Dr. Luis Quinonez's Weblog

What is the ideal number of cases a cardiac surgeon should do in one year to maintain competency? Estimates range from 100 to 200 cases. It may be argued that doing more cases will translate into better outcomes. However, I will question this assumption and state that there is a threshold above which improved outcomes and safety are compromised. I do not know what this threshold is, but I have chosen an arbitrary number of 400 cases per year as a starting point to put forth my arguments.

My arguments do not apply to the most advanced and specialized centers in the world. These I would consider as quaternary referral institutions. In these centers, the infrastructure exists such that a surgeon may perform 400 cases in one year without the limitations I will outline below. These clinics will have associates, fellows, advanced support staff, and infrastructure that make 400 cases per year for one surgeon safely possible. It also attracts and recruits surgeons and physicians with skill and motivation that are at the upper end of the bell curve. This essay applies to the rest of us.

If a cardiac surgeon performs 400 cases in one year and he/she works 48 weeks in that year (4 weeks off), then they are doing just over 8 cases per week. If an average daily case load is 2 cases per day, then the surgeon is operating 4 days in a week. This leaves one day for an outpatient clinic, continuing medical education, administrative responsibilities, and research (if applicable), assuming a “normal” working day and a 5-day week, excluding on-call duties.

Doing 8 cases per week over time, in my opinion, will lead to chronic physical and mental fatigue. I believe surgeons are trained and encouraged (not overtly) to ignore fatigue and it’s deleterious effects on performance. This “toughness” is rewarded during training by silent approval and the opportunity to do cases. It is later rewarded financially in a fee-for-service environment. This circumstance is further aggravated when on-call duties are taken into account. Some surgeons will operate the next day after having been up the previous night. This acutely fatigued state will aggravate the chronic condition. The negative effects of acute fatigue in the form of sleep deprivation have been clearly documented in medicine. I am unaware of research on the effects of chronic fatigue in medicine, but it is likely to have a similar negative effects. Much like flying an airplane, operating in a cardiac case is a very complex task, where fatigue will compromise the safe conduct of the operation, and potentially lead to an adverse outcome.

Operating is not only a technical act. It is not enough to just know how to operate, but also to know who to operate on, what operation to do, and how to deal with complications as they arise. These are the components of good surgical clinical judgment. Most, if not all, of the decisions about the patient and the operation should be made before one even enters the operating room, including how to deal with potential problems. This can only be done if the surgeon has the time to review thoroughly, completely, and in detail all the available patient data. In addition, the surgeon should have the time to think about the case and develop a plan. The key word here is time. If these intellectual components of surgery are not adhered to with discipline, then quality of care and patient safety are compromised. How can an average surgeon working at an average institution and doing 8 cases per week adequately prepare for a case? I do not believe that they can. To use the flight analogy again, flight planning is as important as the flying.

A surgeon who spends his or her time in the operating room will also not have much time to dedicate to the patients, either pre-operatively or post-operatively. How many patients complain that their surgeon is rushed and does not spend the necessary time to address their concerns? This happens much too often.

Surgeons are not only called upon to operate. They also have other responsibilities related to their profession. These include administrative responsibilities related to their own practice and the institution in which they practice. They also include continuing medical education or maintenance of certification. The latter, in particular, are exceptionally important to the well being of patients. In addition, research and teaching may be components of an academic practice. All of these aspects of a surgical career require time and attention to be done well, or to be done at all. I have directly observed, and experienced as a trainee, the negative effects of a busy surgical practice on research and teaching. I can only surmise the compromises being made to continuing medical education. A professional pilot is expected to have ongoing training and assessments of competency and time is allocated for these endeavours. We owe to our patients and trainees the time to stay current in our discipline. We are also obligated to be academically productive if we are in a University practice.

Most importantly, as human beings, surgeons should also have the time to spend with family and to pursue “hobbies”. This will make us more balanced individuals and in the long run happier people. This can only benefit our patients.

In conclusion, a cardiac surgeon who does 400 cases in one year may be compromising quality of care and patient safety, if they are working in less than a quaternary referral center. What is the ideal number of cases to maintain competency? What is the ideal number of cases to maintain proficiency? These numbers may be an issue for debate. However, it is clear to me that 400 are too many. A surgeon doing this many cases should re-evaluate their practice and perhaps offer younger surgeons more opportunities to attain and maintain competence, while at the same time enhancing the quality of care and safety of patients.

Posted by Luis Quinonez at 03:58 AM | Permalink

My last two weblog entries have created quite a hubbub. I will begin by saying that the opinions expressed in my weblog are my own and do not reflect the views of any institution with whom I am or have been associated. However, they are coincident with the views of some and are not exclusively my own. In addition, my writings reflect on my professional experiences over more that a decade. I have trained at different hospitals in Canada and the United States. The essays are a compilation of experience that may or may not reflect on a single place, person, or group.

Critics of my views on the adult CV ICU point out that quality care is being delivered by Intensivists. I do not disagree. My principal point is that quality care can also be provided by an appropriately trained Cardiac Surgeon. I believe that there are particular benefits to having a Cardiac Surgeon be an intensivist to his or her patient and these are outlined in the weblog. My point of view seems irreconcilable with some Intensivist's views, but it remains my opinion.

Interestingly, early on in my career I believed that surgeons could not be intensivists to their patients. This was my Canadian perspective. My views have changed given subsequent experiences in the United States. Rightly or wrongly, I hold Mayo and Cleveland as gold standards of excellence. I believe that trying to emulate what is practiced, thought and promoted at these two institutions has merit.

Posted by Luis Quinonez at 02:14 AM | Permalink

I believe that a well and appropriately trained cardiac surgeon is capable of delivering quality care in the adult CV ICU and that he should be primarily responsible for the management of these patients. The cardiac surgeon should not abdicate the care of his patients to the intensivist. The presence of an intensivist may be helpful in the CV ICU, but is not essential. It is erroneous to believe that the only way to acquire the experience and skills to care for CV ICU patients is by becoming and being an intensivist. How has it come about that intensivists at some institutions have gained control of the CV ICU? We have been neglectful and, perhaps, lazy. And now we have to deal with some intensivists that treat us with contempt and who undermine our authority.

I propose that cardiac surgeons understand cardiovascular physiology better that any intensivist. This understanding is essential for the competent, rational, and pathophysiologic-based care of cardiac surgical patients. Cardiac surgeons alter cardiovascular physiology in the operating room and experience it in a way that is more real than any ICU training or experience can provide. Cardiac surgeons also must be, and are, familiar with cardiovascular pharmacology, and see the effects of drug manipulation on the cardiovascular system first hand in the operating room. Of necessity, cardiac surgeons must also be familiar with hemostasis, ventilatory management, and fluid management, because these are relevant considerations in the operating room. These experiences in the OR translate to the CV ICU and the CV ICU is merely an extension of the operating room.

As the "Most Responsible Physician", the cardiac surgeon is the most motivated to ensure a positive outcome for his patient. If a mortality occurs it is the surgeon, not the intensivist, who is held accountable by Colleges, hospitals, and the patient's family. This results in a level of commitment to the patient that is not equaled by anyone else because, at the end of the day, the surgeon must stand alone to explain the outcome of the patient, good or bad. Others have the option of walking away, and many do.

Cardiac surgeons are also doctors. This means that they will have knowledge of the other body systems. This enables them to care of the whole patient in the CV ICU. However, the cardiac surgeon must realize that he is not expert in all body systems and should consult when appropriate. BUT, it is the responsibility of the surgeon to not blindly accept the advice of another consultant. Any new treatment must make pathophysiologic sense and should be applied taking into account the patient's history and overall condition. The surgeon should be willing to question the opinions of other consultants and is entitled to question the advice given.

The training of a cardiac surgeon should include the constant responsibility for, and primary care of, CV ICU patients so that enough experience is gained to care for these patients and the problems that arise. Operating on and caring for cardiac surgical patients in the ICU (and the ward) should be considered equal aspects of cardiac surgery. It is ALL cardiac surgery. This paradigm I experienced at the Mayo Clinic during my fellowship, where I also truly learned to care for CV ICU patients. I found my Canadian training to be deficient in this regard.

Critics of this model of care will state that cardiac surgeons are not able to be in the operating room and care for patients in the ICU at the same time. There are many practical arrangements that can solve this problem, such as hired intensivists that answer to the surgeons, resident coverage 24/7, and other cardiac surgeons being present in the ICU when their colleagues are operating. The primary surgeon remains responsible for the patient and determines the plan of care along with the details of such plan.

The same critics will argue that surgeons cannot be experts in ICU because they have not been trained as intensivists and they cannot keep up with the ICU literature. Training of a CV Surgeon has been addressed above. I would also add that overall training in ICU is not necessary because CV ICU is a niche where a cardiac surgeon, trained as mentioned, can gain enough experience to be competent at it. Much of the ICU literature does not directly apply to the CV ICU patient. What is more, the relevant ICU and CV ICU advances and controversies will likely be published in cardiac sciences literature, which will be followed by the surgeon. Resources, such as Literature Watch in CTSNet and SESATS can help keep the surgeon abreast of the significant advances in intensive care that apply to cardiac patients.

Intensivists will point out that cardiac surgeons are not capable or trained for a multisystem approach to the ICU patient. The reality is that the majority of cardiac patients have 1 or 2 system problems and most of them will have a brief ICU stay, and they can even be managed by a competent nurse practitioner or physician assistant under the direction of a cardiac surgeon. For the minority of patients that develop multisystem problems, the surgeon, by virtue his training and practice in the ICU, should be able to recognize these problems and request consultations in a timely and appropriate manner. What I must stress again is that the surgeon remains in control of the patient's care and should not blindly follow the advice of other consultants or relinquish to others the care of his patient. The surgeon is ultimately responsible and must ultimately decide what he feels is in the best interest of the patient.

Cardiac surgery is not only surgery, but also cardiac intensive care. They are one in the same. I do not agree with the fractionation of the practice. Sometimes we complain about the manner in which intensivists are managing our patients but we are not willing to re-establish our authority in the CV ICU.

Posted by Luis Quinonez at 04:34 AM | Permalink

I am back in Canada. As I get accustomed to the system again, I see how much I have changed and how different things are to me now, after having been to the Mayo and Cleveland Clinics. Things that seemed normal during my residency bother and shock me now:

The lack of professionalism (dress, informality/familiarity, impoliteness, disrespect); nurses calling in "sick"; intensivist that think they are the only ones capable of managing post-op cardiac surgical patients; OR delays and summer slow-downs; provincialism; doctors "treating trials" rather than using clinical judgement; entitlement; surgeons abdicating the care of their patients.

(Just to name a few...)

Although I am glad to be in Canada because of the public health care system, I am loath to accept these improprieties. These things, and many others, are not acceptable to me. But how can I change attitudes? How does one engender excellence? How does one create a culture of service to the patient?

Canadians doctors have much to learn from beyond their borders. Pierre Trudeau was one to look beyond Canada to improve it, and for this he was accused of being arrogant.

Posted by Luis Quinonez at 07:28 AM | Permalink

Boris Yeltsin died today. You may wonder, what does that have to do with Cardiac Surgery? He was 76 years old. That is 10 years older than my father and 14 years older than my mother. Again you may wonder, what does that have to do with Cardiac Surgery? Our family lived through political persecution and threats of death. We have been political refugees and immigrants. And we have embraced Canada as our home. During all that time we only had each other: immutable bonds forged. Still you may wonder, what does that have to do with Cardiac Surgery? From hard work and good fortune came success, personal and professional. So when my parents enter the twilight of their lives, where will I be? Unfortunately, not geographically close to them. And that has everything to do with Cardiac Surgery.

When I went to my "hometown" to inquire about a job in Cardiac Surgery, it was suggested to me that I return to do a fellowship year there. J'ai reculé. What could they possibly offer me?! After all, I had done my residency there and I was already doing a fellowship at the Mayo Clinic and wanted to stay another year. At that moment, I was not thinking of my parents. However distasteful that proposition was, it was an opportunity to stay on and be close to them in their latter years. I chose to continue at Mayo, closing that door. Obviously, this was the correct professional decision, but not the best personal decision. Now I am faced with the death of Boris Yeltzin, my parents' mortality, and our physical separation. I know they would not criticize me for this decision, but I hope they forgive me for it, because it had everything to do with Cardiac Surgery.

Posted by Luis Quinonez at 08:28 PM | Permalink

I recently passed my Canadian Royal College of Surgeons Fellowship Examination in General Thoracic Surgery. I finished my training in the field in 2002 and after an interlude in Cardiac Surgery, I went ahead and sat the exams. That I passed is not remarkable or worth writing about. What is notable is that I studied, mostly, from the internet, as a matter of convenience and somewhat of a challenge. What does this say about the future of medical education and the apparent unlimited resources on-line? For me, it substituted for the textbook. I was able to take the book's table of contents and research the topics on-line and get all the necessary, relevant, and detailed information necessary to pass the examination. I would caution others that might want to take this approach: I had already, although some time ago, read a standard book in General Thoracic Surgery and completed my residency. Therefore, I could discern what was garbage and what was useful; I had context to fall back on.

Although, all this may not come to a surprise to many, it says to some that unless the quality of the standard textbooks improves, why should they be purchased if the same information is available on-line. Authors and editors of these tomes should provide us with not only data and information, but also share their knowledge and wisdom. The latter two are sorely lacking in "modern" textbooks.

Posted by Luis Quinonez at 08:04 PM | Permalink

As a cardiac transplantation and ventricular assist device fellow I should be excited at the prospect of a new case of either type of surgery. For the moment, I can accept that transplantation is a good option for end-stage heart failure. However, I find myself questioning the wisdom of VADs as they exist today and in the foreseeable future.

I would point out that if the supply of donor organs were not limited there would be a dramatic decline in the need for VADs. And yet, there would still be those who would doggedly pursue what has been a holy grail in cardiac surgery: reliable and durable mechanical replacement of the human heart. I do not oppose such a goal, but I must question the application at the present time of what can only be described as mediocre technologies, with significant costs to the patient and society. Should we wait for the development of adequate technology supported by proper governmental funding?

Waiting has been problematic. Decades ago there was a stated US governmental objective to develop a mechanical heart replacement. However, this was not followed by sufficient funding for such a laudable goal. Instead, it has been left to the commercial sector to develop VADs under governmental oversight. These two facts have limited, and perhaps even impaired, the development of a reliable and durable pump. If computers would have evolved at this pace, we would still be using Commodore 64s. Hooray for the free enterprise system.

But why has the money not been put up by wealthy governments, like the US. I don't know. What I do know is that health providers and officials are lamenting the "epidemic" of heart failure in the US and other nations. Perhaps this has not been enough of an incentive to invest. So we are left with the pumps available to us today.

And what does this mean to the patient? It means highly invasive surgical procedures, bleeding, infections, strokes, re-opertions, pump failures, and limited survival measured in months. And all at a significant financial cost to the patient and society. This is of particular relevance to a public health care system such at it is in Canada.

Posted by Luis Quinonez at 01:20 AM | Permalink