Gynaecologist & Endoscopic Surgeon

Avoid the low volume surgeon

I have just read an interesting article in relation to surgeon volume and outcomes in benign hysterectomy. The data, however, can be extrapolated to other areas of surgery.  The thinking behind the concept is not new and was famously discussed in Malcolm Gladwell’s popular book, “Outliers”.  He argued that 10,000 hours of deliberate practice is required for any skill.  It seems reasonably sensible that to obtain a skill with a repetitive technique be it surgery or landing a plane recurrent practice is required.  Qantas pilots for example need to land at least ten times a year to maintain their proficiency certificates.  It has been argued in many fields of surgery that higher volume surgeons have better outcomes and tend to operate in a more time efficient and cheaper fashion with fewer complications.  Whilst the data in the paper I have read is somewhat mixed and there are different definitions of high volume probably the main point is that low volume surgeons should be avoided as this is the particular group that have higher rates of complications.  They also tend to operate in a slower fashion taking up more time that could be used for other patients in busy operating environments.  The definition is difficult but by way of example the German gynaecological community have produced a document suggesting that high level laparoscopic surgeons should be performing at least 800 laparoscopic procedures over a 5 year period with specific directions as to the surgical procedures performed.

Increasingly I believe this type of thinking is likely to become the norm in Australia and credentialing and accreditation for procedures will have some form of volume assessment.  Within Australia a large number of obstetricians and gynaecologists remain as generalists doing low volume surgical procedures and this will create a problem for these surgeons.  I believe with the passage of time many of the low volume surgeons will find that their operative time is reduced and the number of patients they are seeing will fall such that they will be unable to maintain their credentialing.  The advent of group practices will mean that whilst individual surgeons may have limits as to what they can do, hopefully within a given practice or certainly within a particular hospital a large range of procedures will still be available for patients from different surgeons.

From a patient’s perspective, the point is fairly clear and obvious – avoid the low volume surgeon for your procedure.


Michael Cooper