by Vik Reddy, MD, MHSA, FACS (@VikRReddyMD)
Case schedule: 1.) Right reverse sural flap for a 78-year-old man with an open distal third tibia fracture after an auto-versus-bicycle accident; 2.) Right orbital floor reconstruction for a 24-year-old s/p assault to midface; 3.) Forehead flap for 75-year-old male s/p MOHS resection of left nasal sidewall and left lower eyelid.
This was an afternoon OR schedule from over nine years ago when I was a new attending at an Academic Medical Center in Northern California. I have since moved on to a community hospital in the Metropolitan Detroit area. I think of that day often because it encapsulates what drew me to Plastic Surgery: operating from head-to-toe; having to approach cases in an analytic way; and, the lack of routine (I have never had that particular combination of cases before, and have not had them since).
Additionally, however, as I have become involved in Quality at the health system in which I practice, that day brings me to a concern I have been wrestling with: when does a plastic surgeon stop performing an operation? For surgeons in other fields, this may seem fairly straightforward: once you have decided what your niche is going to be, drop the rest. An orthopedic surgeon who focuses primarily on joint replacement may choose to no longer do upper extremity or trauma cases. A general surgeon who has decided on a practice which will be primarily breast can let others do hernia and gallbladder cases. For plastic surgeons, however, our training and scope of practice is so broad that it is the rare super-specialists who maintain a narrow focus.
From a Quality perspective, unfortunately, this puts plastic surgeons at odds with the push towards “high-volume” and routine. With the advent of the Joint Commission’s Ongoing Professional Performance Evaluation (OPPE), individual medical staffs are tasked with developing metrics that can track how physicians are doing. For a hospitalist, measures such as length-of-stay and readmissions are fairly straightforward. What will be my metric for an operation I may only do three times a year? An infection rate? A readmission? If I have one complication out of the three, should I be placed on probation?
I have not been able to answer these questions because there are operations which I am very comfortable doing, but I do not routinely perform (lower extremity flaps, latissimus dorsi flaps for breast reconstruction, facial fractures). From a Quality perspective, however, I have to ask myself if, for a specific procedure, I can attest that I have enough expertise that my outcomes will be similar to a high volume surgeon or center. Under that framework, I have had to come to the conclusion that I cannot comfortably say that free tissue transfer is still in my wheelhouse. I certainly do not do many, and the hospital where I chiefly operate at does less than a handful each year. This may seem like an easy decision to come to, but, like most of my colleagues, I do have a healthy ego, and the thought that I should abandon a technique I was trained in is difficult. For the benefit of my patients, however, I believe it is the right decision, and I would challenge my plastic surgery colleagues to ask themselves similar questions.