Influence of experience on performance of individual surgeons in thyroid surgery: prospective cross sectional multicentre study
BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.d8041 (Published 11 January 2012) Cite this as: BMJ 2012;344:d8041
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In the 21st century, performance management and key performance indicators are something doctors will simply have to learn to live with. From that perspective, this research is no doubt timely and interesting. However, as the authors clearly state, the study has some significant limitations e.g. sample size, definition of experience, cross-sectional study, inability to extrapolate its findings to other surgical specialties etc. So are the findings valid? If not, what is the point of this very commendable exercise by eleven eminent healthcare professionals?
What intrigued me even further is the narrow definition of performance as determined by specific post-operative complications following thyroidectomy. I imagine this was done to allow rigorous quantitative analysis and comparison. But surely performance is the sum of knowledge, skills and attitudes - not just the first two as this study suggests. And admittedly, attitudes, communication skills, interpersonal skills, leadership etc cannot be measured quantitatively - they require qualitative research methods.
The trend these days is to look at high-performing teams and not high-performing individuals. Were higher complication rates in any way related to poor system design or inadequate team working or behavioural attributes? We simply don't know. And spending further resources on a longitudinal study, as recommended by the authors, won't answer these questions either.
Competing interests: No competing interests
This is a fascinating study - particularly for us older surgeons! It is intriguing that the complication that increases with age of surgeon is hypocalcaemia due to inadvertent removal of parathyroids. Strangely the other measured complication - damage to the recurrent laryngeal nerve - was not increased.
I wonder if this is because colour perception deteriorates with age of natural lens. The subtle distinction between parathyroid tissue and other structures is often due to a subtle colour difference. Having had a new plastic lens inserted for a cataract my colour perception is better through the 'new' eye. I am pleased to say that my own audited results have not yet changed with age. If they do that will be time to retire!
Competing interests: No competing interests
Re: Influence of experience on performance of individual surgeons in thyroid surgery: prospective cross sectional multicentre study
Sir – We read with interest the paper on the influence of experience on surgical performance in thyroid surgery by Duclos et al (1).
Hypoparathyroidism:
In reviewing postoperative hypoparathyroidism, 81% of DuClos et al’s patients underwent bilateral surgery and were reported upon. Thyroidectomy has significantly evolved in the last 25 years, from a lateral dissection approach to a capsular dissection. A single centre report of thyroidectomy practice in Amiens, France, showed that over a 12 year period, total thyroidectomy (TT) became gradually the most frequent surgical procedure, increasing from 17% to nearly 70%, and replacing subtotal thyroidectomy for multinodular goitre (2). To achieve low rates of hypoparathyroidism in TT, a policy of capsular dissection technique with a low threshold to autotransplant devascularised parathyroid glands should be followed. It is thus feasible the group with >20 years experience, trained using the lateral dissection technique continued to employ this approach. Thus, greater clarity is needed in technique in relation to surgeons’ age distribution. Further, the distribution of patients with Graves' disease or Graves' ophthalmopathy, which is associated with greater odds of permanent hypoparathyroidism (3) is unclear, although patient factors accounted for well over 50% of the total variability in surgical outcome. HES data show that in 2010-2011, only 63% of over 6000 thyroidectomies in England were bilateral (total or subtotal) excisions (4), ie 20% fewer patients were at risk from hypoparathyroidism in the first place. This recognised variation in French surgical practice compared with other countries is recognised but not explained in the literature.
Cord palsy:
Variation attributable to surgeons was greater for hypoparathyroidism (32%) than for recurrent laryngeal nerve palsy (10%). At one of the five French centres, Centre E, ‘systematic laryngoscopy was not feasible after each thyroid procedure’ and so the cord palsy rates were based only 20 of the 28 surgeons and 66% (2357 / 3679) of the patients. The median experience of the 8 excluded surgeons, was just 3 years – hence an important exclusion given the thrust of the message. Duclos et al’s overall rate of vocal cord palsy (2.08%) is on the high side for a modern series.
Improvements in techniques and illumination (5) have, over the years, contributed to the preservation of nerve integrity, and there are reports of, for example 0.6% rates in differentiated thyroid cancer (6) while others report no palsies at three months (7). Even closely supervised residents in South California had <1% palsy rates (8).
In short the influence of a centre with inadequate facilities but almost a third of the caseload, a very low median surgical experience over all, a complication rate higher than in published series, a high rate of bilateral surgery and lack of information on the surgical technique and indications for surgery suggest that the issues which characterise thyroid surgery in France go well beyond the ostensible message of the paper.
As Duclos et al (1) point out – poor outcomes in older surgeons may reflect outdated practices – which of course should be eminently amenable to revalidation education. If their report catalyse this process then their paper has indeed been of value to the endocrine surgical community.
Janet Wilson
Ken MacKenzie
Vinidh Paleri
References
1. Duclos A, Peix J-L, Colin C, Kraimps J-L, Menegaux F, Pattou F, et al. Influence of experience on performance of individual surgeons in thyroid surgery: prospective cross sectional multicentre study. BMJ (Clinical research ed.) 2012;344:d8041.
2. Ayache S, Tramier B, Chatelain D, Mardyla N, Benhaim T, Strunski V. [Evolution of the thyroid surgical treatment to the total thyroidectomy. Study of about 735 patients]. Ann Otolaryngol Chir Cervicofac 2005;122(3):127-33.
3. Pesce CE, Shiue Z, Tsai HL, Umbricht CB, Tufano RP, Dackiw AP, et al. Postoperative hypocalcemia after thyroidectomy for Graves' disease. Thyroid 2010;20(11):1279-83.
4. www.HESonline.nhs.uk.
5. Zarnegar R, Brunaud L, Clark OH. Prevention, evaluation, and management of complications following thyroidectomy for thyroid carcinoma. Endocrinology and metabolism clinics of North America 2003;32(2):483-502.
6. Filho JG, Kowalski LP. Postoperative complications of thyroidectomy for differentiated thyroid carcinoma. American journal of otolaryngology 2004;25(4):225-30.
7. Mohil RS, Desai P, Narayan N, Sahoo M, Bhatnagar D, Venkatachalam VP. Recurrent laryngeal nerve and voice preservation: routine identification and appropriate assessment - two important steps in thyroid surgery. Annals of the Royal College of Surgeons of England 2011;93(1):49-53.
8. Shindo ML, Sinha UK, Rice DH. Safety of thyroidectomy in residency: a review of 186 consecutive cases. The Laryngoscope 1995;105(11):1173-5.
Competing interests: No competing interests