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Ann Thorac Surg 2004;77:758-760
© 2004 The Society of Thoracic Surgeons
The ethical question being discussed underscores the dilemma of surgeons possessing varying degrees of skill related to a complex operation and whether or not they should refer to surgeons with greater experience. For the purposes of this debate, I have taken the con position in the following essay.
In the ideal world, the best surgeon in the world for a particular disease or condition would operate on every patient with that condition. Obviously, this is not practical or desirable. It would not be physically possible for only a few surgeons to do all of the operations of a particular type, and it would be undesirable not to disseminate knowledge of a new technique. Surgeons going through American thoracic training programs believe that they are competent enough to do most procedures that are required for the American Board of Thoracic Surgery certification, provided they have had exposure to said techniques. The chief of the cardiothoracic surgery service certifies that a trainee is technically and intellectually competent to take the American Board of Thoracic Surgery examination, which determines board certification. The American Board of Thoracic Surgery certificate indicates that this person has demonstrated cognitive and judgmental knowledge satisfactory to practice cardiothoracic surgery in all its aspects. Given the proper environment after training, most of these individuals will learn complex procedures and learn to do them well either as a trainee or as a practitioner. Surgeons who do not attempt to learn complex procedures after training will not gain the necessary training experience to perform the procedures safely. Thus, in this debate scenario, theoretically no one would be able to gather enough experience to do complex procedures if most of these procedures were directed to only a few surgeons, and this is the crux of the matter.
What factors in this era tend to inhibit referrals from one institution to another, or from one surgeon to another? Certainly the desire to keep the patient closer to home and in touch with their local health system in a hospital with doctors that they know and where their family has easy access is extremely attractive. From a surgeon's point of view there are factors inhibiting referrals to other surgeons. The fee structure of cardiac surgery has fallen dramatically because of reductions in Medicare, which have occurred beginning in the late 1980s to the present. In 1988, the real dollar value reimbursement from Medicare for a triple coronary bypass (two veins, one artery) was $4,200. The same operation rate proposed for this past April, which was fortunately put on hold, was to be $1,950 with a real dollar value consumer price index inflation index of $1,250. Therefore, obviously losing cases is something that surgeons do not necessarily like to do, and in fact, most surgeons are increasing their workload to keep the same monetary value as in previous years.
For a well-trained individual who understands the procedure and has considerable operative experience around the aortic root, there is really no reason not to attempt a complex procedure, given the right patient and appropriate indications. The beginning of laparoscopic cholecystectomy in 1985 is a good example of those who would subsequently do these procedures who were obviously less experienced than the surgeon that first performed the operation. Thus the surgeon that started the procedure would obviously always have the longest experience, because no one could ever be anything but second to that individual. However, if individuals with the appropriate training and experience had not learned the operative procedure, then it would not have become widespread and therefore its usefulness would be lost.
In the clinical scenario of this debate, the patient in question would have talked to the surgeon at some point during the discussions related to valve choice, and the surgeon's experience should have been queried by the patient. If the surgeon were to respond at that time, "I have moderate experience with this technique, some 10 to 15 patients, most who have done well," I believe this would be reassuring to the patient. If the patient presses the questioning further, whether the surgeon has done as much as the doctor in the cross-town hospital, he must truthfully say "no," and the patient will infer from this that the surgeon across town is more experienced. It is important to relate your actual experience when queried. In a recent litigation in another subspecialty of surgery, a very complicated operation done successfully (probably only performed by 3 practitioners in the country) was found to be necessary for a patient who presented himself to the surgeon of the subspecialty and who had asked if the surgeon had previously performed this procedure. The surgeon had only seen 1 other case in his training, and had personally never performed this procedure, yet the surgeon responded "yes" that he could do it. The patient expired postoperatively and the family sued the surgeon because there was lack of informed consent regarding the surgeon's ability to perform this procedure. The plaintiff won.
Another factor that may inhibit referral for a Ross operation is an alternative operation, perhaps as good in this particular clinical situation. For a 23-year-old childbearing female, the scenario was that the patient should try to avoid warfarin anticoagulation when she is contemplating pregnancy. Clearly, a bi-leaflet prosthetic valve is the most durable, but it requires anticoagulation, which may lead to birth defects or bleeding problems. So what are the other less complex alternatives that a woman could contemplate instead of a Ross operation? Certainly homograft root replacement could be considered as well as a stentless porcine valve, which is less desirable, or even a stented bioprosthetic valve, which is much less desirable with the knowledge that she would need a follow-up operation at some point because of structural valve degeneration. Minimally invasive procedures can also be used for all of these operations except a Ross procedure [1]. Small incision surgery would then make a reoperation much safer and less morbid. Furthermore, the safety of many of these alternative operations is vastly different then it was 10 years ago. In a recently reported experience at the Brigham and Women's Hospital, isolated elective homograft aortic root replacement was performed in 100 consecutive patients without mortality [2].
Finally, the Ross procedure is not a panacea. We now recognize a number of problems with this operation [3]. In patients with aortic regurgitation and a dilated aortic root, the pulmonary autograft root may become dilated after transplantation as the neo-aortic root. We know that the pulmonary homograft may form severe truncal stenosis in 10% of the patients, some of whom have to undergo reoperations. Most importantly, if we look at the wide range of results with the Ross operation, the Ross Registry mortality is approximately 2.5% [4]. A woman of this age, health status, and low risk should undergo an operation with a risk of less than 1%.
In summary, a surgeon should refer a patient to more experienced colleagues when their own experience is limited to none with a particular procedure. However, if the surgeon has had moderate exposure to the particular procedure, good personal operative experience, good training, and total familiarity with the aortic root under a variety of conditions, then it is appropriate for that surgeon to do these complex operations, such as the Ross procedure. More centers would then be capable of performing these procedures on a widespread basis. Obviously, this concept does not pertain to the areas in which there is a vast expenditure of resources and logistics, such as the total artificial heart or permanent left ventricular assist device.
If all patients requiring complex procedures were always referred elsewhere, only a few surgeons would learn new procedures, and therefore, technologic and therapeutic advancements would not be disseminated in many parts of the country.
References
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