Know thy surgeon: the importance of surgeon-specific information.

In this issue of JGIM, Burge and colleagues describe their study to identify factors that predict the risk of permanent hypoparathyroidism after thyroidectomy.1 Their results include surgeries performed between 1988 and 1995 at four tertiary-care hospitals in Albuquerque, New Mexico. The principal finding was that persistent, postoperative hypoparathyroidism was related to the physician's speciality and to the patient's stage of thyroid carcinoma. Hypoparathyroidism developed in 29% of 31 patients who underwent surgery by an otolaryngologist and in 5% of 111 who underwent surgery by a general surgeon. Fifteen of 103 patients with thyroid cancer but 0 of 39 patients without thyroid cancer developed hypoparathyroidism. The finding that patients who undergo thyroidectomy for thyroid cancer have higher rates of hypoparathyroidism is not new; however, the finding that these otolaryngologists' patients had higher rates of hypoparathyroidism than the patients of the general surgeons is new and deserves closer review. The study's design involved retrospective review of medical records, which is appropriate for identifying risk factors for outcomes, including complications. The authors included many factors that could be related to postoperative complications, and their analytic technique demonstrated that the relation between surgical specialty and the development of hypoparathyroidism was unlikely to be related to other factors such as the presence of thyroid cancer. Given these findings, how can we interpret the study's results? The authors clearly state that other important features of the study must be kept in mind when interpreting the results. First, these findings come from one metropolitan area in the Southwest. Whether these results can be generalized to all otolaryngologists and general surgeons in North America who perform thyroidectomies is uncertain. Second, it has been shown for several surgical procedures, including coronary artery bypass grafting,2 and peripheral vascular surgery,3 that the development of postoperative complications is related to the number of procedures performed by the surgeon. The rate of complications decreases when the number of procedures increases. Unfortunately, the authors did not study the effect of case volume on the rate of complications for individual surgeons, although they did report the average number of procedures performed by the two specialties during the 8-year study period (3.1 for otolaryngologists and 4.1 for general surgeons). Also, the authors did not provide information about the surgical experience of the participating surgeons outside the study or the relation of experience to the development of complications. Third, the use of multivariate analyses does not completely ensure that the increased risk of postoperative hypoparathyroidism found for otolaryngologists was not related to another factor. For example, otolaryngologists operate on more patients with cancer than do general surgeons, and thus the apparent relation between otolaryngologists and hypoparathyroidism may result in part from the relation between cancer and hypoparathyroidism, despite an analysis that attempted to disentangle the two effects. Finally, although persistent postoperative hypoparathyroidism can be a serious problem, it must be kept in mind that all patients who developed hypoparathyroidism had cancer, which also is a serious condition, and the greater risk of complication may be related to a more aggressive operative approach that decreases the risk of cancer recurrence and thus improves survival. Despite these limitations, this study raises several important points. Risks of postoperative complications are surgeon-dependent; therefore, surgeon-specific information should be available to both patients and referring physicians. Physician-specific information is available for other surgical procedures, including cardiac revascularization procedures. Cardiothoracic surgeons voluntarily participate in a quality improvement program involving all procedures performed at the five institutions that practice revascularization in northern New England.4 This program provides physicians with information about their performance on a quarterly basis and informs patients about their chances for major complications and other important outcomes. The New York State Cardiac Surgery Reporting System is another data collection and reporting system intended to improve quality of care by reporting physician- and hospital-specific information.5 The Academy of Orthopedic Surgeons has developed a program to allow physicians to store and analyze data on patients' demographic characteristics, general health status, musculo-skeletal function, and resource utilization (the Musculoskeletal Outcomes Data Evaluation and Management System or MODEMS). This program also allows individual physicians to compare their practices with national norms. The second important point raised by this study involves the appropriateness of the surgeries that were performed. Previous research has shown that a significant number of surgical and medical procedures are done even though the benefits of the procedure are unlikely to outweigh the risks.6–9 The appropriateness of thyroidectomy was not examined in this study. The American College of Surgeons and the American Academy of Otolaryngology–Head and Neck Surgery could develop evidence-based, clinically useful guidelines for thyroidectomy, and these guidelines could be used to determine appropriateness.10 It is appropriate to conclude with the authors' own words: “studies demonstrating an improved outcome with one specialty compared to another should be interpreted with caution.” Who performs surgery probably is more important than the specialty to which the surgeon belongs, and therefore, it is important that patients, referring physicians, and health services researchers all know their surgeons.—Jay F. Piccirillo, MD,Department of Otolaryngology–Head and Neck Surgery, Washington University School of Medicine, St. Louis, Mo. REFLECTIONS Returning Nausea fills my stomach, my foot on the gas pedal, pity, guilt, love, sadness, as I venture past the familiar maple trees, and make the right turn at the convenience store to the white house with forest-green shutters. ”Hello, I'm home,” are the words which echo through the house, anticipating a response, silence, a sigh. The good old days, telling me to come home by 10:00 p.m., forcing me to drink my milk because it is good for me, praising me for getting A's, are now a part of the past. The figure before me stares out the window, occasional grunts, pain, pain, pain, frustration, extends from her body to mine. But I know she holds on to the familiar, the photos over the mantle, the overused blue couch in the living room, the paintings from my youth, her only hope. Occasional glances, a twinkle, a smile, is all I need, to know that I've had a good day. Now the State intrudes, wishes to take away her hope, her life, and place her body, in a sterile, unfamiliar room, which has no meaning. Her silent tears, although inaudible, cannot be muted by her inability, to express herself. I once resided in her womb. 9 months of aqueous bliss, oblivious to the world, but safe and secure, personal care, surrounded by the familiar. My mother must receive the same, our home, her womb, I reciprocate, to go full circle, around life. I fight for this. Sharon S. Lee Syracuse, NY