Tuesday, May 05, 2015

Success in surgery? Not so fast.

Richard Harris at NPR interviewed Marty Makary on the subject of how to know if your surgery was successful.  The summary in a nutshell:

For 99 percent of people in America, when they go in to have surgery, the outcome [of that operation] is not measured. Nobody's keeping track. So I'm amazed at how one-fifth of the economy, [the share accounted for by the healthcare system], functions with so little measure of its performance.

I've noticed this, too, but an even more insidious fashion.  Lately, I've been reading published, apparently peer reviewed, medical papers about certain surgical procedures in which the authors (usually the surgeons in question) claimed that the surgery was successful.  But I've learned of a number of high profile cases of this sort in which the patient or the organ donor later suffered long-term complications that were not evident in the few short weeks following the procedure.

My problem here is piercing the veil of physician and hospital self-interest and patient confidentiality to present those cases to you. I'm working on it, though.  I welcome stories from my readers that fit into this category, particularly when patients or families are willing to share their confidential information or when the information is otherwise public (e.g., in court documents).


dan walter said...

Marty Markary's institution is one of the worst offenders when it comes to tracking outcomes: collateral-damage.net

John Freedman MD said...

We desperately need outcomes results, which are rarely collected outside research studies. Dr. Codman collected them himself a hundred years ago, and I think essentially no one has bothered ever since.

At the risk of accusations of raising another hassle factor, how about payers require at minimum proportion of patients must complete a confidential 3-5 question follow-up questionnaire 30 days post treatment, or else the doc and hospital get docked X% of their pay--just like in the new SGR fix?

Anonymous said...


This reflects the massive information asymmetry that still exists in health care. I compare to getting your car repaired: you may have no idea how to fix your car, but you can determine if the mechanic in fact resolved the problem.

In health care, there are few barometers to judge. "You'll have some lingering pain; that's the best we can do". Well, is it the best that can be done? What should patients be able to expect?

I welcome the greater transparency of many metrics. But even with that, I think it will be very difficult to overcome the asymmetry of information in healthcare. Which will make it all the more difficult to make more efficient.

Anonymous said...

I saw your article today and so agree with all your comments. These hospitals should have to track their outcomes for at least 5 years! My uro-gynecologist- performed three surgical procedures on me in one setting. One year later while still having pain with intercourse and a leaking bladder she discharged me back to my primary saying it will get better with time and more medications. Over 3 1/2 years now and am seeking surgery to repair both that have continued to get worse. I'm sure she considered my outcomes favorable since she has never followed up with me and I surely wouldn't go back to her. She probably use these incomplete statistics with others the same way she did with me to guide my decision making to do the procedures in the first place. No willful I'm sure, but naïve and irresponsible not to know the ultimate outcomes.

Barry Carol said...

Surgical outcomes are not so easy to measure and can vary considerably from one patient to another even if the immediate technical outcome is all that the surgeon hoped for. From a surgeon’s perspective, if there were no complications and everything went as it was supposed to, that’s probably a good outcome in his mind.

For a patient, though, changes in the ability to perform the normal activities of daily living, cognitive ability, the ability to engage in sports or other outdoor activities and pain, if any, after surgery compared to before surgery would all affect his or her assessment of the surgical outcome. If one were quite frail before the surgery and is somewhat improved afterward, that’s good news. If there was a decline in function, especially related to activities that the patient enjoyed doing and deemed important in his life, the perceived outcome will be less favorable.

Like so much else in healthcare, defining and measuring quality remains a huge challenge.

stacey said...

We do acute well.. chronic is a different world..

I have often wondered about this regarding orthopedic procedures...
Healthy athletic person has some knee or shoulder pain. Most likely due to imbalances/poor posture, overuse on a badly aligned body etc.

Nothing major broken or torn. maybe some arthritic spurring... tendons or ligaments a bit frayed.
doc says they can go in and scope the knee, shoulder, etc... and "fix it".
Shaves down the spurs, cleans up the joint. Patient has some residual pain, is sent to PT for 20 visits and is done with treatment.

Months and years down the road, patient has reduced function in the limb that was operated on. Patient seems to expect this. Why? Shouldn't the point of surgery be to improve or restore original function?
If the doc can't promise to make it better or restore original function, what was the point of the surgery?

Every patient should ask their surgeon if the expected outcome of the surgery is restore normal function.

We would not accept this type of outcome from an auto mechanic that fixed our car.