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PubMed1997

Guide to evaluation of permanent impairment of the temporomandibular joint. American Academy of Head, Neck and Facial Pain; American Academy of Orofacial Pain; American Academy of Pain Management; American College of Prosthodontists; American Equilibration Society and Society of Occlusal Studies; American Society of Maxillofacial Surgeons; American Society of Temporomandibular Joint Surgeons; International College of Cranio-mandibular Orthopedics; Society for Occlusal Studies.

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Ankylosis↗
PubMed2005

Surgeon specialty and operative mortality with lung resection.

OBJECTIVE: We sought to examine the effect of subspecialty training on operative mortality following lung resection. SUMMARY BACKGROUND DATA: While several different surgical subspecialists perform lung resection for cancer, many believe that this procedure is best performed by board-certified thoracic surgeons. METHODS: Using the national Medicare database 1998 to 1999, we identified patients undergoing lung resection (lobectomy or pneumonectomy) for lung cancer. Operating surgeons were identified by unique physician identifier codes contained in the discharge abstract. We used the American Board of Thoracic Surgery database, as well as physician practice patterns, to designate surgeons as general surgeons, cardiothoracic surgeons, or noncardiac thoracic surgeons. Using logistic regression models, we compared operative mortality across surgeon subspecialties, adjusting for patient, surgeon, and hospital characteristics. RESULTS: Overall, 25,545 Medicare patients underwent lung resection, 36% by general surgeons, 39% by cardiothoracic surgeons, and 25% by noncardiac thoracic surgeons. Patient characteristics did not differ substantially by surgeon specialty. Adjusted operative mortality rates were lowest for cardiothoracic and noncardiac thoracic surgeons (7.6% general surgeons, 5.6% cardiothoracic surgeons, 5.8% noncardiac thoracic surgeons, P = 0.001). In analyses restricted to high-volume surgeons (>20 lung resections/y), mortality rates were lowest for noncardiac thoracic surgeons (5.1% noncardiac thoracic, 5.2% cardiothoracic, and 6.1% general surgeons) (P < 0.01 for difference between general surgeons and thoracic surgeons). In analyses restricted to high-volume hospitals (>45 lung resections/y), mortality rates were again lowest for noncardiac thoracic surgeons (5.0% noncardiac thoracic, 5.3% cardiothoracic, and 6.1% general surgeons) (P < 0.01 for differences between all 3 groups). CONCLUSIONS: Operative mortality with lung resection varies by surgeon specialty. Some, but not all, of this variation in operative mortality is attributable to hospital and surgeon volume.

Aged↗
PubMed2002

Surgeon volume as an indicator of outcomes after carotid endarterectomy: an effect independent of specialty practice and hospital volume.

BACKGROUND: High-volume hospitals have been shown to have superior outcomes after carotid endarterectomy (CEA), but the contribution of surgeon volume and specialty practice to CEA outcomes in a national sample is unknown. STUDY DESIGN: Using the National Inpatient Sample for 1996 and 1997, 35,821 patients who underwent CEA (ICD-9-CM code 3812) and had data for unique surgeon identification were studied. Surgeons were categorized in terms of annual CEA volume as low-volume surgeons (< 10 procedures), medium-volume surgeons (10 to 29), and high-volume surgeons (> or = 30). Data from cardiac, general, neurologic, and vascular surgical practices were analyzed. In-hospital mortality, postoperative stroke, and prolonged length of stay (> 4 days) were the primary outcomes variables. Unadjusted and case-mix adjusted analyses were performed. RESULTS: The overall in-hospital mortality was 0.61%. CEA was performed annually by high-volume surgeons in 52% of patients, by medium-volume surgeons in 30% of patients, and by low-volume surgeons in 18% of patients. Observed mortality by surgeon volume was 0.44% for high-volume surgeons, 0.63% for medium-volume surgeons, and 1.1% for low-volume surgeons (p < 0.001). The postoperative stroke rate was 1.14% for high-volume surgeons, 1.63% for medium-volume surgeons, and 2.03% for low-volume surgeons (p < 0.001). Surgeon specialty had no statistically significant effect on mortality or postoperative stroke. In the logistic regression model, increased risk of mortality was associated with emergent admission (odds ratio [OR] = 2.1; 95% confidence interval [CI] 1.6 to 2.8, p < 0.001), patient age > 65 years (OR = 2.0; 95% CI 1.3 to 3.1, p = 0.001), low-volume surgeon (OR = 1.9; 95% CI 1.4 to 2.5, p < 0.001), and COPD (OR = 1.8; 95% CI 1.3 to 2.5, p = 0.001). Low hospital CEA volume (< 100) was not a significant risk factor in the multivariate analysis. CONCLUSIONS: More than 50% of the CEAs in the United States are performed by high-volume surgeons with superior outcomes. Health policy efforts should focus on reducing the number of low-volume surgeons, regardless of surgeon specialty or total hospital CEA volume.

Adolescent↗
PubMed2003

Surgeons' anonymous response after bile duct injury during cholecystectomy.

BACKGROUND: Bile duct injuries remain one of the most devastating injuries during laparoscopic cholecystectomy. Few studies target surgeons who have experienced bile duct injuries for their insight, their perspective, and their suggestions concerning this problem. METHODS: A confidential questionnaire was sent to all practicing general surgeons under the age of 65 years in British Columbia, Canada. RESULTS: Seventy-five percent of surgeons responded to the survey. Of the 114 questionnaires completed, more than 97% of respondents had completed formal training in laparoscopic cholecystectomy. One half of surgeons reported experience with laparoscopic bile duct injury. A significant difference in years in practice between surgeons with injury and surgeons without injury was noted. The majority of injuries occurred after the surgeons's first 100 cholecystectomies performed. The first thoughts of surgeons after injury uniformly concerned the patient's well being. The next most common thoughts were in relation to obtaining help or a second opinion from another surgeon. Surgeons cited inflammation and short or anomalous cystic ducts as the most responsible factors contributing to injury. The majority of surgeons felt that these injuries are unavoidable and less than half felt that it was always a surgical error. Fewer than 15% thought injuries could be avoided by performing a cholangiogram. Surgeons suggested meticulous dissection and less haste to divide structures may prevent an injury. Surgeons recommend educating colleagues to remove the stigma of failure associated with conversion to laparotomy. CONCLUSIONS: General surgeons in British Columbia have a one in two chance of experiencing a bile duct injury in their career. There were more injuries in surgeons who had already been in practice for 10 years at the time of introduction of laparoscopic cholecystectomy. The injuries are likely to occur despite high volumes of procedures and increased experience. The incidence of bile duct injuries does not seem to be different in surgeons who perform routine cholangiography and most surgeons feel that cholangiography would have little effect on injury incidence. Surgeons tend to have patient-centered concerns after injury and little concern for medicolegal issues. The majority of surgeons felt that these injuries could not be anticipated and as such it is an inherent risk of this procedure.

Bile Ducts↗
PubMed2002

A lack of consensus in the assessment of fracture healing among orthopaedic surgeons.

BACKGROUND: The assessment of fracture healing is both a clinically relevant and frequently used outcome measure following lower extremity trauma. However, it remains uncertain whether there is a consensus in the assessment of fracture healing among orthopaedic surgeons. Variability in the assessment of healing may have important implications in surgeons' decisions to intervene when they perceive fracture healing is slow to progress. OBJECTIVE: To identify surgeons' approaches in the assessment of tibial fracture healing and the definitions of a delayed union, nonunion, and malunion among orthopaedic surgeons. STUDY DESIGN: Cross-sectional survey of 577 orthopaedic surgeons. METHODS: Focus groups, key informants, and sampling to redundancy strategies were used to develop a survey to examine surgeons' opinions in the assessment of tibial shaft fractures. Surgeons were asked how often the following variables were used in the assessment of fracture healing: (a) callus size; (b) cortical continuity; (c) progressive loss of fracture line; (d) pain with weight bearing; and (e) pain to palpation at the fracture site. Further, surgeons were asked to provide a time point beyond which a delayed union becomes a nonunion. Finally, surgeons specified their limits of acceptable fracture alignment (translation, shortening, rotation, varus/valgus, and procurvatum/recurvatum). The survey was pilot tested for clarity and content validity. This survey was mailed to 577 orthopaedic surgeons who were members of the Orthopaedic Trauma Association, American Academy of Orthopaedic Surgeons, and European-AO International-affiliated trauma centers. RESULTS: Responses were obtained from 444 surgeons (response rate 77%). For each variable, the proportion of surgeons who always used the criterion ranged from 39.7% to 45.4%, and those who occasionally or never used the criterion ranged from 20.7% to 26.9%. Surgeons' definitions of delayed union ranged from 1 to 8 months, whereas definitions of nonunion ranged from 2 to 12 months. There was also variability in definitions of fracture malunion. Acceptable degrees of fracture shortening and translation ranged from less than 5 mm to greater than 15 mm. Surgeons' definitions of acceptable angular malunions (rotational, varus/valgus, and procurvatum/recurvatum) ranged from less than 5 degrees to 20 degrees. CONCLUSIONS: There is a lack of consensus in the assessment of fracture healing in tibial shaft fractures among orthopaedic surgeons. Varying definitions of nonunion and malunion may influence the decision to intervene in an effort to promote fracture healing and/or realign the fracture.

Adult↗
PubMed2005

The learning curve measured by operating times for laparoscopic and open gastric bypass: roles of surgeon's experience, institutional experience, body mass index and fellowship training.

BACKGROUND: Surgeons must overcome a substantial learning curve before mastering laparoscopic Roux-en-Y gastric bypass (LRYGBP). This learning curve can be defined in terms of mortality, morbidity or length of surgery. The aim of this study was to compare the learning curves in terms of surgical time for the first 3 surgeons performing LRYGBP in our hospital with the length of surgery for open gastric bypass (CONTROLS). METHODS: We compared 494 primary LRYGBPs performed by 3 surgeons (393 by 1st SURGEON, 57 by 2nd SURGEON and 44 by 3rd SURGEON) to 159 open vertical banded gastroplasty-Roux-en-Y gastric bypasses (CONTROLS). Data for LRYGBP patients were prospectively obtained. Factors that significantly affected the length of surgery were identified by univariate and multivariate linear regression analysis. RESULTS: LRYGBP and CONTROL patients were similar in age, height, weight and BMI, although more CONTROLS were male. Median time for the 1st SURGEON performing LRYGBP dropped for each subsequent 100 operations: 1st 100 - 190 min, 2nd 100 - 135 min, 3rd 100 - 110 min and 4th 100 - 100 min. Median time for 2nd SURGEON performing LRYGBP was 120 min, 3rd SURGEON 173 min and CONTROLS 64 min. Length of surgery significantly correlated with surgical experience in terms of numbers of operations and BMI of patient. Times for 2nd SURGEON, a fellowship trained laparoscopic surgeon, started significantly faster than 1st SURGEON's, but did not significantly improve with experience. 3rd SURGEON's initial times were similar to 1st SURGEON's, but his times improved more rapidly with experience. Times for CONTROLS were significantly faster than all laparoscopic groups and did not correlate with operation number or patient BMI. CONCLUSIONS: The length of surgery for LRYGBPs continued to shorten beyond 400 operations for the first surgeon performing LRYGBP in our hospital. Previous fellowship training in LRYGBP shortened surgical times during initial clinical experience as an attending for the second surgeon. The learning curve was truncated because of the already established LRYGBP program.

Adult↗
PubMed2005

How much do surgeons like their patients?

OBJECTIVES: Physicians experience feelings of caring and sometimes frustration toward patients during routine visits. To date, no studies have explored surgeons' feelings toward patients. Our objectives were: (1) to examine how much surgeons like their patients and (2) to assess the relationship of surgeons' liking to patient and surgeon characteristics and to patient satisfaction. METHODS: Participants included 66 surgeons (orthopaedic and general surgeons) in community practice in Colorado and Oregon, and 701 of their patients. Exit questionnaires asked surgeons how much they liked the patient on a 1-5 scale ranging from "not at all" to "very much". Patients scored satisfaction with the visit on a 1-5 scale. Logistic regression was conducted with surgeon liking and patient satisfaction as dependent variables. RESULTS: Surgeons' ratings of liking ranged across all five categories. Patient characteristics including age over 65 years, higher education and income, and better health were associated with higher liking scores. Surgeon characteristics hours worked per week, practice setting and surgeons' self-rating of their own health were associated with liking. Patient satisfaction were associated with "liking". CONCLUSION AND PRACTICE IMPLICATIONS: These findings shed light on a rarely addressed issue-surgeons' feelings toward their patients. We found that surgeons do not like their patients equally. Their feelings are associated with surgeon and patient characteristics, and with patient satisfaction. Our findings have important implications for surgeons seeking to improve care striving to enhance or maintain their own career satisfaction.

Adult↗
PubMed2003

Surgeon specialty and provider volumes are related to outcome of intact abdominal aortic aneurysm repair in the United States.

OBJECTIVE: This study was undertaken to determine the relative importance of surgeon specialty, hospital volume, and surgeon volume on outcome after abdominal aortic aneurysm (AAA) repair. METHODS: Data were reviewed for 3912 patients undergoing AAA repair in the Nationwide Inpatient Sample during 1997. In-hospital mortality was compared between high-volume hospitals and low-volume hospitals and between high-volume surgeons and low-volume surgeons. High-volume hospitals performed more than 35 AAA repairs per year, and high-volume surgeons performed more than 10 AAA repairs per year. Vascular, cardiac, and general surgery specialization was identified by analysis of other procedures performed by each surgeon. RESULTS: Overall, AAA repair mortality was 4.2%, and was lower at high-volume hospitals (3.0%) than at low-volume hospitals (5.5%) (P <.001). Lowest mortality was associated with operations performed by vascular surgeons (2.2%) compared with cardiac surgeons (4.0%) and general surgeons (5.5%) (P <.001). Mortality rates were also lower for high-volume hospitals (2.5%) compared with low-volume hospitals (5.6%) (P <.001). In a risk-adjusted analysis, high-volume hospital, vascular surgery specialty, and high-volume surgeon were all independently associated with lower risk of in-hospital mortality. In this analysis, risk reduction was 30% for high-volume hospitals (95% confidence interval [CI], 2%-51%; P <.05) and 40% for surgery by a high-volume surgeon (95% CI, 12%-60%; P =.01). AAA repair by general surgeons compared with vascular surgeons was associated with 76% greater risk for death (95% CI, 10%-190%; P =.02). No significant difference in mortality was found between cardiac and vascular surgeons. CONCLUSIONS: High surgeon volume and hospital volume of AAA repair were both associated with lower mortality compared with low-volume providers. Increased specialization in vascular surgery was associated with markedly decreased mortality independent of AAA repair volume. Health policy in support of selective referral for AAA repair should consider surgical specialization in addition to provider volume thresholds.

Aged↗
PubMed1998

The effect of surgeon experience on velopharyngeal functional outcome following palatoplasty: is there a learning curve?

There is little information in the cleft palate literature concerning the relationship between surgeon volume and clinical outcomes. It is unknown whether such a relationship applies specifically to velopharyngeal dysfunction and the need for secondary physical management of the velopharynx. The purpose of this paper was to explore the concept of an operative learning curve for different surgeons with respect to palatoplasty. Impact of case volume and procedure type on the occurrence of secondary palatal management (the main outcome measure) was assessed. The charts of 472 consecutive palatoplasty patients were reviewed by one speech and language pathologist to determine when the palatoplasty was performed, which surgeon (n = 9) performed the palatoplasty, whether velopharyngeal status was documented at a minimum of 6 years of age, and whether secondary palatal management was prescribed. The results were analyzed by year of palatoplasty, by surgeon, and by number of operations per surgeon to determine total and individual surgeon rates of secondary palatal management. There were 401 palatoplasties (85 percent recovery) with adequate documentation of velopharyngeal status by at least 6 years of age. Palatoplasty rates ranged between 1 and 258 palatoplasties per surgeon. Over the 12 years reviewed, secondary palatal management was performed for 92 patients (23 percent) of the study population. Examination of the proportion of palatoplasty patients receiving secondary palatal management by surgeon and by year showed only one surgeon with a pattern suggesting a learning curve. The proportion of patients receiving secondary palatal management was plotted against the total number of surgeries the surgeon performed. There was a strong relationship between experience and success. The number of procedures this surgeon performed per year increased at approximately the same time as the success rate improved. The categories of "total procedures" and "procedure per year" were highly correlated with each other. Success rates were analyzed by number of procedures performed per year, and there was a clear association between the two variables. To separate the effect of the two variables, a multiple regression model was constructed. The category of "total procedures" was statistically significant in the model, whereas procedures per year was not, suggesting that the key to the dominant surgeon's improvement was cumulative experience rather than frequency of performance of the operation. Palatoplasties performed by high-volume surgeons are more likely to result in better postoperative outcomes (i.e., lower rates of secondary palatal management) as compared with palatoplasties performed by low-volume surgeons. The influence of the surgeon's cumulative experience on improvement seems to be more important than the frequency of performance of primary palatoplasty.

Cleft Palate↗
PubMed2000

Surgeon perspectives on surgical options for early-stage breast cancer.

To evaluate the practice patterns of general and plastic surgeons regarding patients with early-stage breast cancer, all general and plastic surgeons in Quebec and Maryland were mailed self-administered questionnaires evaluating surgeon demographics, practice patterns, treatment preferences, and satisfaction with the results of lumpectomy and radiation therapy or breast reconstruction. Response rates of 38.3 percent and 26.7 percent were obtained for general surgeons in Quebec and Maryland, respectively. The ratio of reported mastectomies to lumpectomies was 1:2 in Maryland and 1:5 in Quebec. All general surgeons considered lumpectomy an important option. Ninety percent of Maryland surgeons versus 44 percent of Quebec surgeons considered mastectomy important. A total of 53.6 percent versus 24.9 percent of general surgeons in Maryland and Quebec, respectively, considered delayed reconstruction an important option. Additionally, 81.3 percent of Maryland surgeons considered immediate reconstruction important, and 79.6 percent discussed it with all stage I or II patients. More than 75 percent of Quebec general surgeons reported discussing immediate or delayed reconstruction with < or =50 percent of these women. Response rates of 53.6 percent and 48.8 percent were obtained for plastic surgeons in Quebec and Maryland, respectively. In one year Quebec plastic surgeons reported that they performed less than half the number of reconstructions performed by Maryland plastic surgeons (7.2 versus 17.3). In Quebec, 82.3 percent of surgeons reported that they frequently discuss delayed reconstruction, 25.1 percent immediate, 62.5 percent pedicled TRAM, and 51.7 percent nonautogenous options. In Maryland, 74.3 percent of plastic surgeons frequently discuss delayed reconstruction, 95.7 percent immediate, 89.9 percent pedicled TRAM, and 85.9 percent nonautogenous options. For women with early-stage breast cancer, regional variations exist in the surgical options discussed and provided.

Attitude of Health Personnel↗
PubMed2006

Correlates of between-surgeon variation in breast cancer treatments.

BACKGROUND: Determinants of between-surgeon variation in breast cancer treatment utilization are not well understood. OBJECTIVES: The objectives of this study were to evaluate variation in receipt of surgical treatment (ie, mastectomy or breast-conserving surgery with or without radiation) for women with stage I, II, or III breast cancer and receipt of breast reconstruction attributable to surgeons, and to assess factors associated with this between-surgeon variation. METHODS: We surveyed all attending surgeons (n = 456) of a population-based sample of patients with breast cancer diagnosed in Detroit and Los Angeles during 2002 (n = 1844). Our analytic dataset linked data from 1477 patients with that of 311 surgeons. We used random-effects modeling to account for the multilevel dataset and evaluated 2 outcomes: 1) primary surgical treatment (mastectomy vs. BCS); and 2) receipt of reconstruction before being surveyed (yes vs. no). Independent variables included patient-related factors (clinical and demographic), surgeon-related factors (breast procedure volume, practice setting, and demographics), surgeon treatment recommendation, and referral propensity. RESULTS: Surgeons explain some variation in use of both mastectomy and reconstruction (9.9% and 26%, respectively). Patient clinical factors and surgeon volume together explain approximately one-third of the between-surgeon variation in mastectomy. Patient factors and surgeon demographics explain approximately 60% of between-surgeon variation in reconstruction, and surgeon referral propensity explains an additional 15%. CONCLUSION: Our findings suggest that similar patients may get different treatment depending on their surgeon. Broader dissemination of guidelines coupled with increasing patient access to consultations before definitive surgery may reduce between-surgeon variation. Contributing factors such as patient-physician communication should be explored.

Adult↗
PubMed2002

Beyond easy answers: the plastic surgeon and prenatal diagnosis.

OBJECTIVE: To explore how plastic surgeons handle the issue of prenatal diagnosis of cleft lip and palate. DESIGN: Mail survey. PARTICIPANTS: The plastic surgeon listed as team contact in the team directory of the American Cleft Palate-Craniofacial Association was identified. In cases in which a plastic surgeon was not listed as a team contact, the first plastic surgeon listed as a team member was identified. A total of 211 surgeons were contacted. INTERVENTION: Each surgeon was mailed a survey asking for his/her experience in prenatal diagnosis for cleft conditions. Ethical issues concerning the surgeon's personal beliefs about abortion and the potential influence of the surgeon's presentation of information were explored. RESULTS: A 50% response rate was obtained. Eighty-five percent of respondents were experienced in prenatal counseling; 92% offer consults on a routine basis. Ninety-six percent indicated they did so because they felt it was helpful to families. Treatment (98%), appearance of clefts (96%), cleft etiology (94%), and associated problems (40%) were discussed most commonly. Termination was rarely discussed (5%). Of those who had not met with a family, 82% said they had never been asked to do so. Most respondents felt families sought consultation for information and rarely sought consultation to decide on abortion. The majority felt their personal beliefs about abortion did not influence their willingness to meet with parents. The majority of surgeons in both groups felt it was ethical to give an opinion on pregnancy termination if asked (55% of experienced surgeons, 44% of inexperienced surgeons); however, a significantly larger number of the surgeons who had not met with a family were unsure of their opinion. CONCLUSIONS: Prenatal counseling of parents of a fetus with cleft lip/palate is common among plastic surgeons. There is uniformity in the information discussed. There is no agreement among surgeons about the ethical issues of pregnancy termination and the surgeon's role in that discussion.

Abortion, Induced↗