Who Is the Right Surgeon for Your Patient?
Health care in the U.S. is becoming increasingly subdivided and subspecialized. Neurosurgical care is no exception. An increasing number of neurosurgical graduates pursue additional training in the form of a fellowship in order to further perfect their surgical skills and develop expertise in a specific clinical arena. Two recent high profile examples have been the rise of endovascular and spine fellowships. Some studies have demonstrated that high-volume so-called “Centers of Excellence” are correlated with better patient outcomes. However, the relationship between surgeon training, in particular fellowship experience, and patient outcomes has not been established.
Hospitals and health care systems are subject to ever more scrutiny from accreditation bodies and patient safety organizations. One frequent target of close examination is specialty certification, such as Primary or Comprehensive Stroke Certification by the Joint Commission. A significant amount of money is at stake for hospitals in these certifications, which often detail which types of subspecialists must be on-staff and on-call at hospitals. The Leapfrog Group, a consortium that represents multiple large institutional stakeholders on the payor side, went so far as to insist that hospitals must staff their intensive care units (ICUs) with subspecialty-trained intensivists. In the aftermath of this recommendation, many hospitals closed their ICUs, denying many neurosurgeons the ability to write orders for their own patients who were admitted to the ICU. The AANS and CNS, working through multiple channels, did much to reverse this recommendation, working with the Leapfrog Group and other stakeholders. Nevertheless, the questions many neurosurgeons must ask with more frequency is, “Who is in charge of my patient?” “Who is the surgeon best qualified to take care of this patient?”
The Institution and the Surgeon: Are They Both Prepared?
Any neurosurgeon who regularly takes emergency room call knows that a call shift can deliver any type of patient to your door: a severe TBI patient, a spinal cord injury, a ruptured arteriovenous malformation (AVM) or a shunt malfunction. In academic medical centers and large tertiary care hospitals, general call is typically divided among all neurosurgeons, but the ultimate surgical disposition may be determined based on a specific surgeon’s subspecialty interest or training. For example, a ruptured aneurysm may come in overnight. The patient requires an external ventricular drain, which the on-call surgeon places overnight. In the morning, after reviewing the vascular imaging, he may hand off the patient to his partner, who is trained in open and endovascular techniques and who coils the aneurysm for dome protection. This is an argument for clustering neurosurgeons into high volume centers where each surgeon’s skills may complement those of his partners and all can work in general neurosurgery and also have particular niche practices.
But what about neurosurgeons who work in more sparsely populated areas? There are many neurosurgeons who maintain a vital practice by themselves or with one to two partners. Their hospital may have a basic ICU but not the other ancillary services associated with higher-volume centers (e.g. a biplane fluoroscopy suite for performing endovascular procedures). For those surgeons, what is the right decision for patients who come through their emergency department?
It is important for neurosurgeons to remember that patient outcomes are not simply a function of their technical prowess and clinical acumen. There is a myriad of other staff at the hospital that are involved in the care of critically ill patients, such as a ruptured aneurysm with subarachnoid hemorrhage. A surgeon must carefully consider the capability of his hospital before deciding to admit a patient for definitive surgical management. To use the ruptured aneurysm example again, while the lack of an endovascular suite does not necessitate immediate transfer (craniotomy for clipping is a reasonable option), there are a host of other factors to consider. Is the OR staff prepared to deal with a ruptured aneurysm case, in particular the event of intraoperative rupture? Is the ICU prepared to deal with a very ill subarachnoid hemorrhage patient post-op? Are the ultrasound technologists capable and comfortable performing transcranial Doppler ultrasound to monitor vasospasm?
The subarachnoid hemorrhage case is only one example of the importance of knowing not one’s own limitations but the limitations of the hospital when considering whether a complex case is appropriate to perform there. There are others: long segment scoliosis corrections with large amounts of blood loss, high post-operative complication risk and the need for intensive physical therapy and rehab. Large skull base tumors may need a great deal of intensive care unit attention post-operatively, with percutaneous gastrostomy tube (PEG) and tracheostomy requirement, and neurology consultation for neurologic sequelae for seizure management.
It remains to be seen whether the current tide of consolidation in health care is ultimately a positive one for physicians and their patients. Neurosurgeons historically have had a strong independent streak and have prided themselves on their technical skills coupled with clinical mastery of all aspects of patient care. Because of the robustness of our training, we are still in a strong position to maintain a prominent role in the management of all of our patients. We are still our patients’ best advocate as they negotiate an ever complex health care environment. But, we must be wise and know our own limits and the limits of our facility. It may be that some complex cases are best handled by one of our partners, who has more experience handling a particular disease process. Or it may be that, based on the resources at our disposal, that the best answer for a patient is transfer to a higher-level care facility for treatment by experts. The physician oath is primum non nocere, first do no harm. In many cases it may not be for lack of skill that harm is done, but a lack of resources and expertise within the hospital that leads to a patient’s demise. As neurosurgeons, we must always have our patient’s best interest in mind aside, and sometimes that means laying aside our ego even when we would love to tackle a very complex case.
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