What makes a good surgeon?

[ljube_02]

How do you screw up??

i.e. if you must remove appendicities or something else, would a bad surgeon remove some different organ ? or a good surgeon can make the scarring clearly less than a regular surgeon?
same with any other specialty (i.e. heart surgery)

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[Andrew_Doan]

This is a very broad question. I will give you a short example to illustrate the difference between a good surgeon and bad one.

Using your example of appendicitis, this is a diagnosis that can be difficult to make. If missed, then the mortatility rate is very high. Surgeons are often asked to make the diagnosis to decide if surgery is necessary. A good surgeon is the one who knows what tests to order and what clinical signs to look for in order to make the diagnosis. A bad one is the one being sued because the appendix perforated after he/she refused to do the surgery and the patient dies due to sepsis.

Being a surgeon is more than cutting and sewing. It's knowing how to apply medical knowledge, tests, and clinical exam to the care of patients. With this knowledge, the good surgeons will also know how to manage wierd anatomy and complications during the procedure. They will also know how to manage complications post-op. You don't do surgery, and then say 'good-bye'. Every procedure will have the risk for complications. Some may be minor and others may be major. A good surgeon will know how to manage his complications.

 

[ljube_02]

Thanks!

 

[droliver]

I think the case with appendicitis is a poor example. If you just explore everyone with RLQ pain you'll have a 0% false negative rate but you'll do lots of non-therapeutic operations and most people would agree, show poor judgement. A better judge of that surgeon would be to have a low (but not 0%) rate of non-therapeutic surgeries for that presentation, suggestion accuracy in diagnosis.

I think the really great surgeons have the best judgement about not operating, rather than technical ability. This is true for all surgeons from general to plastic surgery.

 

[Andrew_Doan]

Originally posted by droliver
I think the case with appendicitis is a poor example. If you just explore everyone with RLQ pain you'll have a 0% false negative rate but you'll do lots of non-therapeutic operations and most people would agree, show poor judgement. A better judge of that surgeon would be to have a low (but not 0%) rate of non-therapeutic surgeries for that presentation, suggestion accuracy in diagnosis.

I think the really great surgeons have the best judgement about not operating, rather than technical ability. This is true for all surgeons from general to plastic surgery.

My point with the appendicitis is that good surgeons have the ability to make the correct diagnosis and then implement the proper treatment, which includes both surgical and non-surgical interventions. I did not imply that everyone gets a RLQ exploration. However, the surgeon who errors on the side of making the wrong diagnosis is worst than the surgeon who is more conservative and does the explorative surgery. I'd rather do a few more surgeries to find nothing, rather than not doing enough and miss the one that will kill 1 person.

 

[ApacheIndian]

Originally posted by droliver

I think the really great surgeons have the best judgement about not operating, rather than technical ability.

Isn't this somewhat of a paradox? So the best surgeons operate less and are also therefore paid less ? As a non-surgeon, I've often wondered about this...

 

[droliver]

Cuts,
the best surgeons tend to get a reputation for excellence from their peers, other physicians, nurses, & other AHP's and they make up the difference for the ones they don't operate on by the volume of their subsequent referrals.


Ophtho_MudPhud,
there's really a fine balance b/w making the correct diagnosis & having an acceptable non-therapeutic operation rate (as there is real morbidity from these operations ). It's not that often that people die from appendicitis, what you're usually looking @ is the difference in morbidity b/w post-operative courses of ruptured & non-ruptured appendicitis. I'm not sure the conservative surgeon is "worse" than the aggressive one, both management strategies have their pitfalls when you get it wrong (I've seen several deaths from post-op MI's & PE's and iatrogenic injuries on some of these non-therapeutic surgeries). We'd all like to have an idealized 0% negative ELAP rate, but in practice shooting for that will lead to a certain # who have ruptured appendices as you point out. A number of experts feel that a 5-10% negative exploration rate is a happy medium b/w conservative/aggressive management. Advances in imaging could potentially push this toward the lower end.

thanks!

 

[EidolonSix]

The best surgeons know when not to operate, when to relinquish control, and know the medicine behind their practice.

 

[Andrew_Doan]

Originally posted by EidolonSix
The best surgeons know when not to operate, when to relinquish control, and know the medicine behind their practice.

This is very key. They know the medicine behind their practice. It's more than going in, cutting, and then sewing.