Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Is there a place for mediocre surgeon?
- Kamal Kumar Mahawar, Dr. Manoj Raja Natarajan (18 April 2003)
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The surgeon as a risk factor: there is more to it than volume.
- Harsh Grewal (18 April 2003)
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No substitute for efficient surgery
- Quentin A. Fisher (18 April 2003)
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Surgeon a risk factor
- mohammed shamim absar (19 April 2003)
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No substitute for efficient surgical training
- Saoji R. Rajesh, Udupa K. V. (19 April 2003)
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Reducing risk by improving surgical training
- Callum W McBryde, B31 2AP (22 April 2003)
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High cost of surgical failure
- Richard G Fiddian-Green (22 April 2003)
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Re: Is there a place for mediocre surgeon?
- Daniel R McGrath (23 April 2003)
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What would the patient choose?
- Daniel R McGrath, Allan D. Spigelman (23 April 2003)
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The influence of the surgeon on outcome
- Frank A. Frizelle, John Frye (29 April 2003)
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: Improving surgical performance at trainee level
- Beryl A De Souza (6 May 2003)
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Re: improving surgical training
- Richard G Fiddian-Green (7 May 2003)
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Importance of selection in surgical results
- Miles Fox (11 May 2003)
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Physician Experience Is An Important Determinant for HIV Positive Patients' Outcomes
- Alison Currie, Rak Nandwani, Consultant, GUM (3 June 2003)
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Kamal Kumar Mahawar, SHO General Surgery Caithness General Hospital, Wick KW1 5NS, Dr. Manoj Raja Natarajan
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Surgery is definitely a high risk profession and what a surgeon does or doesnt can easily be verified and examined. It does make surgeons feel very vulnerable. It certainly is not a nice feeling to work with a sword hanging over you all the time. I agree with the authors that a culture has to be evolved in which the system and not the individuals are held accountable for isolated mishaps.
We'll have great surgeons but we'll also have mediocre surgeons. It is unfair to expect every surgeon to perform and deliver like the experts in the field. The working conditions of individual surgeons can be vastly different and so are the results likely to be. Not everyone can be best. It should be enough if you just deliver your best.
Competing interests: None declared |
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Harsh Grewal, Associate Professor of Surgery and Pediatrics Temple University Children's Medical Center, Philadelphia, PA 19140, USA
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I think Mr. Carter's editorial is important and timely in the context of medical errors and the public perception of the professions of medicine and surgery. However, emphasizing that volume is the key predictor of surgical error, and inferring that a surgeon who has not performed a certain number of procedures is a riskier surgeon, is not supported by any controlled data. Competent surgical training, in my opinion, is a better predictor of competence and hence risk of error or poor outcome. Performance on a surgical simulator prior to an operation, much as a fighter jet pilot trains, may in fact be a better way of ensuring and predicting competence of a surgical procedure. Mandates that test surgical competence on surgical simulators, much like a pilot does before being licensed, may ensure better outcomes, then reliance on outcomes from flawed volume based databases that are poorly controlled for numerous other risk factors. Competing interests: None declared |
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Quentin A. Fisher, Professor of Anesthesia Medstar-Georgetown University Hospital, Washington, DC 20007
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Dr. Mahawar pointed out that “not everyone can be best” but then states that “it should be enough if you just deliver your best.” I disagree. It it too bad some surgeons so infrequently ask for help from colleagues when the surgery gets tough or they find themselves in unfamilar territory. I often tell friends who want to check on their surgical referral to ask the anesthesiologists. We all know which surgeons are more meticulous and efficient, and whose patients loose excessive blood or more frequently return to the operating room for complications. While it may be difficult to prove differences in outcome between the slower, sloppier surgeons, and the faster, more efficient ones, one repeatedly notices that patients who have less blood loss, tissue trauma, and briefer visceral exposures have smoother recoveries in the hospital and subsequent weeks. There is just no physiologic or pharmacologic substitute for efficient surgery. Competing interests: None declared |
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mohammed shamim absar, specialist registrar in surgery trafford general hospiatl,manchester
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Dear editor, Professor Carter has gently touched a smouldering topic in the surgical world.As a surgical trainee it is a bit frightening that surgeons form over one third of the referrals to the National clinical asssessment authority in England. It certainly is necessary that each surgeon should be assessed for his outcome and service provided on regular basis but as professor carter has suggested it is also necessary that the results are interpreted properly.this bring us to the next subject of continous training re- training .The system of regular training and regular update of skill should be incorporated as part of surgical practise.We should not feel bad to go through regular training programme as it is certainly going to become compulsory in the coming years. It is not uncommon to find surgeons who live and work in a world of their own and although not lacking in surgical skills are slightly out of touch with present practise. I am certain that in the near future this is going to be a subject of intense discussion as the public and goverment rightfully wants to know what they are getting.A very interesting and stimulating aricle. Competing interests: None declared |
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Saoji R. Rajesh, Senior Registrar in Surgical Oncology Tata Memorial Hospital , Parel, Mumbai, India 400012, Udupa K. V.
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We think Mr. Carter's editorial is important as public awareness about surgeon’s performance as a determinant of success is increasing. We agree with the authors that surgeons do not work in isolation and success depends on effective collaboration and team working. But I disagree with Mr. Mahwar that individuals should not be held accountable for isolated mishaps. Final responsibility always lies on the chief surgeon. We agree with the authors that referral to a high volume hospital does not guarantee that surgery will be performed by a high volume surgeon. But high volume centers are better geared up to manage surgical mishaps. There is always some efficient senior surgeon who is experienced in dealing with these mishaps and this is important in final outcome of the patient. We agree with Mr. Grewal that competent surgical training is a better predictor of competence. To assure quality control in newer technologies and specialized techniques, we think appropriate training at specialist centers should be made mandatory. From a residents viewpoint seeing and assisting competent seniors and being assisted by seniors in first few cases always helps to acquire newer skills with confidence and helping him to develop in a efficient surgeon. It always important to watch other surgeons, so that you can learn from their mistakes. We think that great emphasis should be given on surgical training to develop a efficient surgeon who will not be considered a “ poor risk factor” for surgical outcome. Competing interests: None declared |
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Callum W McBryde, Senoir House Officer, Orthopaedics Royal Orthopaedic Hospital, Birmingham, B31 2AP
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Dear Editor, Professor Carter’s editorial states that the determinants of surgical skill are “technical skill…thorough training, compassion, sound judgement, good communication skills, honed clinical skills, knowledge…and team working.”[1] As a junior surgeon I agree entirely with this assessment of the ingredients for success and I suspect so would members of the public. With the reduction in the hours worked by trainees and the reduction in the length of training from medical school to consultancy the development of these skills is under threat. In a time of increased scrutiny on surgical performance it is essential that these areas are highlighted during training and addressed with some urgency prior to the CCST being awarded. At present there is a great emphasis on both SHO’s and SpR to produce publications and these are often of varied quality and completed at the expense of time seeing patients. At present, short-listing prospective surgeons for interview to the next stage of their career invariable the determining factor is the quantity of peer-reviewed research completed. There is no doubt that an awareness of research and audit should also be an essential skill for any doctor. However, in order to reduce the risk to patients by surgical intervention perhaps selection criteria should be more heavily based on those skills mentioned by Professor Carter and less emphasis placed on research. Research has a place for junior surgeons but a balance needs to be struck between producing research in order to get shortlisted and producing research to improve ones skills and knowledge. If we are going to produce new consultants in less time the risk to the public could be reduced by improving the standard of training and emphasising throughout those skills mentioned by Professor Carter. Callum McBryde MRCS
Competing interest: None 1 Carter D. The surgeon as a risk factor. BMJ 2003;326:832-3. (19 April) Competing interests: None declared |
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Richard G Fiddian-Green, None None
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Multiple organ failure, the commonest mode of death in patients dying from complications from major elective surgery, is for hospitals extremely costly and for relatives and loved ones an extremely distressing form of death. Most patients remain in the ICU intubated, often with a trachesotmy, with multiple intravenous lines, nasogastric tube, drains and a urinary catheter until their deaths. In Mythen and Webb's study of patients, mostly having cardiovascular operations, at the Middlesex 48% of the total costs of postoperative care in all 51 patients was accounted for by the seven who deveoped and died from multiple organ failure (1). Disability caused by the strokes complicating carotid surgery, addressed by Professor Sir David Carter (2), may be much more costly for trusts and distressing for relatives. Both events are consistently avoided by some surgeons and not by the majority (3). What is the cost of these complications to a hospital and how much can a hospital afford to hire new staff and buy new equipment if they are to reduce the complication rate to 0%? The following estimates of the costs of developing and dying from multiple organ failure have been made from Mythen and Webb's data obtained from patients mostly having cardiovascular operations (1). In the analysis of the data it has been assumed that the cost of postoperative care for a patient who does not develop a complication is #10,000 (#=POUND). Estimates of the cost of developing strokes after carotid surgery have been made by assuming that each of the patients will require rehabilitation or institutional care for an average of two years at a cost of #200/day. The risk of dying, usually from MOF after oesophageal surgery in the recent analyisis of data from 29 NHS hospitals varied from 0% to 50% with the mode or median being 12% (3). Similar variations can be seen in patients having other large operations such as a pancreaticoduodenectomy but may also be seen in patients having elective colo-rectal surgery in the NHS especially in those patients admitted from the A&E. The risk of stroke or death after carotid endarterectomy in the hands of different surgeons also varied between 0% and 50% in the data reviewed by Professor Sir David Carter but the numbers of cases performed was often less than 5 (2). Risk MOF Stroke 0% #10,000 #10,000 2% #11,200 #12,600 4% #12,400 #15,200 7% #14,200 #19,100 12% #17,200 #25,600 20% #22,000 #36,000 50% #40,000 #75,000 How much money can be spent by a trust if it wishes to reduce its complication rate to 0% and thereby reduce the average cost of care for an oeshophagectomy or cardotid endarterectomy by 50%? The following estimates are expressed in extra pounds that could be spent for each operation done. Present risk MOF Stroke 50% #15,000 #32,500 20% #6,000 #13,000 12% #3,600 #7,800 20% #6,000 #13,000 50% #15,000 #32,500 Several conclusions can be drawn from these back-of-an-envelope calculations. 1. An NHS trust with poor results can afford to pay the staff they need to improve cost-effectiveness a large increment above their base pay. 2. The value of a surgeon/team able to achieve a low morbidity and mortality increases as the variation in standard of care between hospitals and/or surgeons increases. 3. The value of a vascular surgeon/ team able to avoid strokes after a carotid endarterectomy is much greater than that of a cardiovascular or general surgeon able to avoid the development of MOF. 4. The greater the variation in standard of care the greater the desirability of referring a patient to a surgeon/center known to be able to achieve superior results consistently. It is, as Professor Sir David Carter points out, extremely difficult to know how good or bad a surgeon is even if one holds regular morbidity and mortality meetings. As Quentin A. Fisher, Professor of Anesthesia at Medstar-Georgetown University Hospital, Washington, DC points out in his rapid response it is often the anasesthetist who knows best. This is especially true if they also care for the patients in the ICU. Even then it is only an impression. It indeed takes a career to develop a meaningful database for uncommon operations such as an oesophagectomy or carotid endarterectomy as Professor Sir David Carter suggests. From the logistic regression analyses I have done, however, an analysis of all cases done by the same surgeon appears to be a meaningful surrogate. The anatomical location of the operation done in my unpublished analyses was not found to be an independent risk factor. Unfortunately what is included in many of the standard texts are practices that many have abandoned which brings into question the technical and clinical competence of many authors even if they are well known. What is also included are the data from series performed by well known surgeons whose results many would consider unacceptable in this day and age. It is easy, therefore, for a trainee and even for a consultant who has not kept up with developments to accept complications and even deaths as an inevitable part of doing "big cases" and to ascribe them to the "co-morbidities" present. It is equally easy for cases who would benefit from surgery to be turned down for similar reasons. An important step in improving cost-effectiveness is, therefore, to ensure that the surgeon, theatre sister, and anesthetist know what standard others are achieving. Many have the ability to achieve excellence consistently and the need to train registrars should not be an impediment (4). Achieving excellence consistently is a function of many technical and clinical variables many of which are acquired from one's own and others' experiences. Most of these "tricks" are not even mentioned in the standard texts. None has been the subject of a prospective randomised study nor will it ever be. There is no substitute, therefore, for the opportunity of discussing, watching and if necessary working with surgeons who have been able to obtain superior results in acquiring new "tricks". It is, however, extremely difficult if not impossible to teach old surgical dogs new tricks. It may, therefore, be much more cost-effective for a poorly performing trust to pay premium prices to recruit and hire a new surgeon who has been able to achieve superior results and give him/her the opportunity to hire and fire their own scrub-nurse, anesthetist and supporting staff in achieving a 0% morrtaity for all major elective operations. Given the right team and the proper support I see no reason why it should not be possible to turn a poorly performing hospital into a premier one within two to three years. These figures may provide the financial incentive to do so even if that includes paying for early retirement for exiting staff to make way for the new appointments. Dr Foster has yet to publish outcome data for emergencies other than for fractured hips. The likelihood that the outcomed are alarmingly poor. If so the financial incentive for NHS trusts to implement radical changes may be very much greater. 1. Mythen MG, Webb AR. Intra-operative gut mucosal hypoperfusion is associated with increased post-operative complications and cost. Intensive Care Med. 1994;20(2):99-104. 2. The surgeon as a risk factor David Carter BMJ 2003; 326: 832-833. 3. Only one standard: 0% morbidity and mortality Richard G Fiddian-Green (16 April 2003) Rapid response to : Mortality control charts for comparing performance of surgical units: validation study using hospital mortality data Paris P Tekkis, Peter McCulloch, Adrian C Steger, Irving S Benjamin, and Jan D Poloniecki BMJ 2003; 326: 786-7884. 4. Praseedom RK, Paisley A, Madhavan KK, Garden OJ, Carter DC, Paterson- Brown S. Supervised surgical trainees can perform pancreatic resections safely. J R Coll Surg Edinb. 1999 Feb;44(1):16 Competing interests: None declared |
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Daniel R McGrath, Lecturer, Surgical Science University of Newcastle, Australia
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Dear Dr. Mahawar: If there is a place for the mediocre surgeon, it is unlikely to be approved by the General Medical Council or the general public. Competing interests: None declared |
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Daniel R McGrath, Lecturer, Surgical Science University of Newcastle, Australia, Allan D. Spigelman
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Dear Sir: Patients with rectal cancer however, may be less inclined to choose a low volume surgeon who is twice as likely to perform an abdomino-perineal resection than the highest volume surgeon 2. 1. Carter D. The surgeon as a risk factor. BMJ 2003; 326: 832-3. 2. Spigelman AD, McGrath DR. The National Colorectal Cancer Care Survey. Australian clinical practice in 2000. Melbourne: National Cancer Control Initiative, 2002.
Competing interests: None declared |
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Frank A. Frizelle, Professor of Colorectal Surgery Christchurch Hospital, New Zealand, John Frye
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Professor Carter’s Editorial is an interesting assessment of the various determinants involved in surgical outcome (1), however the surgeon is not a factor in isolation but is one of many complexly inter related factors in determining surgical outcome. While surgical care and surgical performance from the patient’s point of view is more focused on a very identifiable individual – the surgeon – more than perhaps in other fields of medicine, one should remember that is in fact an illusion. With the focus on surgeons technical skills and decision-making, it is important not forget that surgeons don’t work in isolation. Surgeons in looking for good results are attracted to centres that get good results. Good surgical results are the result of multiple factors which are interdependent including anaesthetics, intensive care, medical, nursing and paramedical support, and a culture in search of excellence. The most significant progress in the surgical management of patients in the last one hundred years has been in regard in regard to the non- operative components of surgical care; ie, anaesthesia, antisepsis and asepsis. Surgeons were regarded as “savages with knives” and the surgeon’s ability was really considered a significant factor in outcome. With the surgeons fame rested on his dexterity, precision and speed. These days despite the claims of Professor Carters the surgeon is less important than ever before with realisation that it is the systems in which we work that lead to best outcomes. Just as all credit for success should not attributed to the surgeon, nor should the failures. Surgeons and patients do like to think the surgeon as the most important ingredient in the surgical outcomes cake, and therefore it is perhaps not so surprising that surgeons account for a large number of referrals to the National Clinical Assessment Authority in England (2) and similar Health and Disability Commissioner in New Zealand (3). The focus on the individual surgeon however is often a shortsighted and simplistic assessment of the situation. Technical skill although very important can’t overcome poor case selection or inappropriate indications for surgery. It is the structure of the clinical systems put in place within a clinical team and the culture of the unit that can help ensure the correct clinical decisions are made. As we have previously stated “(those with) more experience in their particular field may have a wider range of operative and non-operative approaches available than less experienced units and may also have more subspecialist resources available within the unit for improved decision making pre and post-operatively. Units with the benefits of better support of auxiliary surgical and medical services may also show improvements in their figures which reflects the multi-disciplinary nature of modern surgery.” (4) If you take a surgeon with excellent clinical results and transplant him into a situation were the results are poor then it is unlikely that the change of surgeon alone will produce a significant change in results. While the surgeon is a statistically significant independent variable in outcome, they are unlikely to be a clinically significant variable. The ability to improve the outcome in a centre with poor results by changing the surgeon alone, is managerial in its simplicity. To isolate the surgeon as the most important factor is too simplest and fails to recognise the real complexity of issues involved of surgical outcome, and makes the same mistake that league tables do. 1. Carter D. The Surgeon as a risk factor. BMJ 2003; 326: 832-3 2. White C. Surgeons top number of referrals to assessment authority. BMJ 2002; 325:235 3. Compliants Resoluction “Resoluction not retribution”. http://www.hdc.org.nz/complaints/index.html (accessed April 23, 2003) 4. FA Frizelle, JN Frye. Assessment of outcome is complex. BMJ 2003 URL http://bmj.com/cgi/eletters/326/7393/786 (accessed April 17, 2003) Competing interests: None declared |
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Beryl A De Souza, Plastic Surgery Registrar Chelsea and Westminster Hospital, 369 Fulham Road, Chelsea SW10 9NH
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Professor Carter's editorial (1) summarises succinctly the work of the surgeon and outlines the determinants of surgical performance. As a surgical trainee I have found it most important to have good communication skills to be able to explain the need for an operation and to obtain informed consent. This combined with empathy and compassion is equally essential. Clinical judgement becomes easier with increasing experience and if one is allowed to make decisions and verify these with Seniors very early on in training it makes for a more confident approach to problems. To learn the craft requires a lot of operating practice and clinical knowledge is fundamental. Assisting at different operations, attending masterclass courses, visiting units to learn a particular operative technique should be part of training. I have found it useful to write short notes after assisting at key operations and to supplement this with an intraoperative digital photograph. It is vital to follow patients through post-operatively and in the outpatient clinic as this constitutes good patient care but this becomes increasingly difficult with curtailment of junior doctors hours. Training in different units gives juniors the chance to see a varied case mix. It may give the opportunity to see the same operation performed differently. With the added benefit of seeing the outcome to make one's own conclusion as to the best operative technique. Finally, to be able to reduce risk and work as a team, it is a useful exercise for juniors to be involved with administration and audit - particularly of outcome. Developing teaching programmes for other juniors and nursing staff with regard to care pathways and guidelines for good surgical practice forms the foundation for management skills and should be encouraged by seniors early on in training. Competing interests: None declared |
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Richard G Fiddian-Green, None None
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The mortality in 573 carotid endarterectomies performed over 23 years [average of 23 cases/year] at the John Radcliffe Hospital in Oxford was 0.8% and the perioperative neurological deficit rate was 6.9% (1). Nerve injury was common, 5.1%. The senior author, Professor Sir Peter Morris, was the Nuffield Professor of Surgery and is presently President of the Royal College of Surgeons. In 35,821 similar operations performed in hospitals in the US the mortality was 0.44%, 0.63% and 1.1% for low (<10/year), medium (10- 29/year) and high (>30/year) volume surgeons respectively and the postoperative stroke rate was 1.14%, 1.63% and 2.3% (2). If the surgeons in Oxford are classified as medium-volume surgeons then their mortality, 0.8% was equavalent to that in the US, 0.63%, but their stroke rate, 6.9%, was four approximately four times higher than that in the US, 1.63%. This difference does not seem to be a reflection of more honest and accurate reporting for the nerve injury rate, 5.1%, was equally high. The nerve injury rate, which were not reported in the US experience, is an unequivocal measure of suboptimal technique. If carotid endarterectomies could be performed in the NHS with a stroke rate of 1.63% rather than 6.9% the cost of carotid endarterectomies could fall from an estimated £19,100 per case to £12,600 per case (3). There was no difference in outcome between carotid arterectomies performed by registrars and those performed by consultants in the Oxford study. In a study of upper gastrointestinal surgery performed in Edinburgh the finding was the same, outcome from operations performed by registrars being no different from those performed by registrars (4). The same applied to the results of pancreatic operations performed in the same institution in Edinburgh (5). The government might in its zeal to contain the rising costs of healthcare be tempted to interpret this evidence as justification for shortening the training of registrars and making them consultants without the right to do private cases as soon as they have completed their training. That would be unwise for upon closer examination of the data the subgoup of 19 patients whose pancreatic operations were performed by supervised trainees had the lowest anastomostic leak rate and no mortality. Why then are the results of surgery performed by select surgeons in select hospitals in the US apparently so much better than the results in the NHS? Might it be that supervising trainees, as is almost routine in the US, is the best way to do surgery? Is it that British surgeons are not as good as US surgeons even at the John Radcliffe which is said to be the best staffed in the country? Whatever the reasons the government would be well advised to take a much deeper look at surgical training and manpower requirements than it has done to date. Reducing the high costs of surgical failures must be seen to be one of the highest priorities in containing the rising costs of care. Professor Mortensen's plea in yesterday's The Daily Telegraph for additional funds to purchase laparoscopic equipment at the John Radcliffe misses the point. The experience with biliary surgery in San Francisco, due to be reported by Larry Way at the Society of Surgery for the Alimentary Tract, suggests that laparoscopic surgery might be adding enormously to the costs of care because of a lowered threshold to performing surgery and higher complication rates. 1. Hussain T, Senaratine JW, Green FR, Collin J, Hands L, Morris PJ.Vascular surgical society of great britain and ireland: twenty-three years of experience of carotid endarterectomy Br J Surg. 1999 May;86(5):690 2. Cowan JA Jr, Dimick JB, Thompson BG, Stanley JC, Upchurch GR Jr.Surgeon volume as an indicator of outcomes after carotid endarterectomy: an effect independent of specialty practice and hospital volume. J Am Coll Surg. 2002 Dec;195(6):814-21. 3. High cost of surgical failure Richard G Fiddian-Green (22 April 2003) The surgeon as a risk factor David Carter BMJ 2003; 326: 832-833 4. Paisley AM, Madhavan KK, Paterson-Brown S, Praseedom RK, Garden OJ. Role of the surgical trainee in upper gastrointestinal resectional surgery. Ann R Coll Surg Engl. 1999 Jan;81(1):40-5. 5. Praseedom RK, Paisley A, Madhavan KK, Garden OJ, Carter DC, Paterson- Brown S Supervised surgical trainees can perform pancreatic resections safely. J R Coll Surg Edinb. 1999 Feb;44(1):16-8. Competing interests: None declared |
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Miles Fox, Consultant Urologist (retired) Retired
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Selection is one of the major factors in the result of higher risk surgery, which is referred to only cursorily in the last sentence of Professor David Carter’s article (BMJ 19th April). To deny surgery with opportunity of cure to a patient with, say, a mortality risk of 30%, is likely to be turned to 100% if he or she be sent home or die elsewhere. The surgeon’s mortality figures and hospital league table results will thus remain unblemished, star rating and better funding unaffected! Rigorous and adequate training, strict selection and junior support are the undisputed keys to create consultant professionalism which should be unfettered by central control with restrictions and directives, thus creating contented surgeons not resigning in droves by the time they reach 60. Freedom with autonomy have their dangers but professional satisfaction and fulfilment becomes reflected in results and also excellence, which cannot be achieved with restrictive levelling out of socialist practices. Miles Fox MD ChM FRCS
Competing interests: None declared |
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Alison Currie, SpR GUM Sandyford Initiative, 4-6 Sandyford Place, Glasgow, G3 7NB, Rak Nandwani, Consultant, GUM
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Carter’s recent editorial (1) highlights the influence of the doctor’s individual performance on surgical outcome. It is also worth bearing in mind that there are similar determinants for physicians which affect medical outcome, however in contrast to surgery, these appear to be linear in medicine. In patients infected with HIV Kitahata and colleagues (2) found that after adjusting for the severity of disease and changes in the treatment of AIDS over time there was a 31% lower risk of death for patients cared for by physicians with more experience of dealing with HIV as compared with patients of physicians with the least experience. Experience was defined according to their experience with AIDS during residency training and the cumulative number of patients with AIDS they had cared for in their practice. However, it is worth remembering that this research occurred before the advent of modern therapeutic options (3). A more recent study in the era of highly active anti-retroviral therapy (HAART) showed that patients of doctors with greater experience of treating HIV infection were substantially less likely to die after starting therapy at a low CD4 count (4). A physician was defined as “experienced” if he or she had cared for more than five HIV-positive patients before a patient evaluated into the analysis started treatment. The researchers found that patients of experienced doctors who started treatment at CD4 counts below 50cells/cmm were substantially less likely to die than patients of inexperienced doctors. It is therefore important for HIV patients to be cared for by physicians with reasonable experience of the condition especially as positive outcomes need to be demonstrated as part of the appraisal and revalidation process. This is doubly so in the case of HIV infection because of the rapid advances in HIV therapy. Alison Currie, SpR, Rak Nandwani, Consultant Physician & Associate Director, Genitourinary Medicine, Sandyford Initiative, Glasgow (1) Carter D. The surgeon as a risk factor. BMJ 2003; 326:832-833 (2) Kitahata MM, Koepsell TD, Deyo RA, Maxwell CL, Dodge WT, Wagner EH Physicians’experience with the acquired immunodeficiency syndrome as a factor in patients’ survival. N Engl J Med 1996, 334:701-706 (3) Lewis CE Management of patients with HIV/AIDS. Who should care? JAMA 1997, 278:1133-1134 (4) Wood E et al. Is there a baseline CD4 cell count that precludes a survival response to modern antiretroviral therapy? AIDS 2003 17: 711-720 Competing interests: None declared |
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