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What is Patient Selection?

An Excellent Surgeon Knows when NOT to Operate!!!!!!

"A Good Surgeon Knows How to Operate'                                                                                                                                                      'A Very good Surgeon Knows How to operate very well"                                                                                                                              "An Excellent Surgeon Knows when NOT to Operate"

I was given this advice by a very senior surgeon when i was a trainee Orthopaedic Surgeon. This advice has Stayed with me and i think it is the most important aspect of being a Surgeon- PATIENT SELECTION

"Patient selection is the process by which an evaluating surgeon decides whether to accept responsibility for the care and treatment of a potential patient. It is assumed the doctor has the requisite knowledge to assess the anatomic disorder (disease) and the technical ability to render appropriate care if needed. An unsatisfactory outcome can be measured not only by failure to resolve the disorder but also by expenditure of a disproportionate amount of practice resources in achieving resolution of the problem." (Clin Occup Environ Med. 2006;5(2):217-23, v.)

What this statement means is that if the surgeon selects the wrong patient for the right operation the outcome will be less than optimal and vice versa if the wrong operation is chosen for the correct patient the outcome will be the same.

Many patients and General Practitioners send patients to surgeons for treatment. The expectation is that the surgeon will operate and fix the problem. However this should be last resort. We are taught in surgical training -" Non operative before Operative". After assessment the surgeon feels that the patient could benefit from an operation but needs a degree of patient optimisation prior to surgery so as to decrease the chances of post operative complication. This is not a failure on the surgeons part to provide treatment nor is the surgeon neglecting the severity of the patients symptoms. The surgeon is choosing to be safe on the patients behalf.

So often i see that the patient will eventually seek out a surgeon who will take the risk and provide surgical treatment. Now the issue here is - Is the surgeon Brave or is the Surgeon a risk taker. This can be easily answered by how the patient does post operative. If there  are no complications the surgeon is a Hero, but if there is a complication than the surgeon was reckless. However in most instances  the risk taking behaviour is passed on as " at least he/she tried" "the other surgeon would not even try", "he/she was just not interested", "it was too hard for him/her".

In Orthopaedic Surgery any incidence of a known complication greater than 1% (1 in 100) is too high. These cases need to be very carefully assed and the patient optimised before surgery. A risk taking surgeon may take a risk of 5-10% but on the bright side he/she has 90-95% happy patients who think that the surgeon is great. The question for the medical fraternity is - "IS THIS ACCEPTABLE"

Surgical Audit Data will pick up postoperative complications, However it may not necessarily  pick up the patient selection trend. This is where we fail and let our patients down. A preoperative consult with patient education, work-up, investigation and referrals take time and money. It is a lot easier to meet patient expectations by offering an operation. It is Quick, Easy, Appease the Patient, Appease the GP, and it is more Financially rewarding then refusing to operate and spending time optimising the patient for a better outcome.

As a patient you should seek out a Surgeon who is actually looking for non operative solution before operative , who is looking at you as a whole patient and not just a Knee or a Hip or a Shoulder. It is time to accept some responsibility for your own health.

In surgery their is an old Idiom- " if you look hard enough you will find someone to operate on you" and this may not be the best outcome for you in the long term. 

Patients - Be informed, Take Responsibility, Educate yourself, Seek out sensible advice, and remember there is no quick fix - every surgery has the possibility of complication and it is your surgeons responsibility to understand you as a whole and not just your disease .