Low-volume surgeons

In reality, both goals are a response to the same problem–about 80% of gynecologic surgeons in the United States are low-volume surgeons (typically defined as <1 hysterectomy per month). Without question, this cutoff value suffers the problem of all cutoff values (ie, are there differences in surgeons who do 0.9 vs 1.1 and 1 vs 10 hysterectomies per month?). However, these studies have found that when this definition is utilized, low-volume surgeons were less likely to use a minimally invasive route for hysterectomy, had significantly higher complication rates (eg, operative injury, intensive care unit admission, transfusion), had longer operative times and, as a consequence, utilized more resources with a variance of 260% in dollars spent per surgery between the most and least cost-effective surgeons. It seems reasonable to assume that outcomes and cost-effectiveness will likely improve linearly with volume beyond this cutoff although the level at which the plateau occurs is currently unknown.

What you permit, you promote

We all wish for our patients a culture of quality and safety in our gynecologic operating rooms. That being said, since low-volume surgeons produce less optimal outcomes and most gynecologic surgeons are by definition low volume, are we practicing in a culture that normalizes deviance? Since this is being permitted, are we as a country promoting less than optimal gynecologic surgical outcomes for our patients?

What you permit, you promote

We all wish for our patients a culture of quality and safety in our gynecologic operating rooms. That being said, since low-volume surgeons produce less optimal outcomes and most gynecologic surgeons are by definition low volume, are we practicing in a culture that normalizes deviance? Since this is being permitted, are we as a country promoting less than optimal gynecologic surgical outcomes for our patients?

Are there solutions?

The problem is obvious–there are too many low-volume gynecologic surgeons and this is the root cause of the problem. The explanatory factors that enable low-volume surgeons include the following.

• 1.
  

  Decrease in the yearly hysterectomy rate: mainly due to improved management of abnormal uterine bleeding, uterine leiomyomas, and benign ovarian neoplasms, the yearly hysterectomy rate in the United States has fallen from 500,000-600,000 per year to around 400,000 per year.

  
  
• 2.
  

  Limited exposure of residents to surgery: without addressing the issue of the value of the educational experience based on trainee level during surgery, neither the minimum requirement for minimally invasive hysterectomy (MIH) required over a 4-year period by the Residency Review Committee (15 vaginal and 20 endoscopic hysterectomies) nor the median number of MIH performed over a 4-year residency (23 vaginal and 40 endoscopic hysterectomies) meet documented learning curves required for surgical proficiency (20-30 vaginal and 30-125 endoscopic hysterectomies to achieve proficiency). In addition, compared to urology and general surgery residency, obstetrics/gynecology residents spend considerably less time on surgical rotations (18-24 months vs 48-60 months). This is compounded by work hour restrictions.

  
  
• 3.
  

  Diversification of approaches for hysterectomy: over the past few decades, the number of options for hysterectomy has doubled from abdominal and vaginal to abdominal, vaginal, robotic, and laparoscopic. Each approach requires to some degree a different skill set to accomplish and has demonstrably different learning curves.

  
  
• 4.
  

  Too many trainees: to meet obstetrical demand, there are too many trainees relative to surgical volume; thus obstetrics and gynecology has the highest number of surgeons per capita of any specialty.

  
  
• 5.
  

  Insufficient postresidency surgical volume due to problems 1 and 4.