Assembly line versus take your time

[David M]

Yeah, most open inguinal surgeries are supposedly under an hour. I think the average for a shouldice is around 45 minutes. Lichtenstein is less than shouldice. Kang is less. Still, several of these could add up to a tired day.

I imagine the 12 hour surgery was almost certainly some other type of more complicated surgery.

• This reply was modified 7 months, 4 weeks ago by  David M.

[David M]

MarkT, While you are correct about projection being a part of my judgment concerning fatigue, I also had in mind this conversation between Dr Towfigh and her guest. I had even summarized this video in its thread. Check out the video at the 57 minute mark.

https://m.youtube.com/watch?v=RpulDqYVy5A&t=19s&pp=ygUKSGVybmlhdGFsaw%3D%3D

[David M]

Mark, you are correct that we are projecting somewhat. It really is still the opinion of some of us to be wary according to our own understanding.There is nothing wrong with that. It’s how people make decisions.

Surgeons are human and they most likely do get fatigued. And surgeons with good reputations are going to probably have more surgeries than they can handle. So, you will have cases where some of them are not doing the surgery from start to finish.

Your last paragraph seems to say that you want a balance between experience and volume. I think that is all that those of us who are somewhat wary of the highest volume surgeons also mean.

[MarkT]

There is no good reason to believe higher-volume surgeons are ‘fatigued’ or bored or less attentive or whatever than anyone else. That idea is based on your subjective opinions without any real evidence to back it up.

Some people are simply very passionate about their work, even if others do not find it exciting or would be bored with it after a while. Some people have a remarkable work ethic and are very diligent even when their work is somewhat tedious or taxing. Some people find repetition desirable and comfortable. Some people will tell you there is enough diversity in what seems like repetitive work that it keeps them on their toes and interested (there is a fair bit of diversity between human bodies and hernias).

Beware projecting your own thoughts and beliefs onto others. If someone does 8-10 surgeries a day, a few days per week (virtually no one is in the the ER all day long, five days a week) and has been doing so for a very long time, maybe ask them what their motivation is and how they stay sharp instead of not only assuming they must be ‘fatigued’ at the end of each day but that this fatigue correlates to some decline in proficiency or increased likelihood of mistakes.

I don’t think I would necessarily choose the ‘highest-volume’ surgeon if it looked they were simply trying to do as many as humanly possible for whatever reason…but I would rather have a high-volume specialist vs. someone only doing a few per week, and possibly doing multiple different things (like a general surgeon) so that they are actually only doing a relatively small frequency of YOUR repair.

[David M]

GI, your original post ended with this question:

“Why would you avoid somebody who has done hundreds or thousands of the same repair, ten times a day, for years? Doesn’t really make sense.”

I think I answered your question and gave you one of the reasons why a person might choose to avoid the highest volume surgeons. As such, I don’t see why you say it missed the point. Experience Is important, but it’s not the only consideration.

[Good intentions]

All of the issues raised here can be answered by your surgeon. If you don’t trust your surgeon enough to believe that they won’t hand you off to an assistant then you should probably find a different surgeon. Of course, most people don’t ask too many questions or they get evasive answers when they do.

Thinking back to my initial mesh implantation I should have paid more attention to my own misgivings about the surgeon as a person. He was too smooth in his demeanor, and did some things that made me wonder, like showing me a piece of mesh while saying it was not the type that he would be using but it was close. But I wanted to believe in a professional. I had already passed on a different surgeon in the same clinic because he seemed so unenthused about what he did.

So, this question really seems to boil down to trust. If your surgeon tells you he’s feel great at the end of a day of ten hernia repairs, within a week of 50 repairs, do you believe him/her? Conversely if your surgeon says that they only do two to three surgeries a day because any more is too many, do you believe that the third one is just as good as the first?

You can go round and round. But, back to the original point – experience leads to expertise. I’m not talking about fatigue. Or trust, or large scale hernia repair mills. Just the benefits of performing many surgeries on a regular basis. Would you rather have a Marcy repair by Dr. Kang or a Marcy repair by somebody who’s only done ten over the course of a year?

I have mentioned in the past that Dr. Billing said that trying to remove all of the mesh inside me, two sides, in one go was too much. Because he would get fatigued. So, he apparently knew his limits and didn’t try to exceed them.

[Alephy]

My doubt with high volume surgeons is that sometimes they only supervise the surgery, maybe jumping from one room to the other…I am talking about a hospital like environment. In this respect I would go for a low volume specialist as opposed to a bigger center. I got my first hernia repaired 20 years ago: I was supposed to have a surgeon the department chief, but it was an assistant who did it in the end. She reckoned the hernia was small enough that mesh was not needed. I believe the chief surgeon would have seen it differently probably. So sometime lower rank is better as it translates to more attention to the patient (the repair still holds, and apart for the first few weeks of careful movements I never had any problems)

[Good intentions]

How would a person seeking a surgeon evaluate the “fatigue factor”? The multi-persona person seems to go by gut feel. Can somebody suggest a number to use, some sort of break-point? Should a surgeon’s age be considered? Older people fatigue more easily.

The last statement in the post above, funnily enough, seems to have been written under the duress of fatigue (no offense, it really is kind of funny and it was late). The original topic isn’t about learning while fatigued. It’s not even really about fatigue. It’s about the experience gained by doing many surgeries of the same type.

Of course, my first post brings Dr. Kang to mind since that’s what the multi-persona person has implied in his/her posts. But it could also be applied to Desarda (Tomas) or any of the high volume lap mesh surgeons or any of the Shouldice Hospital surgeons. How many surgeries per week or day or month is too many? How old is too old?

Hearing a number and feeling like “that’s too many, they must be tired at the end of the day” doesn’t seem like a very precise way to choose.

[David M]

I get that experience is very important. But would you rather be operated on by an experienced surgeon of 2000 inguinal surgeries who is fresh and at his/her prime, or a surgeon of 5000 inguinal surgeries who is fatigued? I would choose the 2000 experience with a fresher mind and body.

I think even learning is more difficult when you are fatigued. So, there might not even be an experience advantage.

[Good intentions]

Stumbled across an article that seems relevant.

https://pubmed.ncbi.nlm.nih.gov/11711938/

Plast Reconstr Surg
. 2001 Nov;108(6):1618-23. doi: 10.1097/00006534-200111000-00029.
Anatomic variability of the ilioinguinal and genitofemoral nerve: implications for the treatment of groin pain
M Rab 1, J Ebmer And, A L Dellon

[Good intentions]

Thanks David M. The take-away from your point seems to be “get an early surgery time”. Not sure that the “tired at the end of the day” really applies to the point I was making. I was talking about experience leading to precise knowledge.

[David M]

There probably comes a point in the day where fatigue overtakes the diminishing returns of experience. I had thyroid surgery and they would say to choose someone who does at least 50 thyroid surgeries a year and 500 altogether. Beyond that, I assume you’re initially probably getting some benefit, but not as much.

Meanwhile, thinking about driving your car on a trip for 8 hours vs 2 hours. By that 8th hour, you’re going to be far more accident prone (sleepy, etc.) than you were on the 2nd hour.

Someone who does 10 surgeries a day probably has a good reputation, so there’s that, but one might question whether and why they are pushing against their limitations.

So, good experience and not being overworked probably both count.

[MarkT]

That’s not a ‘routine’ surgery though…a 12yr surgery would very much be an exceptional case.

[MarkT]

Interesting vid.

There is no doubt that long surgeries are taxing, but just as Dr. Towfigh states in that clip:

“You go into, like, your zen mode…I forget everything, I have no bladder, sensation, my thirst sensation is gone, everything is gone, I’m just focusing on surgery…(her guest then says “I’m the same way”)…I kind of like it, it’s kind of like our little country club, the surgery, operating room, and so on…’

This speaks to the attentional focus, the motivation, etc. that characterizes expert surgeons. She noted that she once had a 12yr surgery! No doubt that is quite physically and psychologically demanding and doing that every day would be challenging, but that is not the norm. I think we can imagine how comparatively ‘easier’ (still not ‘easy’!) it is to do a series of short, routine repairs where you do have some sort of natural break in between.

Note her guest mentions his ‘clinic day’ and how he ‘dreads’ it because he would much rather be in the OR. From that we know that he’s not in the OR five days a week, all day long…and two, he wishes he was, which again speaks to motivation. If he were unduly fatigued by his work, he would probably look forward to those clinic days 🙂

I do agree with your point that I’m looking for some reasonable middle ground though…although not really the ‘middle’, as I’m still tending towards high-volume specialists.

Unfortunately, we don’t know the magic number in terms of frequency and volume required to achieve a level of proficiency that correlates with the highest odds of having complication-free outcomes. I don’t doubt there is a point of diminishing returns that is below what the highest-volume folks are doing…but I would still err on the side of a high-volume specialist, because the skill/experience they have accrued is logically a positive, rather than a negative, in comparison to a generalist or someone who simply does have the same number of ‘reps’.