Making the Cut – Which surgeon you get matters — a lot. But how do we know who the good ones are?

“You can think of surgery as not really that different than golf.” Peter Scardino is the chief of surgery at Memorial Sloan Kettering Cancer Center (MSK). He has performed more than 4,000 open radical prostatectomies. “Very good athletes and intelligent people can be wildly different in their ability to drive or chip or putt. I think the same thing’s true in the operating room.”

The difference is that golfers keep score. Andrew Vickers, a biostatistician at MSK, would hear cancer surgeons at the hospital having heated debates about, say, how often they took out a patient’s whole kidney versus just a part of it. “Wait a minute,” he remembers thinking. “Don’t you know this?”

“How come they didn’t know this already?”

In the summer of 2009, he and Scardino teamed up to begin work on a software project, called Amplio (from the Latin for “to improve”), to give surgeons detailed feedback about their performance. The program—still in its early stages but already starting to be shared with other hospitals — started with a simple premise: the only way a surgeon is going to get better is if he knows where he stands.

Vickers likes to put it this way. His brother-in-law is a bond salesman, and you can ask him, How’d you do last week?, and he’ll tell you not just his own numbers, but the numbers for his whole group.

Why should it be any different when lives are in the balance?

The central technique of Amplio, using outcome data to determine which surgeons were more successful, and why, takes on a powerful taboo. Perhaps the longest-standing impediment to research into surgical outcomes — the reason that surgeons, unlike bond salesmen (or pilots or athletes), are so much in the dark about their own performance — are the surgeons themselves.

“Surgeons basically deeply believe that if I’m a well-trained surgeon, if I’ve gone through a good residency program, a fellowship program, and I’m board-certified, I can do an operation just as well as you can,” Scardino says. “And the difference between our results is really because I’m willing to take on the challenging patients.”

It is, maybe, a vestige of the old myth that anyone ordained to cut into healthy flesh is thereby made a minor god. It’s the belief that there are no differences in skill, and that even if there were differences, surgery is so complicated and multifaceted, and so much determined by the patient you happen to be operating on, that no one would ever be able to tell.

Vickers said to me that after several years of hearing this, he became so frustrated that he sat down with his ten­-year-­old daughter and conducted a little experiment. He searched YouTube for “radical prostatectomy” and found two clips, one from a highly respected surgeon and one from a surgeon who was rumored to be less skilled. He showed his daughter a 15­second clip of each and asked, “Which one is better?”

“That one,” she replied right away.

When Vickers asked her why, “She looked at me, like, can’t you tell the difference? You can just see.”

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