Jessica is a 44-year-old G2P2 who has had one previous caesarean section and then a VBAC. She has had painful and heavy periods for the last three years that has failed to respond to a Mirena or ablation. Her uterus has been described as ‘10-week size, and well supported.’ With her gynaecologist’s advice, she agrees to a total laparoscopic hysterectomy (TLH). Jessica lives in a rural town, 1200km from the closest city. Her gynaecologist informs Jessica that she performs about eight TLH per year, and there is the option of her travelling to the city to have the surgery performed by a dedicated advanced laparoscopic surgeon.
Should Jessica consider staying locally, or should she go to the city? During the consent process, how should the gynaecologist inform Jessica regarding their surgery numbers and complication rates?
The medical world is becoming more subspecialised. We joke that sometime soon, you’ll only be credentialed to operate on either the left or right ovary. This push towards subspecialisation is based on the assumption that if you do the same thing over again, you will become better at it, hopefully an expert. Complication rates and outcomes will therefore be better for the patient. We appreciate and agree that there is medical literature to support this in surgery and gynaecology, and this concept has become famous in contemporary literature by Malcolm Gladwell in his book Outliers. Gladwell argues to become an expert, you need to do something for over 10,000 hours.1
One area in which subspecialisation has not thrived is rural and remote medicine. You have to do a bit of everything, because often the closest or next O&G is hours away, sometimes by plane. Even if all high-risk cases were transferred out, others may become perilous very quickly during surgery and present as an emergency, requiring immediate action.
In the case mentioned above, the rural Fellow has performed eight TLHs in the last year, likely a lot less than their subspecialist laparoscopic colleagues in metropolitan areas. However, as generalists it is highly likely they have performed at least another 10 total abdominal hysterectomies, more than 20 vaginal hysterectomies and repairs, as well as many other laparoscopic cases that include endometriosis resections. They have most likely lost count of the number of caesarean sections they have performed, many of them complicated. All the skills required for each of these surgeries cross over, such as tissue handling, anatomy and troubleshooting.
Rural Fellows often have to rely on themselves when things go wrong. In a rural hospital, they become experts at picking high-risk cases that are beyond their skillset and are able to ensure that the patient go elsewhere for surgery and care.
These concepts have also been made famous more recently in contemporary literature by the book Range: How Generalists Triumph in a Specialized World by David Epstein.2 The foreword to this book was written by Gladwell from Outliers who stated, ‘I enjoyed the experiences of being told everything I thought about something was wrong.’
For the case in discussion, we very much agree that the regional surgeon should tell the patient the number of surgeries they have performed throughout the year as well as the complication rates. We do this ourselves when consenting our patients and in particular, discuss our conversion to open rate, comparing this to our dedicated advanced laparoscopic metropolitan colleagues. Our experience is that the patients often choose to stay where they are, even if a procedure is needed, as they want family to be close for visits and for after care.
There are significant costs associated with needing to travel and stay in larger cities, both for the health system and the patient. Patient travel assistance schemes rarely cover all added costs. This includes lost employment time which can incur further expenses if multiple trips are needed for pre-operative, anaesthetics and surgical requirements.
Fitch et al previously found that rural patients in a tertiary hospital oncology unit would make informed decisions to elect treatment in the country where cancer outcomes may be poorer, but where they were able to have other needs met.3 Furthermore, if a complication occurs postoperatively, it is preferable that the patient is seen by their surgeon who will be aware of any difficulties encountered during the operation and have a higher index of suspicion of the likely cause. This becomes problematic if the patient has had their surgery at another location and then returned home. Being able to provide local continuity of care is emotionally and financially beneficial for the patient during the long-term postoperative period.
If a high mandated number of cases were required to remain credentialed for each procedure, our most vulnerable patients will miss out and be excluded from treatment. This would inevitably become one of our greatest concerns for the future. We know that some First Nations and rural women, for many reasons, do not want to and will not travel to a city, and will continue to suffer instead. We have seen this with the loss of tension-free vaginal tape in many rural areas. For women with lower socioeconomic means, the expense associated with travel to a high-volume surgeon excludes them from access to treatment.
We therefore agree that high volume surgeons have lower complication rates. However, rural gynaecologists often perform high numbers of all types of cases combined, but have low numbers for each individual procedure. They may have experience outside of gynaecology, as there is never a vascular surgeon or bowel surgeon easily accessible if difficulties are encountered. Their case selection is carried out very carefully in conjunction with their anaesthetic colleagues. Often more complicated surgery is booked when two consultants are in attendance to further minimise any risk. Therefore we would both be happy to offer local surgery to Jessica, ensuing she is well aware of our complication rate, and the alternative to travel to the city to see highly specialised and skilled doctors there.
In our opinion, most patients will want to stay with their family and support networks. They have faith in their regional O&G generalist ‘general’ skills. Their O&G most likely delivered their babies and may have even performed surgery locally. The town and regional area benefits from the surgeon retaining their skills and being able to offer the treatment to women who cannot afford, or don’t want to travel to the city.
We therefore urge policy makers, now and into the future, to look at the whole picture when credentialing surgeons. Considering a surgeon’s numbers for one procedure is like operating on just one ovary!