The majority of general thoracic surgical operations in the United States are performed by surgeons not specializing in thoracic surgery. [despite the fact that] Both general thoracic surgeons and cardiac surgeons achieve better outcomes than general surgeons.” Schipper et. al (2009).
Research has shown that speciality specific training contributes greatly to surgical outcomes, yet large numbers of surgeons persist in operating outside their area of expertise.
In fact, in the United States, the majority of thoracic surgery procedures are not performed by board-certified thoracic surgeons. Unfortunately, the majority of patients are uninformed about the different training and subspecialties among surgeons, and it appears that general surgeons are not hastening to inform them. While most patients are sophisticated enough to realize and understand that a general surgeon is not the best candidate to remove a large brain tumor, this does not apply to a lung tumor.
It is up to us, as patient advocates, and specialty practitioners to inform and protect the public. (Lest you consider this statement suspect due to self-interest – read the linked article, which reviews the body of literature comparing surgical outcomes in thoracic surgery among thoracic and nonthoracic surgeons.)
Why does this happen? As Wood & Farjah (2009) explain: (italics are mine)
“Thoracic surgeons are well aware of the apparent moral hazard that occurs in a community when a patient is referred to the local general surgeon for lung cancer resection but to the general thoracic surgeon if the patient is higher risk, is a “VIP” (health professional or relative, community or business leader), or if the patient demands specialist care. If high-risk or “important” patients benefit from operations done by thoracic surgeons, it seems likely that other patients will as well. This tacit understanding of the benefits of specialty care is obvious and is supported by research from Schipper and others, yet appears to be undermined by local factors that have yet to be confronted by hospitals, payers, patient advocacy groups, or policy makers.
Physicians referring patients requiring thoracic operations may prefer to direct a patient to a nonspecialist due to local politics and economics, potentially benefiting directly or indirectly if the patient is cared for within the same hospital or same medical group. Although many hospital credentials committees require specialty board certification to provide specialty care, this is often overlooked because of local traditions, reluctance to restrict or offend current medical staff, and concern about potential financial implications if lack of hospital “specialists” results in redirection of certain patients to a competing hospital.”
“National specialty societies representing surgeons are generally silent on the issue in an effort to avoid disenfranchising one or more of their constituencies. These well-intended but incongruous local incentives could be overcome by policy decisions by health care systems, payers, agencies evaluating quality, and government policy makers.”
Does local politics, local traditions and financial incentives to the referring physician seem like a good reason to refer a patient to an unqualified surgeon – when conclusive, and comprehensive data shows otherwise?
The Influence of Surgical Specialty on Outcomes
“STS: Lung Cancer Survival Best When Thoracic Surgeon Wields Scalpel” Dr. Farjah, “Using those figures, he estimated that “500 to 1,000 lives could be saved if all lung cancer surgeries were performed by board certified thoracic surgeons.””
Full-text article at Thoracic Surgery news – Dr. Michele Ellis on lung resection mortality by surgeon specialty.
8/24/2011 : after a telephone interview with Ilene Little, this story was highlighted at Traveling4Health, a medical site for consumers.