Preparing for surgery is a scary process. As a surgeon I consider it a privilege when a patient entrusts me with their health and safety for surgery. Developing repertoire with a patient is essential for a successful surgical outcome. Once you have found your surgeon (9 clever ways to find the best Orthopedic Surgeon near you), consider asking these tough questions to learn more about how your surgeon approaches surgical preparation. This is a list I have compiled through my years of practice of some of the most difficult and uncomfortable questions patients have asked. If you have other questions that you think belong here, feel free to share your thoughts in the comments section below!
Do you double book surgeries?
There are some surgeons that will book multiple surgeries simultaneously. This practice has recently come under public scrutiny (see Washington Post Article) after an investigation exposed Massachusetts General Hospital’s questionable policies permitting double and triple booking of surgeries. While this case is currently making its way through the courts, it highlights a little known practice abused by unscrupulous surgeons. Some surgeons that have a fellow/resident under training, or an experienced physician assistant under supervision, will complete the “critical portions” of a surgery, and defer the less critical components such as wound closure to an assistant. In the medical community this is considered a perfectly acceptable use of resources assuming the surgeon is indeed completing the critical portions of the surgery. Where this practice is ripe for abuse is how a surgeon may define the “critical portion of the surgery”.
When I was a chief resident, in my last year of training, even though I was very comfortable operating alone, my attending would be present and supervising the critical portions of the case. Although cases would overlap, cases were staggered such that while I was closing the wound and wrapping up a case, the next case would be starting in the neighboring operating room under the direction of my attending. No matter what the circumstance, because cases were staggered, critical portions of two cases never overlapped, and hence no patient care was compromised. Moreover, the attending was always a few feet away in the event any need were to arise for their help. If executed properly, and coordinated well with the OR staff, this is a very efficient way for surgeons to get multiple cases done. As you can imagine though, this practice can easily be abused. If a fellow or residents does an entire case with minimal oversight, that is the attending is absent, or only passes through the operating room for a cursory glance or ceremonial hand wave, the surgeon is essentially committing fraud and misrepresenting their role during the critical portions of the case. There is no justification for this practice in my opinion, and when it is abused, it is often driven by greed and/or laziness. From the billing surgeon’s perspective, it is a lucrative way of maximizing billing. It is a disservice and violation of the patient-physician relationship however.
So as a patient how do you screen your surgeon for this practice? Unfortunately there is no foolproof way to accurately assess this, and ultimately it comes down to trusting your surgeon. There are some questions you can ask to help you glean some insight. It is your right to ask the surgeon- “What part of the case do you delegate to your trainees or assistants?” It may be hard to get a straightforward answer to this, but the way your surgeon reacts to the question should give you insight into the way the conflict of interest is managed or mitigated. Perhaps some of my anecdotes are making you anxious about proceeding with surgery in an academic center. I don’t want to discourage anyone from seeking surgery in an academic medical center. In fact, truth be told, some of the best surgeons can be found in academic centers pioneering new techniques and training the next generation of surgeons. My best professors in training would anticipate the errors I would make, and were so skilled, they were capable of rescuing me no matter what surgical misadventure or error I may have committed before causing any harm. Part of the bargain in getting a surgery at an academic center is that there will be trainees involved. The good news is that studies have examined the outcomes in academic centers with involvement of trainees and compared it to outcomes in practices without such set ups, and no difference in surgical outcomes have been detected.
Will you see me post-operatively?
This may seem like a benign question to many, but it may surprise folks to learn that some surgeons delegate this responsibility to their physician assistant or trainees. Many folks are unaware that the physician is not reimbursed per say for each individual post operative visit in the first 3 months after surgery. The surgeon is given an upfront lump sum payment that encompasses the surgical time and initial post operative care. As a result, for some unscrupulous surgeons, it is from a revenue generation standpoint, more efficient to visit with new patients, as opposed to managing routine post operative care. It is more fiscally prudent to have a physician assistant or someone else participate in the immediate post operative care. There is nothing necessarily wrong with having a physician assistant perform a wound check or physical exam after surgery. Most post operative care is pretty algorithmic. However if your expectation is to deal exclusively with the surgeon, this may come as a disappointment. A well balanced approach would be to have some post operative visits with the surgeon and perhaps some with the assistant as a compromise. The assistants often are experienced enough to recognize when a patient’s recovery is deviating from the normal progression and are quick to involve the surgeon. Again when executed well, this practice makes sense, but when surgeons abuse this, the patient’s experience can be impacted. Don’t hesitate to request your surgeon’s evaluation if things are not progressing as outlined pre-operatively.
What bills will I get after surgery?
Organizing a surgery is a complicated process that involves multiple parties and several specially trained professionals. The surgeon’s bill is only one component to the cost of your surgery. You may receive separate bills for the surgical facility, anesthesia, implants, medical equipment, etc. While your surgeon’s fees may be covered by your insurance, finding out after the fact that the surgical facility or your anesthesiologist is out of network can be a nasty surprise. In my practice we make it a point to give our patients a ballpark estimate of what their surgery will cost them out of pocket, portion covered by insurance, and a summary of the different bills to anticipate. As deductibles continue to climb higher, the costs associated with elective surgery require planning. Having that knowledge up front can avoid misunderstandings. In this day and age of managed care, most institutions and practices can provide some level of transparency as to the fees. The unrealistic expectations consumers have for the cost of a surgery still surprises me. It is these circumstances in which foresight can help avoid a very uncomfortable conversation afterwards. I try to engage the patient up front so that if there are financial constraints, the plan can be discussed and tailored to the individuals circumstance. For example, instead of recommending an expensive cryotherapy cuff, I might suggest the patient forgo it’s convenience and focus instead on doing the tried and true traditional cold compresses with a bag of frozen vegetables or ice packs. Compromises like this can sometimes make a previously untenable surgery a more palatable proposition.
How often do you do this surgery?
I am not sure why so many patients are afraid to ask this question. Often when people do ask, they always begin with the disclaimer “please don’t get offended”. Personally, I think this question is completely appropriate. You wouldn’t want the auto transmission specialist to make their first foray into body work on your car. Likewise, I want the confidence that my surgeon has done this surgery before and knows exactly what they are getting into. Now the caveat here is that some diagnosis are more common than others, so you need to be aware how common your condition is. If you have something that is rare to begin with, then don’t be alarmed if your surgeon only does one or two of those surgeries a year. In my post entitled 9 clever ways to find the best Orthopedic Surgeon near you, I discuss some online tools you can use to independently verify your surgeons credentials and operating experience that might come in handy for you. Having a friend or family member vouch with a positive surgical experience really helps too!
What is your success rate with this surgery?
This is a loaded question. I think the purpose of this question is two fold- 1) to get a realistic idea of what might be accomplished with surgery 2) to gauge how the surgeon handles the question. Every surgeon gets complications. There’s an old adage among surgeons that goes “if you aren’t having complications, you aren’t operating”. Meaning every surgeon, in spite of their best efforts, will encounter some complications in the course of their practice. It is inevitable and unavoidable. It is what keeps me up at night as a surgeon to know that in spite of my best efforts, there are times when things just go wrong. If someone guarantees you 100% success, hook, line, and sinker, that is a red flag. Patients need to have a clear understanding of what they are getting into. Now there are surgeries that have 99% success rates and complications rates that are exceedingly low. But for a surgeon to guarantee success is in my opinion being less than honest. A good surgeon puts in place many practices that minimize risks. Pay close attention to your surgeon’s attention to detail, level of organization, and the overall process of the surgical coordination. I want a surgeon who prides themselves on a smooth, streamlined on-boarding process that accounts for potential pitfalls with surgery. Don’t be afraid to ask what safeguards are in place to prevent complications like infection or blood clots. Another good question to ask is what complication the surgeon fears most. Surgery is a less than perfect science (art?). No surgery can be 100% successful. As long as you are aware of the risks and potential for success, you will be mentally prepared to tackle any challenge that may arise.
Can I delay my surgery?
This is another loaded question. Most elective surgeries can be delayed indefinitely. If a surgeon begins to pressure you to schedule or is insistent on getting you scheduled, to me is considered another red flag. Obviously there are exceptions, and for some surgeries there may be a benefit from doing it sooner rather then later, but the risk associated with delaying surgery should be articulated by the surgeon so you can make that informed decision. I never want to pressure anyone into undergoing surgery. That will only lead to regret or problems if some complication arises. My patients are just as invested in undergoing surgery as I am and the relationship has to start on a solid foundation. If there are any doubts I encourage my patients to discuss with family, do more research, seek a second opinion, and proceed only once they are comfortable with me as their surgeon. When I first began operating, I would worry whether patients would come back or pursue treatment elsewhere. As my practice has grown and I have matured as a surgeon, I have realized I only want to operate on patients I have developed a repertoire with.
Have you ever cancelled a surgery because you were mentally or physically unfit?
This question can be hit or miss. Acknowledging one’s weaknesses can sometimes be the hardest thing. Surgeons that have undergone arduous hours of training, including many relentless nights of call, and have endured mountains of stress to succeed as a surgeon may find this question off putting. But a surgeon that can put their ego aside, and place the patient first, is one that is self-aware and one that I want operating on me. The most common concern patients seem to have is whether I have had enough sleep the night before surgery. Often someone in the family will express the concern as I am visiting with them in the surgical preparation area- “You get enough sleep doc?” with a bit of a nervous chortle. Realistically in the surgical preparation area minutes before anesthesia induction, its is a bit too late to vet your surgeon’s self-awareness. Asking the question above in advance though can at least generate a dialogue in clinic that may reveal how self-aware your surgeon is. I learned early in my practice that patients actually appreciate a surgeon that can recognize their limits. Once after a long trauma call with multiple back to back emergent surgeries, I realized my fatigue had approached a point that could compromise my ability to operate effectively. After several minutes of deliberation, I defeatedly approached the patient about rescheduling her long awaited elective surgery. Much to my surprise she was nothing but pleased I proposed postponement.
This is a far from comprehensive list of questions relating to surgical preparation, but these are the some of the questions that I have encountered through the years that have made me pause and reflect. If you have something to add, feel free to leave a comment. I would love to hear your opinions.