By SANDEEP JAUHAR, M.D
“Who should do this case?” That was the question a senior surgeon posed to me outside a patient’s room in the cardiac care unit. Judging by his expression, he already knew the answer.
The patient had a serious infection that had eroded her heart valve, rendering it “incompetent.” Fluid was filling up in her lungs, making it difficult for her to breathe. A helium-filled balloon pump had been inserted into her aorta, the main artery coming out of the heart, to support her low blood pressure, but her condition was deteriorating.
The senior surgeon explained that the patient had been referred to a young surgeon in his practice who had just graduated a year before. “Ethically, I’m not comfortable with him doing the case,” the senior surgeon said. “This lady’s mortality is already high, probably close to 40 percent. In his hands, it’s even higher.”
The young surgeon was obviously going to have to learn to do such cases, but he wasn’t going to start that day. The patient’s condition was too unstable, and even a small mistake could have had devastating consequences. The senior surgeon obviously appreciated his young colleague’s eagerness in seeking out referrals to build up his practice, but he and I knew that a junior surgeon wasn’t the best man for the job.
Every doctor’s expertise is earned on patients, but unfortunately, there is a learning curve.
How to protect patients while doctors learn is a conundrum faced in all areas of medicine. For example, studies have shown that surgeons’ outcomes improve up to four years after their first hospital appointment. Some have argued that neophyte surgeons during this period should take on only the most straightforward cases. Yet every doctor eventually has to perform a procedure for the first time.
A few weeks ago, a second-year cardiology fellow told me that he had taught a first-year how to pull out a balloon pump. “When we went in the room, the patient said, ‘You’re not learning on me, are you?’ And I had to lie and say: ‘No! He’s done this many times. We’re going to do it together. You get two for the price of one.’ That calmed him down. Then I had to talk the first-year through the entire procedure, pretending like I was explaining it to the patient.”
It isn’t only doctors who face this quandary. Hospitals too have their own learning curves. Medical teams work better together with practice. The first few cases of a new procedure frequently have subpar results.
In the early 1990s, a hospital in England introduced an innovative operation to correct transposition of the great arteries, a congenital heart abnormality in babies. Before this, newborns with this condition were treated with a palliative procedure that had poor long-term outcomes. Children at the hospital ultimately benefited from the innovation, but a heavy price was paid. The death rate for babies in the first few years was several-fold higher than with the palliative procedure. Commenting on the poor outcomes, a pediatric surgeon wrote that it was understood that “there would initially be a period of disappointing results.”
The question of how to innovate without hurting patients comes up in my practice. For example, as a heart-failure specialist, I have long wanted to provide left ventricular assist devices (LVADs) to my terminally ill patients. LVADs, such as the one former Vice President Dick Cheney had, are tiny rotor pumps made of plastic and titanium that piggyback onto the heart, pumping blood directly out of it and into the aorta, which transports it to the rest of the body. Most of my patients who require an LVAD say they would prefer to have it implanted close to home on Long Island rather than at the more established centers in Manhattan.
So a couple of years ago, we started an LVAD program for patients with acute cardiac shock. As the cardiologist on the team, I received two days of classroom instruction. My surgical colleagues additionally received animal training (they implanted the device into a calf).
We have now successfully performed the procedure on several patients. A few months ago, I treated a young man who had had a heart attack. His blood pressure was so low that his kidneys had stopped working. I called one of my surgical colleagues to put in an LVAD. He agreed to do it, but he asked me whether my patient wouldn’t be better off being transferred to a hospital that had more experience. “Do we have the best team in place to manage potential complications?” he asked. If it were your father, he said, what would you want?
And he was right. We have had good results with the few implants we’ve done. However, some centers in Manhattan do more than a hundred a year. Though our surgical teams are excellent, theirs are undoubtedly on a flatter portion of the learning curve.
I often wonder whether certain procedures should be “regionalized.” There is a positive correlation between a hospital’s surgical volume and its surgical mortality. For example, hospitals that do 200 or more coronary bypass operations annually have death rates nearly a third lower than hospitals with lower volumes.
But in American medicine, we believe in democracy. Any hospital can apply to be credentialed in a new procedure as long as it can demonstrate a need in the population it serves.
In the current economic climate, with ever-decreasing profit margins, many hospitals are trying to move into profitable surgical ventures. But we need to be careful. Hospitals have the right to innovate, but adequate protections such as expert supervision need to be put in place so patients are not harmed while doctors and institutions learn on them.
Sandeep Jauhar is a cardiologist and the author of “Intern: A Doctor’s Initiation”and the soon-to-be-published memoir “Doctored: The Disillusionment of an American Physician.”
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