It’s Thanksgiving time again, and once again, around our family’s dinner table as the turkey’s being served, everyone will ask: Who’s going to carve the turkey? Should the job go to Uncle Jason, since he’s good with his hands, or should it go to my father, since he’s the eldest, or should my wife do it, since she cooks more?
Naturally, since no one volunteers for this job, the task comes to me, the only surgeon there. I’ve never understood the logic of this decision, since I’m not trained in cutting poultry. Even so, I always get the honor of carving the Thanksgiving turkey.
When the family centerpiece is on the line, one can never be too choosy. But what if your life and not just your meal were at stake? If you had to find a good surgeon to operate on you or your family member, what criteria would you use and why? Would you verify the surgeon’s credentials and qualify his or her expertise? Or perhaps you’d contact the Office of Professional Misconduct to see what sort of complaints if any have been filed? Or perhaps you’d do all this and still feel unsure, what then? Many patients tell me that in these circumstances they’d go on their gut instincts. But before you do that, I’d like to offer up a few of my suggestions. They may not be the best advice nor will they be comparable with what you may have heard before. But just as there are many ways to carve a turkey, there are many ways to find a good surgeon. Use these to help bolster your due diligence, if needed.
A Good Surgeon Has Steady Hands
Just like any other technical skill, there is great variation from surgeon to surgeon. I’ve seen average appearing surgeons perform amazing dissections with rapid speed, almost like magic, and other technically skilled showman-like surgeons that take forever in the operating room. There are some surgeons that are not too good with their hands, but with patience and perseverance, they get the job done.
But you may say that surgery is different than plumbing or painting, and I’d agree. It’s truly a privilege for us surgeons to legally and ethically be allowed cut into another human being. But just as with any other profession, it takes a passion for what we do and a desire to constantly improve that ultimately matters most. Whether it’s surgery, or painting, technique is a learned skill, which can be obtained by just about any one. Many are master technicians, whereas some go beyond the technique, becoming talented artists. But first and foremost, the surgeon’s clinical judgment is paramount, more important than any surgical skill they may possess. The best surgeons are ultimately the ones that know when and when not to operate.
One word of wisdom that I learned from one of my mentors is that how quickly and safely a surgeon moves through a surgical procedure is not determined by how fast the surgeon operates. In fact, it’s how good the first assistant is that determines the final outcome. Imagine if you are the captain of a battleship. Could you win a battle if you simultaneously steered the ship, loaded the cannons, looked for the enemy, aimed the guns and called out the orders? A good captain delegates, letting others push the buttons, pull the levers, and turn the steering wheel, while he or she makes critical decisions, thinking ahead and preventing any adverse outcomes.
Whenever I have a good resident as a first assistant, the procedure goes much more smoothly. During delicate or dangerous parts of the operation, I do the procedure myself, but for routine parts, I sometimes first assist, and the operation proceeds faster. Sometimes I just call out, "cut here…tie there, retract here…" Other surgeons are so in tune with co-surgeons that such verbal instruction becomes unnecessary. One just anticipates what the other surgeon is going to do. Having a good scrub nurse participate in this sort of intricate dance is truly a pleasure.
The Best Surgeons Operate The Most
It is true that practice makes perfect. On the other hand, practice without improvement will have the same results. As Albert Einstein once said: “The definition of insanity is doing the same thing over and over again and expecting different results”. Without learning from your mistakes and making positive changes, doing thousands of procedures will not make one a better surgeon with better outcomes. Similarly, there is a wide range of surgeons who have performed high volumes of procedures that have vastly different outcomes and complication rates.
Conversely, there are some surgeons that have performed very few numbers and are very good at what they do. This may sound overly simplistic, but I see surgery like being an elevator operator. Suppose an elevator operator worked 15 years pushing the buttons to various floors, but for some reason, was never asked to go to the 23rd floor. One day you get on this elevator and ask to go to the 23rd floor. Would you wonder whether he or not he was able to get you to the designated floor? Would you question his ability to push the right button since he’s never had the chance to push the button to the 23rd floor in the past? What would concern you most? Her ability and experience in pressing a button for the first time, or getting you to the 23rd floor?
In selecting the right surgeon, the other major variable is the patient. Humans are not like computers where one hard drive is just like any other. Every patient is different. One can perform the same exact procedure from a technical standpoint on ten different patients and get two to three different results.
So if a patient were to ask me how many of a particular surgery I’ve done, I really should be answering, "zero.” Since every patient is different and every surgery is vastly different, I never operate the same way twice. In this way, surgeons’ skills can’t be defined by the number of procedures they’ve done.
A Good Surgeon Is Complicated
Complications are a fact of life as a surgeon. But there’s so much variation in terms of the complexity of cases amongst surgeons that it’s hard to make any sort of generalization. A world-renown expert who performs a rare or risky procedure will have a higher complication rate, whereas a technically weak or insecure surgeon will only choose low-risk cases and therefore exhibit a seemingly “low complication rate”. The dilemma here is that if the surgeon has never had a complication similar to the one that you may have, then will she be able to handle it if it occurs? You want someone who has done a moderate number of procedures but has had enough complications to be able to manage yours, if in the case it should arise.
A Good Surgeon Is The Captain of The Team
I’ve been taught during training that as the surgeon, I should be "in charge" and take control of whatever crisis situation arises. In many situations, particularly with airway emergencies, other doctors yield to ENT doctors for management, but in a routine procedure, the best way to work is as part of a team. In my hospital (a teaching hospital) there is usually a scrub nurse, a circulating nurse, an anesthesiologist, and one or two resident or medical student assistants. The surgeon, although responsible for the patient’s welfare, should also get along well with others to set a good "tone" and working environment in the operating room for better teamwork and ultimately, better outcomes.
Good Surgeons Have Big Egos
It’s only natural that someone that saves lives day after day might feel a little special or privileged. I’m reminded of a scene from a movie (which I can’t remember) where a cardiothoracic surgeon proclaims, "I am God", in reference to his lifesaving skills. In real life, there are some colorful surgeons. Some just huff and puff and are harmless, and others can be abrasive and abusive, especially when in the operating room. I’ve overheard many surgeons cursing out their residents, sometimes in front of patients. When I was a surgical intern, I even overheard my chief resident tell another senior resident, "There are two ways to lead: by gaining respect, and by instilling fear. I lead by fear".
The worst situation is when a surgeon loses his or her cool when things start to go wrong during a procedure. Like in the TV show ER, the monitors start blinking and beeping, and anesthesia is nervously telling you some bad news. Usually in our field it’s some sort of airway problem, where the breathing tube can’t be placed inside the windpipe, or it becomes dislodged. The best surgeons that I remember during my training had "grace under pressure". Those that don’t have this will begin to panic, yelling out multiple orders and creating havoc in the operating room, ultimately to the detriment of the patient and the team.
The vast majority of surgeons that I know are kind, humble, respectful and keep their tempers under control when things go wrong. But as with any profession, there are bound to be some insecure people who take their frustrations out on others. Ask yourself, "Do I want to have a surgeon like this operate on me, no matter how technically skilled he is? You may need to do a little asking around, but try talking to people who work in the operating room along with the surgeon (nurses, OR technicians, nursing assistant, etc.). You may get some interesting answers.
A Good Surgeon Is Rich
It depends. Successful cosmetic surgeons do very well. Most surgeons make a decent amount of money, but there is such a wide variation that it’s hard to say what a decent amount is. One thing for sure is that if the surgeon takes insurances, he or she’s probably struggling to get paid from the insurance companies just like all doctors. From my personal experience and from what I hear from other colleagues, many insurance companies routinely delay or deny payment automatically, asking for more paperwork or not paying altogether. So unless the doctor’s office has top-notch billing and claims staff that can stay on top of these denials, most surgeons likely lose money in most cases. Add to this the fact with the volume of paper work that’s needed to get a claim paid, it’s less cost effective to take a patient to the operating room.
In other words, a typical surgeon can “lose” money by taking patients to the operating room. This is happening in otolaryngology and some other fields as well. With some insurance companies paying less than $200 for a tonsillectomy, which takes about one hour in the operating room along with all the risks and postoperative care involved, some surgeons have opted to cut back on recommending procedures in the operating room. As a result, I have seen situations where a child that obviously needed a tonsillectomy was told he would outgrow it with time. As you can see, there are some pros and cons to choosing a surgeon simply based on his or her financial status.
Surgeons Can Carve Turkeys
I’ll let my family decide this Thanksgiving. On an interesting historical note, the first surgeons were barbers (read Those Good Old Days of Surgery on page 6). Using this logic, that would make me a good haircutter as well. I tried this a few times on my children many years ago. Needless to say, it didn’t work out too well. But with a little training and practice…
Being a surgeon myself, I admit that the 7 traits mentioned above are somewhat biased. But these are the considerations that I use when I choose a surgeon for my own family members.
For most people, the decision on how to choose the right surgeon is a difficult one. Chances are, if you were referred by your doctor, the surgeon you were referred to probably passes all the criteria on the list that you got from WebMD or your newspaper article on how to choose the right surgeon. Realistically, you’ll go to the surgeon that your doctor recommends, as long as he or she takes your insurance. How many of you will shop around and interview 3-4 doctors for your sinus surgery? Very few people have the time or the energy to even get a second opinion. Even when a second opinion is obtained, for most routine procedures, the second surgeon will usually concur. Ultimately it comes down to trust. You trust that your medical doctor sent you to someone that she trusts, and that once you develop a trusting relationship with your surgeon, you’ll most likely go ahead with the surgical recommendation, assuming it’s necessary. You trust that even if something goes wrong, he will do the right thing. At this point, the number of procedures, number of years in practice, or board certification, all become secondary.
When I had a major hand infection many years ago, and faced the possibility of surgery on my hand, the last thing on my mind was how many he’s done, or if he’s qualified to do the procedure. In my mind, I was thinking, "Can I trust him to do a good job?" Instead of asking him how many times he performed this procedure, I placed my hand (and my career) in his hands, and decided to trust him entirely.
I’m reminded of the old Smith-Barney commercial, "where the relationship is everything." This applies to medicine and surgery as well. Most doctor-patient relationships last longer than many marriages. If you don’t feel comfortable with your surgeon on the initial visit, either because of his demeanor, choice of words, or office staff, find someone that you’ll be comfortable with. If there’s a flashing red light going off in your head, take notice. Malcolm Gladwell, in his book, Blink talks about thin-slicing, which he describes as an immediate, innate gut feeling or intuitive sense that can’t be easily verbalized. It goes without saying that surgeons can be thin-sliced as well.