Quality of surgery is variable

In Belgium we are having a discussion on quality of surgery and cost for the patient. At the University hospital gasthuisberg, patients were informed that for private patiens the Professor would do the intervention himself; otherwise it would be

done by a registrar in training. This has been widely considered unethical and socially unacceptable since equal quality for everybody is a dogma of Belgian medicine.  In a press release, the conclusion was that quality was the same for everybody since the registrars in training  were well supervised and since all gynecologist or surgeon are considered equal because of their diploma.

Unfortunateoly this is  not true and the quality of diagnosis and of treatment can be very variable for endometriosis, hysterectomy , myomectomy and pelvic floor surgery.  This is easy to illustrate for surgery and the examples given are restricted to comments made before during presentations or in publications.

Quality is variable

“We only recognize what we know ”. This is well known for the diagnosis of endometriosis. Even large and vaginally visible nodules are often missed during clinical exam. Even during surgery many severe deep endometriosis nodules of the sigmoid will be missed.

‘The best technique is the one the surgeon is familiar with  ”, is often heard at meetings . This is unacceptable.  If the superiority of a technique has been demonstrated, the surgeon should be obliged to use it.  The advantages of a laparoscopic treatment of an extra-uterine pregnancy in comparison with a laparotomy are well demonstrated. Yet so many women are still treated by laparotomy because the gynecologist on duty does not have the skills.

“Do the best you can ”  The many  advantages of a laparoscopic hysterectomy over a laparotomy are well demonstrated. Yet over 70 and in many countries over 80% of hysterectomies are treated by laparotomy.

“Medicolegal correct” is the median care by the median gynecologist. It is not the best available. Women should know this.

“The duration of surgery decreases with experience and skills of the surgeon”. A laparoscopic hysterectomy of an uterus of less than 500 grams takes less than 1 hour if performed by an experienced and skilled surgeon ; the same intervention by a registrar in training will take 2 to 3 hours. Knowing that time of recovery and postoperative adhesions increase with the duration of surgery, the quality is different.  In addition there will be differences in blood loss, in near mistakes and in repaired mistakes. Thus also fertility rates will be different 

 Lack of quality is often intentionally hidden.

Quality of surgery in the individual patient can only judged by vido-registration .  Years ago we pubblished that video-registration will increase quality of surgery and suimultaneously decrease cost of surgery.  Videoregistration should therefore be mandatory for reimbursement.  But video-registration is opposed by most gynecologist/surgeons by fear of medico-legal problems , of big-brother of by the possibility it might be used for intermittent re-qualification. It is even opposed by university and by thos in power since it could become clear that the oldest is not always the best, or that the better surgeon are often found outside the universities.

“No regular physical checks for surgeons.” In Belgium and in maost EU countries a qualified surgeon can loose 1 even two fingers … and 1 eye : the system will wait for an accident to stop him to do surgery.

Conclusion

The quality of surgery performed by the registrar in training will be less than the quality of an experienced surgeon

Quality of surgery varies widely even between experience surgeons : the omni-specialist is rare.

As a patient I would run a surgical check-list

How to solve this uncomfortable truth is another debate.

But if I would be minister of heath, I would start by making video-registration mandatory.

Philippe R. KONINCKX,   
Prof em OBGYN  KULeuven Belgium,  Univ of Oxford-Hon Consultant, UK, Univ
Cattolica, Roma, Moscow State Univ.