These three key questions can transform healthcare decisions.
When one needs a serious medical procedure—the kind that can determine future quality of life or chances of surviving a disease—it can send one on a quest for the right surgeon and hospital. Who do other physicians recommend? Are there any public ratings of these physicians? And if so, how valid are they? What are the hospital’s mortality and complication rates? You and your loved ones can spend days seeking information to guide your choices.
Even after extensive research, you may still be unsure where to get care or want to confirm you’ve made the right choice. Rather than relying on magical or wishful thinking, these three practical questions can help move you in the right direction and increase the likelihood that a surgery will be a success and that you’ll avoid complications.
How many times has this surgeon or hospital performed the procedure?
Research has shown repeatedly that surgical volume matters: Patient outcomes are better, complications are lower, and the risk of death is less when a procedure is performed by surgeons who (and in hospitals that) have greater experience with it.
And yet, an analysis of 11 cancer procedures in California during 2014 found a surprising number were performed by hospitals that had done just one or two that year. This was the case in 63 percent of esophageal cancer surgeries and 48 percent of bladder cancer surgeries, for example. What’s more, the study found that 70 percent of the cancer patients in the one- or two-procedure hospitals needed only to drive 50 miles or less to find another hospital that was in the top 20 percent in volume.
What is an acceptable procedure threshold is up for debate, and it varies based on the type of procedure. Last year, three large academic health systems—Johns Hopkins Medicine, University of Michigan, and Dartmouth-Hitchcock pledged to meet what we felt were reasonable thresholds for major surgeries. We took a conservative approach, aiming to ensure that no surgeries were performed by doctors with annual volumes in the 20th percentile or lower. According to an analysis by John Birkmeyer, a general surgeon and researcher at Dartmouth-Hitchcock, just eliminating these low-volume surgeries would save 1,300 lives a year.
Few states publish surgical volumes for hospitals on the Internet, but for patients in California, this data is available for some procedures at calqualitycare.org. Hopefully more states will follow this model.
Is the intensive care unit staffed with doctors who are specially trained to care for critically ill patients?
After any major surgery, you can expect to spend some time in the intensive care unit. Yet not all ICUs are equal. Your chance of survival is 30 percent higher when the unit is managed by physicians who specialize in the care of critically ill patients. ICUs with this staffing model are known as “closed.” In an “open” ICU, care is overseen by various physicians who have significant duties elsewhere—perhaps the surgeon who performed your procedure.
Why is ICU staffing so important? First, critical-care specialists have focused training on how to heal patients in their most vulnerable state, when the risks of infections and other complications are high. Second, these specialists are constantly focused on management of ICU patients, while in an open ICU the physician overseeing their care might be down the hallway, performing another case in the operating room, or even in an off-campus medical office. They may conduct rounds on their ICU patients in the morning but depend on nurses to page them with updates or urgent requests at other times. Finally, when you have dedicated ICU physicians, they are more likely to standardize practices so that care consistently follows medical evidence and the entire care team works together in a more coordinated way.
To find out how a hospital’s ICU is staffed, simply ask them. You may also find it on hospitalsafetyscore.org if the hospital submitted patient safety data to the Leapfrog Group, a nonprofit that uses transparency to improve the health care system.
According to Leapfrog, of roughly 1,600 hospitals responding to its ICU physician staffing question, nearly 47 percent fully met the standard. Hospitals can meet Leapfrog’s measure either by having an intensivist on site at least 8 hours every day, or through a combination of 24-hour telemedicine and on-site intensivist time.
Does the surgeon invite conversations about goals, treatment options, and preferences?
Surgeons undergo years of training to hone their craft. They know what the evidence says about how to achieve the best outcomes and what steps will reduce the risks of harm.
But as a patient, you know your story: your goals for your care, your fears, the risks you are willing to take. The best physicians take the time to understand that story. They take your questions seriously and help you make informed decisions that work best for you.
This is not easy. It means that they not only lay out your treatment options, describe the procedure, and prepare you for care, but also engage you in a conversation. This might help you to decide which side effects or risks you are more willing to tolerate.
An example: When patients have a heart valve replacement, the surgical team will often decide against re-starting blood-thinning medications in order to reduce the risk of internal bleeding. Yet the bleeding risk must be balanced against the risk of stroke, which can be reduced with the same medication. In my role as an ICU physician, I have had complex conversations with patients about this risk, and sometimes they decide that they are more concerned about the stroke risk. Those patients get re-started sooner on the medication.
There is no perfect method for picking the best surgeon or hospital for a procedure. Still, by knowing the right questions to ask, we can make informed decisions that make the most sense to us and have the best chance of improving our health without magical thinking, based on solid data and personal comfort.
Peter Pronovost, MD, PhD, is the senior vice president for patient safety and quality at Johns Hopkins Medicine.