Heart Health

“How Many of These Have You Done?”

April 20, 2009

“How Many of These Have You Done?”

Practice doesn’t make perfect, but it’s helpful

As I discussed a cardiac catheterization with a patient last week, she interrupted me to ask “How many of these have you done?”

It seems that every time I open a weekly news magazine or any one of a number of journals my wife reads (euphemism for O, the Oprah magazine) I find an article that aims to tell you how to handle your interaction with your doctor.  One of the hallmark points you’re supposed to nail down with your physician, whenever he or she wants to perform some procedure on you, is exactly how many of these surgeries he’s done.  Now don’t get me wrong about this—a doctor who has done only a few of these (or happened to catch the right episode of ER on TV) will certainly be more likely to botch the job than a doctor who performs the procedure on a regular basis.  But my question for authors of these articles is this: what, exactly, is a patient supposed to do with the answer?

As an example let’s take a couple of procedures I do.  A cardiac catheterization (also known as a coronary angiogram) is a routine procedure that is nothing more than a fancy x-ray.  The trick is to get the x-ray dye in the right spot before you take the picture.  To do this I put an IV-like tube into a large artery in either the arm or leg and pass a smaller but longer tube up to the level of the coronary arteries at the top of the heart.  This is obviously fraught with many potential complications (such as bleeding, clotting, and the uncomfortable anxiety that someone’s messing with sharp instruments down where the sun doesn’t shine) and you would obviously want someone very skilled at this.  I don’t know how many of these I’ve done, but it numbers somewhere in the thousands.

There is another procedure called a pericardiocentesis that I am credentialed to perform.  This constitutes draining unwanted and potentially dangerous fluid from the compartment that surrounds the heart and is usually something that needs to be done right away.  To do this I insert a needle very close to (but hopefully not into) the heart muscles and pull off fluid.  Whenever possible I try to enlist the assistance of a heart surgeon in this endeavor, but many hospitals these days don’t have heart surgeons on staff.  Additionally, a simple pericardiocentesis is probably a lot riskier than a complicated coronary angiogram.

In some circumstances, most qualified is better than no one

You’d probably feel comfortable having me do an angiogram, but what do you do when you need an urgent pericardiocentesis and I tell you I’ve done it no more than 20 or 30 times in my life?  Do you ask for another cardiologist?  Do you request transfer to a hospital with a heart surgeon and risk a delay in treatment.  Do you just suggest I watch season 3 of ER?

The problem here is that most cardiologists are just like me—limited experience with pericardiocentesis and not very excited about stabbing a needle toward a beating heart.  The procedure is so uncommon that in three years of cardiology training we are required to complete only a handful.  But even though the number I quote is 20 and not 2000, I’m still the most qualified person in some hospitals to perform the procedure and you’ll probably want me to do it.

Having said this, I still think it’s actually quite a good idea for you to ask your doctor how many times he or she has performed a particular surgery.  Why?  Because you remind him that it’s your body and life he’s dealing with.  Plus, I think you can tell a lot about a doctor by how he or she responds to this tough question.  If he becomes defensive and curt then you should probably find yourself another doctor.  Any decent doctor should be able to field challenging questions from his patients without suffering an ego bruising.  Finally, it’s the only way to find out your doctor has more experience than just watching Dr. McDreamy do it on TV.

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One Comment
  1. Avatar

    Jeff

    Eric, Great blog. While we don't want to get all caught up in the numbers, it is very important to recognize that in a number of procedural areas, "the more one does, the better they do it." Certainly in the realm of interventional cardiology where I practice, there is a firm recommendation by the American College of Cardiology, that a physician perform at least 75 procedures annually. At Alegent Health, we adopted that benchmark as part of our credentialling policy several years ago, and were the first hospital system in the city to do so. Volume was also a large part of the reason that we at Alegent Health made the very difficult decision to consolidate the Immanuel and Bergan Mercy cardiac surgical programs. This allowed us to concentrate all of these very important and complex surgeries on one hospital campus. The upside of this to the patient is that not only is the surgeon exposed to a large number of cases, but so is the OR staff, the floor nurses, the rehabilitation nurses, the pharmacacists, and the list goes on. We believe (and are supported by national data), that we can anticipate better outcomes for our patients through this consolidation. While we always need to put the patient at the forefront of our decisions, looking at numbers can sometimes be important as well.

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