The Surgical Assembly Line

When I think of an assembly line, two images pop into my head:

  • The I Love Lucy Chocolate Factory episode where Lucy and Ethel are trying to wrap chocolates (and eat them too!) and can’t possibly keep up.
  • My high school history class, when we learned about Henry Ford’s invention of the concept of an assembly line, where hundreds of cars were being assembled in one day. It revolutionized manufacturing, helping companies produce much more than ever before.

I thought of both when I read about this surgeon, Brett Greenky, and his assembly line of hip and knee replacement surgeries – 14 in a day, and 3 at one time – and the $2 million malpractice suit he lost because he ruined a patient’s quality of life. Mistakes were made. He couldn’t keep up.

Assembly line surgeries have been going on for years, ever since surgeons – and the hospitals and day surgery centers they operate in – followed the money: the more surgeries, the more income. The shorter the wait for a patient, the better chance they would choose to have surgery. And of course, it’s a lot less expensive for one surgeon with one paycheck to do more surgeries, than it is to hire more surgeons and have to pay more paychecks.

In fact, “assembly line surgery” or “production line surgery” isn’t a new concept, nor is it a bad idea. In particular, academic medical centers, where student surgeons are learning their trade and honing their skills, have operated in assembly-line-surgical fashion for years. They are very efficient, of course. There are even awards for surgical efficiency when built as production lines.

Further, if you think about it, “division of labor,” making sure that the person most skilled with one aspect of a surgery performs that one aspect, while another professional more skilled at another part of the surgery is performing that aspect, can be highly beneficial to a patient, improving quality.

The problems crop up when efficiency becomes more important than effectiveness and quality; when the almighty dollar becomes more important than the patient’s outcomes. It turns out that Brett Greenky operated for 14 hours that day he messed up his patient’s hip replacement. No matter how skilled a surgeon he was, he must have been too tired to do a good job. When personnel are tired, it’s not just a problem with the mechanics of the surgery, but it may also increase the probability of cross-contamination and the spreading of infection. Ugh.

So what can we learn from this? How might this affect the decisions we make about surgery?

There are a few takeaways for smart patients:

First – ask questions. Ask your surgeon how many operations he does / will do on the day of your surgery, and how many other professionals will be involved – hands on – with your surgery. Also ask how long he operates, on average, on each patient.

Then do the math. Are you confident your operation will get the attention it deserves, and that your surgeon will not be rushed?  Your tolerance for the numbers should depend on what sort of surgery you’re going to have. Open heart surgery will have very different requirements from, say,  arthroscopic knee surgery. If you are interviewing more than one surgeon, this might also help you choose your preference.

While you’re asking – ask your surgeon to justify why his or her process works the way it does. If the answers are like “my strength is ____ while my partner’s strength is ____”, then that’s probably a good answer. If the surgeon hems and haws, or avoids answering, or for some reason gives you the impression he/she does it for efficiency’s sake only, then you might want to look elsewhere.

Finally, ask to see a copy of the Informed Consent Document you’ll be asked to sign. Check to be sure it accounts for the different professionals who will be involved. If you don’t understand any part of it, ask for clarification. Do I think it will be clear and understandable? Probably not. More likely it will be full of legaleeze that benefits the providers.  But the fact that you have asked for it, and then asked questions about it, puts your surgeon on notice that you are a smart patient, one to be respected.

If this seems at all overwhelming to you, or if you are at all uncomfortable asking these sorts of questions, then how can you be confident that your surgery will be successful?  Surgery is scary enough without having to figure all this out all by yourself!

Ask a professional to help you out. An independent patient advocate can help you ask the questions, assess the answers, and provide you with some peace of mind as you prepare to go under the knife.

Knowledge is power, and your advocate can help you gain the peace of mind, and confidence you need.

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