Surgical skill or bedside manner?

We had a great debate over breakfast the other day. The question was –  if you had to choose, would you prefer a surgeon with great surgical skills and average bedside manner, or average surgical skills and great bedside manner? Of course, one hopes that you never have to make this choice, but it was a good debate!

My argument was that I wanted great surgical skills, given that I am unconscious at that point and once you are opened up they need to deal with whatever the situation actually turns out to be (which may be rather different from the best guesses on the scans). Having seen how incredibly thin and fine things like nerves are in many places, the fine-motor skills of dealing with this feel very important (and obviously in things like arthroscopy are one-step removed like a computer game!) I have to admit that I was only conscious once as I got wheeled into theatre (the other 6 times I was in a small ante-room with just the two anaesthetists) – but I was completely stunned to see 10 people and realised what a team leadership role the surgeon has!

But the counter-argument for the importance of bedside manner was a great one. The sad statistic is that many people continue to have pain after surgery (for instance, failed back surgery is said to run at about 40%, according to Penn Medical in the USA). So what you most need is to find a person who has the depth of skills to really understand what is going on in your body, and what interventions are most likely to help the situation. Therefore, someone who has a good ‘bedside manner’ to truly understand what is going on and whether surgery is a good option is what you most need. It can save you a lot of trauma and uncover a much better path.

The argument goes further. If you do have the surgery, the recovery phase is critical. Being able to explain what recovery and rehabilitation approach works best, and adaptations to make really increase the chance of recovery. Not to mention the softer factors, such as the level of trust and belief, which many would argue also play a key role in the mentality of the patient and therefore their biochemical make-up during the recovery phase.  

Supporting evidence that bedside manner may be much more important…

Having had four male surgeons, I was somewhat stunned that there was a statistically significant difference in the outcomes by the gender of the surgeon in this British Medical Journal comparison of postoperative outcomes amongst patients treated by male and female surgeons via a population-matched cohort study. It showed that fewer patients treated by female surgeons died, although there was no statistical difference in the proportion that were re-admitted to hospital or had complications within 30 days, compared to the matched group treated by male surgeons. If everything in your mind is screaming out that this cannot be true, then I will leave you to read all of the statistical analysis in the paper (including the interesting finding that the same pattern was true in emergency surgery, where the patient did not choose their surgeon):

https://www.bmj.com/content/359/bmj.j4366

But perhaps more interesting is the why’s, which the paper says need more study. But they already suggest that there is a gender difference in how male and female physicians practice medicine, such that it can affect patient outcomes.

They say that there are 4 core components of surgical practice:

  • Knowledge
  • Communication skills
  • Judgement and
  • Technical proficiency.

Obviously, post-surgery there are more people involved in the care so there are more factors too – and a previous study of beneficiaries of US Medicare that were treated by female general internists in hospital had lower rates of 30-day mortality and readmission than those treated by male internists (Tsugawa et al), which they attributed to female doctors being more likely to:

  • use a patient-centred approach and
  • to follow evidence-based guidelines

So what could this mean for your surgery?

Having never been in this surgical world before it was thrust upon me, I had no idea how to move forward. So here are a few tips that I would say now:

  • If you have Medical Insurance, ensure that it allows you access to the maximum pool of consultants (they generally operate in a number of different hospitals and each of them is self-employed, so worry about the surgeon access, not the hospitals)
  • Always try to find a surgeon who has worked with sports people.
  • Get recommendations from people in the know. There is no meaningful data that you can access on the outcomes by different surgeons, but nurses and people in the hospitals know it. Call on your network shamelessly to try to understand the real story. Take time over this – for all that you probably feel that you do not have time on your side in your situation, it is really worth doing lots and lots of investigation.
  • If you have to wait, it is a good sign. Whilst none of us want to wait when we are in pain, it is much better to be seen by a surgeon with a full plate and lots of patients, rather than the one with lots of gaps. Firstly, it is an indication of their reputation. And secondly, if they are busy, human nature suggests that they may be more balanced in whether surgery is the best option for you.
  • Don’t be afraid to ask for a second opinion. Many people say always go for a second opinion before surgery, and that surgeons should not be offended as they should also recognise that it is a big decision. I would say that if what they say doesn’t seem to fit, or you want to have more comfort before making a big decision like a second or third surgery, then a second opinion really helps. They say that the key is not to tell the second person what the previous diagnosis is so that you get a genuine fresh pair of eyes on the issue.
  • Go into the appointment with a list of questions and a second person in support. My experience is that almost all of the surgeons that I have met are extremely introverted and tend to say very little. Therefore it is down to you as the patient to elicit responses, and to keep asking the questions until you feel that you have understood the answer adequately. This is why I always take someone else to the appointments who also has the list of questions and understands what we are trying to understand from the appointment, as I have felt quite intimidated and not managed to get all of the responses that I was looking for when I was alone.
  • Always go to another medical specialist too. The old saying is that when you have a hammer in your hand, everything looks like a nail. So the surgeon is always likely to come back with the choice of wait and hope it gets better, or do surgery. Hence getting an alternate view of how another specialism would approach your issue is very useful – go to:
    • a good clinical physiotherapist (one who has done cadaver work, reviews scans, and works across a range of techniques that are not just manual therapy and strengthening exercises),
    • a chiropractor with a good track record (who again reviews scans and uses more approaches beyond the classic ‘twist and crunch’)
    • a sports rehabilitation specialist (who again reviews scans and does screening to present a treatment plan that shows clear milestones with review points for reassessment and case studies of where this has worked before with/without surgical intervention)

So I changed sides on the debate

Through the debate (and long after I had finished breakfast), I realised that the core of the issue for me is that I was falling into the trap that I think many of us fall into – the idea that surgery is a quick intervention that creates an instant fix.

Once I articulated that I believe that surgery is sometimes one step in the rehabilitation path, it becomes clear that the communication skills to make the right decisions with the patient are much more likely to get to a better outcome. And since communication is a two-way street, we as patients also need to do lots of work to make sure that we communicate and understand well through the process.

One Reply to “Surgical skill or bedside manner?”

  1. I haven’t had surgery due to injury but this resonates when it was discovered that I have osteoarthritis.

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