Why is this variation relevant to a medical student or resident?
Inadequacy of clinical guidelines: Throughout medical school and residency, young physicians learn how to diagnose illness and determine if a patient meets clinical criteria for a certain treatment. Understanding and applying clinical guidelines is the best first step in determining appropriateness for a certain procedure. However, using clinical guidelines alone may overestimate the number of patients who should receive a procedure because such guidelines do not take into account patient preferences. This was demonstrated in a study published in 2001 by Hawker et al, which examined the patient populations receiving knee and hip replacement in two Canadian regions, one with high rates of surgery and the other with low rates. They defined the population-based need for arthroplasty as those patients who met certain clinical criteria: specific symptoms and signs of severe arthritis. These patients were then informed about the risks and benefits of the surgery through a standardized interview and were subsequently asked about their desire for surgery. Of those patients meeting the clinical criteria, only 15 percent in the high-use region and 8.5 percent in the low-use region decided to proceed with arthroplasty. [7] The study showed that evidence-based guidelines grossly overestimated the number of patients in both regions who should receive surgery. Patient preferences for arthroplasty did differ between the regions, but practice patterns did not reflect those preferences.
Delegated decision-making: Medical training teaches young physicians to make recommendations in the best interests of the patient. But many treatment options involve varying benefits and risks to the patient and tradeoffs in the patient's quality of life. These tradeoffs include recovery time, follow-up care, morbidity, and cost of care. One example is the decision between medical therapy, PCI, and surgery for stable angina due to coronary artery disease (CAD). Recent studies have shown little difference in long-term survival for the three treatments when used for the initial management of stable chronic disease. [8,9] In cases such as this, the preferences of well-informed patients may differ from each other and from their physicians. These patient preferences should guide the choice of treatment. Instead, all too often the local practice style heavily influences which procedure is performed. [5]
The "right" rate of surgery should represent all patients deemed appropriate for a procedure by the most current guidelines who also choose to have the operation based on their own preferences and values. Variation due to other causes is unwarranted and represents a misuse of care or even a medical error (operating on the wrong patient). Residents who train at hospitals that emphasize patient preferences and shared decision-making will learn to give patients the information they need to make the best decisions for their care. Formalized shared decision-making programs for patients facing health care decisions are relatively rare. Fortunately, the Center for Medicare and Medicaid Innovation recently announced a grant to fund the implementation of shared decision-making programs for hospitals in the High Value Healthcare Collaborative, which include, among others, the Mayo Clinic, UCLA Health System, and Scott & White Healthcare. [10]
What this means for surgical training: Residents will learn from physicians in teaching hospitals and will model their behaviors after their faculty. Some of the important goals of surgical training include developing operative skills, clinical judgment, and a greater understanding of the pathological basis of disease. However, most residency programs do not equip physicians to fully understand treatment choices and to elicit patient preferences. As residents work closely with supervising senior residents and attending physicians to develop their own clinical judgment, they will be influenced by the practice styles of mentors and peers. Regardless of where they train, young physicians must strive to elicit the preferences of patients in order to always perform the right procedure on the right patient at the right time.