Lessons learned from HPB surgery in Kathmandu, Nepal.

The article by Lakhey et al. [1] from the Tribhuwan Teaching Hospital in Kathmandu, Nepal, is a tribute to modern medicine, modern methods of teaching, and our current ‘‘flat’’ world of communication. Excellent state-ofthe-art results are no longer isolated only in the hallowed Ivory Towers of ‘‘true academia’’—whatever that is now. This article has shown us that excellent, even outstanding results can be attained with appropriate training, attention to detail, and, of course, dedication. In addition, this article should teach us that great HPB surgery is performed not just by surgeons in the high-visibility, ‘‘world-famous’’ university centers, but also by technically gifted, caring, thinking surgeons who are found worldwide, even at heights of 4,400 feet, like in Kathmandu, Nepal. Our current quest to determine the best benchmark for ‘‘quality’’ has focused (almost solely) on volume, e.g., Leapfrog [2–5]. Many smaller medical centers, often private-practice groups, have described their talents and published/exposed their often-outstanding results attained by talented, well-trained, often Fellowship-trained surgeons to the largely deaf (unbelieving or uninterested) ears of some third-party payers or group initiatives. Such results challenge the all-too-simple criterion of ‘‘case volume’’ as the only benchmark worth following. Indeed, many of the more broad-based scorecards, such as the National Surgical Quality Improvement Project (NSQIP) or other riskadjusted evaluations, warrant more notice and notoriety and allow possibly (maybe realistically) a more valid comparison of outcomes across often vastly different practices and patient volumes. Granted, volume-based decisions are, arguably, the easiest and possibly the most reliable single criterion; however, with this type of unilocular vision, smaller institutions that ‘‘deliver’’ truly quality care will be overlooked and inappropriately so! Another consideration mandates mention, i.e., VALUE. I work in an institution revered by many (and I believe rightfully so) as one of the best (and in our opinion arguably THE BEST) medical health-care delivery systems in the United States, and possibly the world—the Mayo Clinic. We have always prided ourselves as seeking the best quality of outcome. But even our visage has morphed. Our previous leadership changed the Mayo message from simply ‘‘Quality’’ to ‘‘Value’’ where Value = Quality/Cost. Indeed, discussion of value is quite timely. The 1970 s, 1980 s, and even 1990 s were financially glorious times. Technology advanced exponentially—spiral CTs, MRIs, PET scanners, and molecular diagnosis, but with these advances came the ever-spiraling upward costs of health care and the ‘‘charges’’ (expanded ‘‘costs) transferred to the patient or his/her health-care insurance policy to pay for this QUALITY (often defined by the TECHNOLOGY used). The turn of the century, the recent financial crisis, and current economic realists (despite their unpopular reputation in the naive lay public) have, however, reigned in (or attempted to rein in) this unbridled enthusiasm for an unconditional striving for quality at the expense of uncontrolled increases in the cost of health care. We simply cannot go on as we are—the bank is or soon will be broken, our health care system is broken, our congressmen and congresswomen are too caught up in preserving their own parochial survival, and all of this is occurring at the expense of an affordable, value-based health care system. So, what did I learn from this article from Nepal? (1) that excellent results can occur in lesser-volume hospitals with good doctors; (2) that truly cutting-edge diagnostics or M. G. Sarr (&) Department of Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA e-mail: sarr.michael@mayo.edu