of life outweighs the small risk of something bad happening. Neurosurgeons are often forced to intervene because the risk of NOT doing surgery becomes too high, i.e. high risk of death or disability due to the natural history of the disease. In cases like that, the benefits are SO great (life-saving) that they outweigh almost any risks of the procedure, which are much higher than an ortho case. That's when bad outcomes happen, and they are mostly unavoidable.

But to your point, the surgeon did not cause the disease or put the patient in the position of having to choose between death and serious risk of disability. Outside of malpractice and gross negligence, bad things happen and sometimes have to happen when the pathology is so dire (e.g. hearing is often sacrificed on one side to completely resect a schwannoma; that's a way worse outcome than the risk of almost any ortho procedure, but most patients sign up for it knowing 100% it will happen). Morbidity is often expected and is easier to accept when the benefits still outweighed the risks and the life was saved.

This is an interesting framework to think about this issue rather than just outcomes. Are you a neurosurgeon?

Even though the "incomes" for orthopedics and neurosurgery are quite different, and that is what in large part explains the "outcomes", it's hard to get around the fact that at the end of the day as a neurosurgeon it seems like you're giving a lot more bad news to families than as an orthopedic surgeon. The highs (curing someone's brain cancer) might be higher, but the lows (take out too much tumor and now the patient is in a coma) are much lower. It seems to me like to be successful as a neurosurgeon you have to be emotionally hardwired in a way to be able to let those high highs get you through those extremely low lows and I'm not sure that will work for me.

I'm a resident. You're absolutely right that we give more bad news. If that's what matters to you and what was motivating this discussion of outcomes, ortho will probably be a better fit. But please, if you're just about to start med school, don't discount your ability to handle it and write off working with sick patients yet.

You do have to be willing to deal with death (and fates worse than death, IMO), but bad outcomes are not all low lows—this goes back to my original point. If the patient came in dying, you saved his life, and now he's hemiplegic, that's a bad outcome for the patient compared to where he was 24 hours ago, but it's a good result because the work was meaningful and made more of a difference than any shoulder scope ever could.

For me, the low lows come with the diagnoses. Scrolling through the MRI of a patient with a headache and finding a GBM is a low low. Seeing a high cervical injury in a teenager in a car crash is a low low. From there, we do what we can to make things better, and that's rewarding. Those two cases are the worst because there's not a whole lot we can do, but most of the time we can make an impact.

 

[dpmd]

Damn straight. Somehow all the other fields can avoid a lot of operations by saying “not a candidate for surgery.” Usually a few days before I have to take them to the OR.

Occasionally I see an patient whom vascular has deemed not a candidate for surgery and it is always a tip off that they are not likely going to be getting my services either.

 

[LucidSplash]

Occasionally I see an patient whom vascular has deemed not a candidate for surgery and it is always a tip off that they are not likely going to be getting my services either.

Ha yes but we are a terrible canary in coal mine because usually in that case you can tell from the door.

Although last week I had a patient in their 30s with an infected thigh loop HD graft. Looked like a pretty robust guy and told us he was poised to get another (3rd) kidney transplant. He just moved to the area and anesthesia wanted cards workup first. Turns out his EF is like 20% with biventricular failure and he got hypotensive with a sniff of sedation when they were cathing him. Turns out guy knew all this but is kinda in denial so leaves it all out when telling us his history because he thinks he can still convince someone to do another transplant in him if he doesn’t tell anyone.

So we ended up hacking out the graft under local with a sniff of ketamine. Which was fun. But I’m refusing to put anymore prosthetic in him. He has vein in his dominant arm but has always refused doing anything there. So he can keep his catheter forever as far as I’m concerned. This is like his 4th or 5th infected graft in 2 years.

 

[dpmd]

Ha yes but we are a terrible canary in coal mine because usually in that case you can tell from the door.

Although last week I had a patient in their 30s with an infected thigh loop HD graft. Looked like a pretty robust guy and told us he was poised to get another (3rd) kidney transplant. He just moved to the area and anesthesia wanted cards workup first. Turns out his EF is like 20% with biventricular failure and he got hypotensive with a sniff of sedation when they were cathing him. Turns out guy knew all this but is kinda in denial so leaves it all out when telling us his history because he thinks he can still convince someone to do another transplant in him if he doesn’t tell anyone.

So we ended up hacking out the graft under local with a sniff of ketamine. Which was fun. But I’m refusing to put anymore prosthetic in him. He has vein in his dominant arm but has always refused doing anything there. So he can keep his catheter forever as far as I’m concerned. This is like his 4th or 5th infected graft in 2 years.

It helps because I know not to add the guy on from home and instead see him first. Sometimes other info from the chart will do that too but depending on the problem I might still entertain doing it (so like a perfed viscus on a young person who looks really unstable by numbers I might still take to or but your patient there and your note about why nothing under general lets me know he needs a hospice discussion instead of calling the team in)

 

[OrthoTraumaMD]

In ortho, someone comes in with knee pain and the possible outcomes are worsening knee pain or less knee pain. Or someone comes in with a terrible comminuted fracture and the worst possible surgical outcome is amputation. I get that these problems impact quality of life, but quality of life and presence of life are different ballgames. I don't mean this pedantically or condescendingly at all—it's just a matter of perspective that when people talk about outcomes, they tend to ignore the substrate you have to work with.

While I agree in general about “presence of life” in neurosurgery, I will point out that if you look at outcome data, a Pilon fracture in orthopaedics (ankle joint comminution) is on the same level as an MI in terms of affecting quality of life.

 

[akwho]

Lots of good points made in this thread.

I went into ortho because patients in general love their outcomes and we can get many of them back to close to 100%. I also am doing a fellowship in joint replacements because those patients tend to be the happiest of any in the orthopaedic field. So patient reported outcomes is a huge driver in my motivation to be a surgeon and a doctor and I've found myself quite happy in what orthopaedics can deliver on that front. We have our bad days and complications on routine joint replacements can be devastating for both patients and surgeons.

However it's just not the same for neurosurgery and vascular where their patients start out in a much more debilitated place and the patient expectations are often unrealistic. From my experience it seems like patients are more appreciative of going from 80% to 100% with orthopaedics than from 30% to 70% with Neurosurg/Vascular. And even though the neurosurg/vascular docs provided more utilitarian benefit with their surgery, the patient's/families don't seem to recognize that and are often unhappy with their outcome. I am glad that people out there want to work with the sickest of the sick and find deep personal satisfaction in doing so - because we need them as a society. However, I for one I'm glad I'm in orthopaedics.


TLDR;
If you like working with the sickest of the sick and making profound life and death differences in peoples lives, than neurosurg/vascular is for you. This involves unavoidable bad outcomes, complications, and lots of counseling for patient/family expectations.

If you like high patient satisfaction, getting people back to their normal activities and less frequent but still devastating complications, than orthopaedics is a good fit for you.

 

[dpmd]

Lots of good points made in this thread.

I went into ortho because patients in general love their outcomes and we can get many of them back to close to 100%. I also am doing a fellowship in joint replacements because those patients tend to be the happiest of any in the orthopaedic field. So patient reported outcomes is a huge driver in my motivation to be a surgeon and a doctor and I've found myself quite happy in what orthopaedics can deliver on that front. We have our bad days and complications on routine joint replacements can be devastating for both patients and surgeons.

However it's just not the same for neurosurgery and vascular where their patients start out in a much more debilitated place and the patient expectations are often unrealistic. From my experience it seems like patients are more appreciative of going from 80% to 100% with orthopaedics than from 30% to 70% with Neurosurg/Vascular. And even though the neurosurg/vascular docs provided more utilitarian benefit with their surgery, the patient's/families don't seem to recognize that and are often unhappy with their outcome. I am glad that people out there want to work with the sickest of the sick and find deep personal satisfaction in doing so - because we need them as a society. However, I for one I'm glad I'm in orthopaedics.


TLDR;
If you like working with the sickest of the sick and making profound life and death differences in peoples lives, than neurosurg/vascular is for you. This involves unavoidable bad outcomes, complications, and lots of counseling for patient/family expectations.

If you like high patient satisfaction, getting people back to their normal activities and less frequent but still devastating complications, than orthopaedics is a good fit for you.

One thing that I really appreciated before my rotator cuff repair was a discussion about the expectations. He discussed that best case scenario I would always know it was operated on (so don't expect perfection) but at least the cycle of activity causing pain and leading to inactivity would be done with. That is so important because if things are not debilitating and only mildly bothersome unless you try to do certain things then deciding whether eliminating the moderately bothersome periods and maybe some level of future disability is worth what you go through to get to it (in terms of post op pain and physical therapy). Since it was framed like that I am not just satisfied, but pretty impressed that the difference is so much less than what I thought it would be and would have been satisfied with.

 

[MilesDavisTheDoctor]

Something I forgot to ask but I think was in the undercurrent around this discussion is how much of the time are the outcomes bad because of you? For example in neurosurgery there are tons of "bad outcomes" but how much of that is really because you made a mistake rather than the patient being so sick that something terrible was bound to happen. I'm interested in this distinction because I think dealing with bad outcomes would be a lot easier if you at least had the comfort of knowing that you didn't cause them.

 

[longhaul3]

Something I forgot to ask but I think was in the undercurrent around this discussion is how much of the time are the outcomes bad because of you? For example in neurosurgery there are tons of "bad outcomes" but how much of that is really because you made a mistake rather than the patient being so sick that something terrible was bound to happen. I'm interested in this distinction because I think dealing with bad outcomes would be a lot easier if you at least had the comfort of knowing that you didn't cause them.

Going back and reading this thread, this was my main point in "incomes" vs. "outcomes." You can only work with what comes through the door. A very small percentage of bad outcomes are due to surgeon error in my experience, and these errors are not like "whoops I just bovied the brainstem," but they're more errors in judgment that are only errors in hindsight. Like maybe I should have taken a little more/less of this tumor, maybe I should/shouldn't have done this embolization first, maybe I should/shouldn't have waited to take this patient to the OR. Lots of counterfactual second-guessing that you can never know the answer to. Because small mistakes can maim or kill, bad neurosurgeons don't last long, except for Dr. Death apparently. (I listened to that podcast recently. Wow.)

Where the technical errors are the worst is in the elective cases, like damaging nerve roots in spine surgery. Those errors in judgment are also magnified in elective surgery, like "should I have even done this case in the first place." The results of spine surgery are often equivocal, and there's a lot of risk. Like I mentioned earlier in the thread, there is no comfort to be found in hurting someone who was healthy and would have been better off never having met you.

The hard part about neurosurgery residency is that you will make mistakes, just like any other surgical resident But mistakes of the same small magnitude can kill someone in neurosurgery and may not even impact the patient at all in general surgery or ortho, where they may even be fixable intra-op.

 

[dpmd]

There is always the issue where the outcome isn't necessarily your fault but you still feel like a worthless piece of **** because of it. Maybe that is more related to personality (and I like to think that because I do take everything so personally that means I am more diligent in trying to make right decisions and doing right actions)