would you perform surgeries out of your scope?

[ACSurgeon]

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If a general surgeon with a decade of experience post residency went to volunteer or work in a third world country where doctors and resources are scarce, would it be unethical to perform surgical procedures that are usually done by fellowship trained surgeons in the US? That is, if a patient in Africa (or any poor country) needs an AAA repair (or kidney transplant… etc), and said GS is the closest thing to a vascular/transplant surgeon out there, would/should they do it? I know it’s less than ideal, but the patient dies otherwise… the way I’m thinking about this is, back in the day when surgeons were just trying new surgical techniques (transplant for example), they had to figure out by trial and error what the best way to carry out this procedure is. If there is only a general surgeon in the area, they at least have the literature to figure out the theory behind the operation, and give that patient an extra 15% (or whatever their success rate is at said operation that is out of their scope) chance of life instead of letting them die. Thoughts?

P.S: I would see why a gen surgeon would NOT attempt a brain surgery or a neurosurgeon attempting a transplant (training is probably significantly different). That is why I am limiting my question to general surgeons and fellowships of GS.

 

[maxheadroom]

What's the point of doing a transplant in a third-world country? Do they have a transplant lab to give you an idea of whether or not the organ and recipient are a match? Do they have access to a lifetime supply immunosuppression drugs and a method to monitor their levels?

Most General Surgeons (depending on the time and place of their training) could probably manage a ruptured AAA, but without ICU care and lots of blood on hand, it probably wouldn't matter.

Is it a good idea to work outside of your training anywhere? Are you helping those patients, or are you treating them as guinea pigs? A kidney transplant isn't that hard of a case (technically), but knowing who to transplant and how to manage them pre-op and post-op is well beyond my training.

Extraordinary circumstances arise at home and in the third world. I put a chest tube in a trauma patient last year (two years out from my preliminary GenSurg training) when the Trauma intern froze up and his senior was in the OR. Was it outside of my scope of practice? You bet!

Patients in the third world have the same human rights that U.S. patients have. American physicians shouldn't be going off to provide sub-standard care just because they're beyond the reach of our medical societies and courts.

 

[Winged Scapula]

Operate outside my scope of practice in an emergency? Sure, IF its the ethically appropriate thing to do.

As max so clearly points out, the mark of a good surgeon is to know when to operate and sometimes the right operation is not the right thing to do. If you don't have the support, it doesn't make sense to do a transplant. You could probably get away with doing an elective AAA repair and try to manage him without SICU staff but if you don't have the ability to manage the possible complications or to manage BP post-op, should you be doing the case?

I would argue that subjecting a patient to a potentially devastating operation is not necessarily better than not operating, if the outcome may not result in improved survival. The point is that technically you probably could do these cases, but surgery is much more than that.

 

[ACSurgeon]

You guys bring up great points... I guess my question was if one would perform an emergency surgery despite not being fellowship trained for it. Maybe transplant is a bit more complicated, but it was only meant as an example. Thanks.

 

[Winged Scapula]

Although it may not seem like it in academic medical centers, most general surgery in the community is not done by fellowship trained surgeons and patients seem to do ok.

Anyone who is general surgery trained can do the procedures you've listed, although as we noted, the support system may not be in place. But if you could find a true general surgery emergency in which the patient may not need critical care or other allied health services and were to be performed as a life-saving measure in a country where the likelihood of being sued was low, then I'd venture most people probably *would* do it.

In the US, a general surgeon may not have privileges to do a AAA, even if trained during residency to do them; same goes for advanced laparoscopy, sentinel nodes, endoscopy, etc. Even in emergencies, if you don't have hospital privileges to do the procedure you are planning, you with either be blocked from doing it or put yourself at legal risk, so I'd venture most wouldn't do it.

Its a slippery slope and one that every surgeon may make a different decision - operate and potentially save a life, or operate and save a life for the short-term only to end up hurting the patient because either you didn't do the best job or because the necessary allied support wasn't available?

 

[Pilot Doc]

You guys bring up great points... I guess my question was if one would perform an emergency surgery despite not being fellowship trained for it. Maybe transplant is a bit more complicated, but it was only meant as an example. Thanks.

Better example would probably be minor surgeries - basic ortho, optho, GU that you can read in a textbook or do the see one/do one method.

Anecdotally (n=1) I've heard of a FP doing simple sight-restoring optho surgeries.

 

[twood]

i think you're getting at "would you attempt an APR for obstructive rectal cancer even if you hadn't done a colorectal fellowship?"
absolutely. If I can relieve pain or improve quality of life, and there's nobody more qualified to do it, sign me up
-tw

 

[ACSurgeon]

i think you're getting at "would you attempt an APR for obstructive rectal cancer even if you hadn't done a colorectal fellowship?"
absolutely. If I can relieve pain or improve quality of life, and there's nobody more qualified to do it, sign me up
-tw

That is a lot more of what I was thinking, but as a lowly M2 (almost), I could only think of the "big" surgery examples...

Maybe an orthopod doing an appendectomy is more reasonable? But my question has been answered. Thanks.

 

[shag]

In the US, a general surgeon may not have privileges to do a AAA, even if trained during residency to do them; same goes for advanced laparoscopy, sentinel nodes, endoscopy, etc. Even in emergencies, if you don't have hospital privileges to do the procedure you are planning, you with either be blocked from doing it or put yourself at legal risk, so I'd venture most wouldn't do it.

A couple of years ago, I saw the lists of procedures for which several attendings at a community hospital claimed proficiency and were privileged to perform... It seemed as if several people claimed everything that they could possibly justify, regardless of whether they had done the procedure in the past few decades...

I think that general surgeons choosing to do procedures that are included in a fellowship pathway should represent that surgeon's comfort level with the procedure and professionalism. In 10 or so years, the 2 general surgeons who haven't retired will be making that decision every time they enter the OR 🙂.

 

[Winged Scapula]

A couple of years ago, I saw the lists of procedures for which several attendings at a community hospital claimed proficiency and were privileged to perform... It seemed as if several people claimed everything that they could possibly justify, regardless of whether they had done the procedure in the past few decades...

Every hospital has different rules about what they will credential you for.

Most everyone I've seen has additional requirements for Advanced Laparoscopy, Sentinel Node Bx, Head and Neck and Stereotactic Bx. These generally require "proof" of having been trained and done X number of such procedures. I've seen Vascular procedures in this group as well.

I'm privileged to do general surgery (and all that entails ) at some hospitals and only breast surgery at others - the latter is a political move on my part to avoid being forced to take general surgery call; however, not every hospital has a "breast surgery only" credentialing process.

I think that general surgeons choosing to do procedures that are included in a fellowship pathway should represent that surgeon's comfort level with the procedure and professionalism. In 10 or so years, the 2 general surgeons who haven't retired will be making that decision every time they enter the OR 🙂.

Its absolutely about your level of comfort as every training program has some different training, as will your practice once you get out. I do not object to general surgeons doing things they are trained for, although I would think I would draw the line at major procedures (like AAA repair) that a surgeon hasn't done in ages. These are the people you see doing Whipples in the community.

 

[maxheadroom]

How do you prove the cases? Your op log from residency?

 

[Winged Scapula]

How do you prove the cases? Your op log from residency?

In most cases yes. For some they may also require a certificate of course completion (ie, stereotactic, sentinel node, placement of tissue expanders, etc.).

 

[Eyesore]

Better example would probably be minor surgeries - basic ortho, optho, GU that you can read in a textbook or do the see one/do one method.

Anecdotally (n=1) I've heard of a FP doing simple sight-restoring optho surgeries.

Out of curiousity, what is considered a "simple" sight-restoring ophtho surgery?

 

[BlondeDocteur]

Trichiasis operations for trachoma.

I assisted a specially-trained ophthalmic tech (job only in Africa) doing 'em all summer long when I was running a field study once. Very quick n'dirty, and they save sight. It's the most common ophtho procedure in the world, and most US trained ophthalmologists haven't seen a single one. I took pics to show my department chair.

Incidentally the OP's question is the sine qua non of the ethics of international medical volunteerism. Lots of literature as to that question if you're inclined to look it up, lazymed.