SURGICAL EXPERIENCE

What is the foremost quality you look for when you are looking for a surgeon? Chances are most of you will say ‘experience’. If there is one thing young surgeons would envy older ones for, it is the fact that the latter are known to have experience.

Isn’t it a given that experience is good, then? Yes and no. Experience has made me a man. But it has also made me a sadder man. It has reduced my expectations from people and from life. It has made me harder and stronger (in the wrong places). It has tempered my emotions, but also made me less receptive to the emotions of others. Experience has not only made my arteries hard, but also my heart harder. It has made me a wiser, but balder, man.

Experience is the sum of one’s mistakes in life, they say. A more discerning person would say ‘no’. There are three kinds of experience:
First hand experience: you have been in battle, and are scarred. No one knows it better than you.
Second hand experience: you have studied the phenomenon of the experience and analysed it.
Third hand experience: you have heard of it from somewhere or someone.

Of the three, which would you prefer your doctor to have? Instinctively, I think we all would prefer to have had first hand experience of the various aspects of life. In the case we started out with (surgery), surgeons would all prefer to have seen complications and disasters in our own lives so as to avoid or solve them in future. This is the best thing for a doc, right? Wrong!

Though it is great for a doc to have first hand experience, it is perfectly likely that he would be biased or plain wrong in the lessons he has learnt from them. In a typical (hypothetical) case, a surgeon uses no mesh to repair his hernia cases because the one time he did use it in 1982, his patient got an infection and lots of problems. This is the main problem with first hand experience. While life must have taught a lesson to the doc, it might have taught him the wrong lesson!

Third hand experience is, obviously, of limited value: who knows what someone told you is right or wrong?
Which brings us to second hand experience.

If you have seen, observed and analysed someone do the right or wrong things, you will have learnt the right lessons. You don’t need to start off with a steep learning curve and create all the complications and make all the mistakes others before you had made. Because you have trained for it. Forewarned is forearmed. It is this second hand experience that is commonly called wisdom. So, it is better to be wise than to be experienced. Therefore, whether it comes to choosing a surgeon or a spouse, better chose a wise, rather than an experienced, one!
Finally, should you not choose a young surgeon? Remember, you can be young once, but you can be immature forever! Hence, young and trained is not a bad combination to have, especially in the present days of changing technology and evolving treatment methods.

(pic source: forgotten. Sorry!)

26 responses to “SURGICAL EXPERIENCE

  1. Wow, lots to mull over, but my non-herniated gut tells me that with increasing complexity of skill, I would want a surgeon who has done a procedure so many times it’s routine.
    You are in your prime. Probably read all the journals and keep track of changes in your field.
    I don’t want a medical student at a teaching hospital operating on me as practice. Sorry.

  2. Wisdom is good for life. But for surgery, I’ll take experience over wisdom, as Jackie said.

    I doubt that watching videos of surgery, and watching other surgeons operate in and of itself can prepare a surgeon for the actual act of performing surgery. I’m not discounting the role of second-hand experience, or that it can help someone in avoiding common mistakes, but there’s no substitute for first-hand experience (experience) when it comes to surgery.

  3. But it has also made me a sadder man. It has reduced my expectations from people and from life. It has made me harder and stronger (in the wrong places). It has tempered my emotions, but also made me less receptive to the emotions of others.

    rambodoc, looks like you need a warm hug. πŸ™‚

  4. Amit:
    A warm hug? Yes, but I am gender-biased!
    πŸ˜‰
    Jackie and Amit:
    I am not discounting the value of experience… how could I? All I am doing is qualifying the experience. There are, all over the world, large numbers of wizened old surgeons with experience writ large on their creased brows and silver sideburns. They, however, may well be old farts practicing dinosaur age surgery.
    Let me give you one example: a typical surgeon may choose to remove every appendicitis that comes his way, because that is how he has learnt and taught all his life. If you tell him that modern science says that only some cases need surgery, with most settling down with antibiotics, he would pour scorn on you.
    As a famous friend said: “This is eminence-based, not evidence-based, surgery.”

  5. doc, but not all experienced surgeons are like that – you’re now going into special cases, and we can have subsets of surgeons – {experienced, wise and up-to-date}, {experienced, not wise and not up-to-date},{ not experienced, wise and up-to-date} and so on.
    The approach and answer will depend on what subset is being discussed. πŸ™‚

  6. Personally I wouln’t want to over hear a surgeon (when am on the table) saying this “well well well what do we have here…….”

    πŸ™‚

  7. I prefer experience, but also young. Someone mid-way if you know what yu mean. Surgeons after all need to have a steady hand! I think my ideal doctor would have to be in the age range of 40-50. But have to admit I have never had an operation in my life!
    I have something more things I want to say but we are on holiday and it’s not easy to ignore those around me! πŸ™‚

  8. In the transhumanist world where we are headed, we’ll have all the surgical experience and knowledge in a few zillion bytes of information that will move nano-sized fingers around our bodies. Don’t worry, doc, you’ll still have blogging as an occupation πŸ™‚

  9. Personally, I will go for the guy who can tell the difference between a vasectomy and a castration.

    I read a delightful book by Richard Gordon once, in which Grimsdyke, who is appearing for the anaesthesia viva, is asked what the different stages in anaesthesia are.

    “Awake, asleep and dead”, his reply.

    Also remember a mnemonic, from the same book.
    “The Lingual Nerve
    Took a swerve
    Upon the Hyoglossus.
    Oh! We’re mucked!
    Said Wharton’s duct,
    “The dirty blighter’s double-crossed us”

    Or words to that effect. Enjoyed, and been enjoying your “Humerus”stuff.
    Cheers!

  10. R-Doc:

    The following is based on recent observation of someone else’s agony. An inexperienced doctor pokes a patient 3 times and fails to collect spinal fluid, leaving the patient in great pain after 45-55 minutes. Many apologies follow. An experience steady-handed neurologist pokes slightly higher, in a higher-risk area of the spine and extracts spinal fluid in 5 minutes. The patient had no options there but the doctor did not so much as need a word or smile in the process.

    A friend finds unexpected lumps and bumps which need immediate surgery. Mulling over the choice from amongst 3 fine surgeons, she finds herself laughing unintentionally over a macabre statement made by one of them – Whether you chose the right surgeon or not, you only know in hindsight.

    So even if hardened by experience and time, an experienced doctor/ surgeon is always preferable.

  11. @ Doc: //A warm hug? Yes, but I am gender-biased!//
    Okay, here’s your damn warm hug. πŸ™‚
    I tease because I care, ya know.

    Great comments above.
    Doc, I get your point. There are debates that vacillate between good judgement vs. experience regarding things medical all the time. I don’t think skill and intelligence (not to mention a steady hand!) is necessarily a function of age. Having said that:

    Latest I’ve read is the appropriateness of medical treatment protocols – good for newbies, but takes the “art” and judgment away from highly experienced (and competent) docs. An intimidating but excellent physician who comes to our medical meetings said something last year that stuck:

    I was charged (with a pharmacist in this example) with conducting chart reviews for chronic diseases such as diabetes. Yep, there are treatment protocols. You expect A then B then C, and guidelines for parameters such as Hgb A1C, lifestyle, blah blah blah.

    This doc leaned across the table at one of our meets and said to my boss and medical director: treatment protocols do not necessarily address everyone all the time….or something to that effect. Let me treat my patients the way I want to. There is no need for yearly eye exams (he cited recent studies) for stable patients. He was marked down on his ‘report card’ on the audit for not ordering annual eye exams.

    But with managed care is prominent and cost savings a “goal”, we had to do our job. That is what is measurable. But what he said is spot-on. There are always outliers. Experienced physicians need the freedom to practice their science and art…this comes from many years of experience.

  12. I need an editor. Meant to say that the above respected doc said
    “You people measure what is measurable”.
    Soooo true!

  13. Shefaly:
    Yes, I understand. However, I mostly wish to underline the risk inherent in relying on experience alone, as is universally followed. Interestingly, among the qualities of a surgeon (“eye of an eagle, heart of a lion, etc…”), hand skills are given importance only to the extent of 20% (if memory serves me right). Ethical uprightness, clinical judgment, counseling skills, teaching and academic responsibilities get most of the rest.
    Bet you didn’t know that, eh?
    πŸ˜‰

    Jackie:
    Protocol-ised treatment lines should be evidence-based. However, many of the protocols are based on flimsy evidence. Look at the mammogram protocols. There is no evidence that squeezing women’s breast between x-ray plates reduces mortality. Too many angles to this, I know….

    Narendra:
    Great one! Thanks.

    TRF, Xylene, Nita & Amit:
    Thanks.

  14. I hope I would die sooner than having to go under the knife of any surgeon. ( nothing personal doc, I seem to have a natural aversion for hospital beds , anesthesia and medicines)
    But if I have to I’d have normally gone for experience and Now you’ve got me confused.
    I think I will settle for the best looking. πŸ˜‰

  15. R-Doc:

    “..Ethical uprightness, clinical judgment, counseling skills, teaching and academic responsibilities..”

    And these are even harder to judge than experience, no? So experience is used as a proxy measure I suppose as in, if one were unethical, one may not have been around long, if one had extremely poor bedside manner (counselling skills I imagine covers that), one would be unpopular with patients and so on.

  16. Vivek Khadpekar

    Doc,

    Years ago I had to undergo a minor surgical operation (under local anaesthesia). I was referred to a surgeon who was reputedly among the best in the city — Pune — where I was then living.

    During the procedure his wife — she too a medico — joined him in the theatre. Throug the 30 minutes or so that I was under the scalpel, the two were engaged in more or less nonstop conversation on assorted trivialities, including the extramarital affair of a professional colleague (with whom I happened to be acquainted). You can understand my anxiety about how attentive they were to the task on hand, for which I was paying good money (apart from having indemnified them over my wife’s signature against any mishap during or due to the operation).

    The surgery was successful, but I was — and continue to be — very unhappy with the shoddy quality of “craftsmanship” in both the incision and the subsequent stitching up they did. I wonder how much of it was due to their inadequate manual skills and how much to their preoccupation with small talk during what, at least to me, was a serious job. I am sure the surgeons in question qualified on all the counts enlisted in this post, but as far as pride in professional excellence goes, they were wanting.

  17. Vivek:
    There you are. The ‘reputation’ of folks doing surgery often flatters them unfairly. Nature gives us a long rope, and most people are too grateful to their surgeons, not knowing how substandard their surgeries may have been done, though the end-result may have been good. It is only in the ‘difficult’ case that a good surgeon emerges. It would be somewhat difficult for a patient to know about this, but this is probably overcome by the mysterious network of mouths.
    Shefaly:
    It is really difficult to assess, for a patient, who is a good surgeon. Even if you look at academic credentials, the most published men are stereotyped as bad operators (though this is a little unfair). Experience does have enormous value, I agree, but can be (and often is) a deceptive yardstick when choosing a surgeon.
    Remember the spouse analogy!
    Usha:
    “I think I will settle for the best looking.”
    Wonderful choice of method! I am sure I will rank high in your list when (and not if) the time comes. You cannot escape us surgeons easily!

  18. Like the ophthalmologist who was marked “down” for wanting some room to decide, I too have been marked “down” for the same reasons and have chosen to give up teaching- a passion. Does that reflect on my abilities? I would hazard saying it all boils down to what Granma always knew- a recommendation by word of mouth is a great way to choose- the other person’s experience gives you the benefit of hindsight in advance…

  19. i agree doc,
    indeed it is very tricky business, not only that what if the good surgeon has a bad day the very day one is being operated but natural tendency is always to go with experience or with one who at least appears experience
    all in all
    You will always be high on our list πŸ™‚

  20. R-Doc: I see your point and Sonia’s – word of mouth recommendation can only come from alive patients, so that can only be good, no?

  21. Vivek Khadpekar

    Shefaly,

    TouchΓ©! But not all surgery is regarding life-or-death options. There’s considerable middle ground, which is where I guess the w-o-m recommendations do matter.

  22. Gives a lot to ponder over. ^___^

  23. “word of mouth recommendation can only come from alive patients”
    Quite the contrary, Shefaly! You kill one patient, even if you have saved thousands, and the world and its pet dog will know about it. Nothing spreads as well as bad news, as you surely know.

  24. Vivek:

    In the UK, many people leave hospitals now with MRSA. I think death may be preferable to disfigurement and the lifelong impairment that entails…

    @R-Doc

    Didn’t think of it that way. Hm. Thanks. Too late for my friend’s decision now – surgery booked and all.

    Apart from reputational risk arising from patient deaths, I am curious if there are many malpractice lawsuits in India in such cases. In the US, insurance against such lawsuits is a large % of a doctor’s operating (not the same sense of course as on the table!) costs. In the UK, suing the NHS successfully is an upward trend so the government has proposed a patients’ charter which will outline the responsibility of patients (and in my cynical view, formalises rationing for all those who raised a hue and cry each time any specific instances of rationing were found in any given Primary Care Trust).

    Thanks.

  25. Shefaly:
    Most cases are filed in case of death, often to try and get a reimbursement for the medical expenses borne. Non-death cases don’t get much ahead, unless clearly identifiable negligence is documented, like leaving a mop inside the belly.
    I didn’t really understand what you said about the NHS thing.
    Anirudh:
    Welcome!

  26. R-Doc

    Thanks for that clarification.

    About the NHS, which is a service free at the point of delivery, I was just saying that more and more are suing the NHS now. Some successfully so. Since years of preventative healthcare messages have fallen on deaf years, the government has now announced a charter of responsibilities for patients. Things such as if you don’t quit smoking, the NHS may not give you a bypass; or if you don’t lose 5 stones, the NHS may not replace your knees. Some decry these measures as rationing. Which is amusing because it is naive. Rationing has gone on for years because various PCTs are independently run and their individual financial constraints could lead to rationing. e.g. a cancer drug may be available on one PCT but not on another PCT; or some procedures may not be available on some PCTs at all. My point was that measures such as the proposed charter will effectively formalise rationing of treatments by making them conditional on the patient doing his/ her bit as well. And to some extent, the growing numbers of lawsuits against the NHS may have contributed to the proposing of this charter, because the lawsuits put further pressure on finances of PCTs already stretched and since we have a commitment to providing free healthcare, we find ways to be seen to continue doing it while trying to reduce costs by allowable means.

    Clear as mud as I read it again but I shall leave it here anyway.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s