Arielle E. Kanters

Surgeon Variation in Complications With Minimally Invasive and Open Colectomy: Results From the Michigan Surgical Quality Collaborative

Importance Minimally invasive colectomy (MIC) is an increasingly common surgical procedure. Although case series and controlled prospective trials have found the procedure to be safe, it is unclear whether safe adaptation of this approach from open colectomy (OC) is occurring among surgeons. Objective To assess rates of complications for MIC compared with OC among surgeons. Design, Setting, and Participants We analyzed 5196 patients who underwent MIC or OC from January 1, 2012, through December 31, 2015, by 97 surgeons in the Michigan Surgical Quality Collaborative, with each surgeon performing at least 10 OCs and 10 MICs. Hierarchical regression was used to assess surgeon variation in adjusted rates of complications and the association of these outcomes across approaches. Main Outcomes and Measures Primary study outcome measurements included overall 30-day complication rates, variation in complication rates among surgeons, and surgeon rank by complication rate for MIC vs OC. Results Of the 5196 patients (mean [SD] age, 62.9 [14.4] years; 2842 [54.7%] female; 4429 [85.2%] white), 3118 (60.0%) underwent MIC and 2078 (40.0%) underwent OC. Overall, 1149 patients (22.1%) experienced complications (702 [33.8%] in the OC group vs 447 [14.3%] in the MIC group; P < .001). For MIC, the rates of complications varied from 8.8% to 25.9% among surgeons. For OC, rates of complications were higher but varied less (1.7-fold) among surgeons, ranging from 25.9% to 43.8%. Among the 97 surgeons ranked, the mean change in ranking between OC and MIC was 25 positions. The top 10 surgeons ranged in rank from 6 of 97 for OC to 89 of 97 for MIC. Conclusions and Relevance Surgeon-level variation in complications was nearly twice as great for MIC than for OC among surgeons enrolled in a statewide quality collaborative. Moreover, surgeon rankings for OC outcomes differed substantially from outcomes for those same surgeons performing MIC. This finding implies a need for improved training in adoption of MIC techniques among some surgeons.

Surgeon leadership style and risk-adjusted patient outcomes

BackgroundThere are many reasons to believe that surgeon personality traits and related leadership behaviors influence patient outcomes. For example, participation in continuing education, effective self-reflection, and openness to feedback are associated with certain personalities and may also lead to improvement in outcomes. In this context, we sought to determine if an individual surgeon’s thinking and behavior traits correlate with patient level outcomes after bariatric surgery.MethodsPracticing surgeons from the Michigan Bariatric Surgery Collaborative (MBSC) were administered the Life Styles Inventory (LSI) assessment. The results of this assessment were then collapsed into three major styles that corresponded with particular patterns of an individual’s thinking and behavior: constructive (achievement, self-actualizing, humanistic-encouraging, affiliative), passive/defensive (approval, conventional, dependent, avoidance), and aggressive/defensive (perfectionistic, competitive, power, oppositional). We compared patients level outcomes for surgeons in the lowest, middle, and highest quintiles for each style. We then used patient level risk-adjusted rates of complications after bariatric surgery to quantify the impact surgeon style on post-operative outcomes.ResultsWe found that patients undergoing bariatric surgery performed by surgeons with high levels of constructive (achievement, self-actualizing, humanistic-encouraging, affiliative) and passive/defensive (approval, conventional, dependent, avoidance) styles had lower rates of adverse events compared with surgeons with low levels of the respective styles [High constructive: 14.7% (13.8–15.6%), low constructive: 17.7% (16.8–18.6%); high passive: 14.8% (13.4–16.1%), low passive: 18.7% (17.3–19.9%)]. Conversely, surgeons identified with high aggressive styles (perfectionistic, competitive, power, oppositional) had similar rates of post-operative adverse events compared with surgeons with low levels [high aggressive: 15.2% (14.3–16.1%), low aggressive: 14.9% (14.2–15.6%)].ConclusionOur analysis demonstrates that surgeons’ leadership styles are correlated with surgical outcomes for individual patients. This finding underscores the need for professional development for surgeons to cultivate strengths in the constructive domains including intentional self-improvement, development of interpersonal skills, and the receptiveness to feedback.

Dynamics within peer-to-peer surgical coaching relationships: Early evidence from the Michigan Bariatric Surgical Collaborative

Background: Many coaching methods have been well studied and formalized, but the approach most commonly used in the continuing education of surgeons is peer coaching. Through a qualitative thematic analysis, we sought to determine if surgeons can comfortably and effectively transition to a co‐learner dynamic for effective peer coaching. Methods: This qualitative study evaluated 20 surgeons participating in a video review coaching exercise in October 2015. Each conversation was coded by 2 authors focusing on the dynamics of the coach and coachee relationship. Once coded, thematic analysis was performed. Results: Two themes emerged in our analysis: (1) Participants often alternated between the roles of coach and coachee, even though they received assigned roles prior to the start of the session. For example, a coach would defer to the coachee, suggesting they felt unqualified to teach a particular technique or procedure. (2) The interactions demonstrated bidirectional exchange of ideas with both participants offering expertise when appropriate. For example, the coach and coachee frequently engaged in back‐and‐forth discussion about techniques, instrument selection, and intraoperative decision‐making. Conclusion: Our qualitative analysis demonstrates that surgeons naturally and effectively assume co‐learner roles when participating in an early surgical coaching experience.

Justifying our decisions about surgical technique: Evidence from coaching conversations

Background: The quality of an operation depends on operative technique. There is very little evidence, however, regarding how surgeons arrive at their intraoperative decisions. The objective of this study was to determine the extent to which practicing surgeons participating in a coaching program justify their technical decisions based on their experience or based on evidence. Methods: This qualitative study evaluated 10 pairs of surgeons participating in a video review coaching program in October 2015. Using thematic analysis, the conversations were coded in an iterative process with comparative analysis to identify emerging themes. Results: Three major themes emerged during analysis: (1) Individuals often reported modifications in surgical technique after a negative postoperative complication; (2) participants were noted to defend the use of certain techniques or surgical decisions based on the perceived expert opinion of others; and (3) surgeons rarely referred to evidence in surgical literature as a motivation for changing surgical technique. Conclusions: In this qualitative analysis of coaching conversations we found that practicing surgeons often justify their surgical decisions with anecdotal evidence and “lessons learned,” rather than deferring to surgical literature. This either represents a lack of evidence or poor uptake of existing data.