Simplicity is the ultimate sophistication
Leonardo da Vinci
Friday morning vascular department conferences are special for me. For several reasons.
Firstly, it’s the time. The conference starts at 7am. I usually get up at 5am, get ready, read emails and news. Car drive is lonely and quiet. No comparison to LA traffic. I make a point not to be late and not to give a reason for younger people to give me the looks. And try not to miss conferences, unless I am out-of-town. For me, it is a matter of commitment and discipline.
I am really impressed, how well are they prepared and managed. Topics are carefully selected. Most of the time, speakers are knowledgeable and well-prepared, and I know they present up-to-date information. Some are more entertaining than others, but of course, these are teachers, not performers.
But I am the most impressed by the level and civility of discussion afterward. I see a level of communication and presenting of the experience of discussants rarely seen in my past encounters. That’s uplifting.
Last Friday’s conference was originally designed to report on the newest usage of vascular ultrasound. I had already prepared a question about 3D technology and its application in the workup before surgery without pre-op angiograms.
Then the subject was changed, and the presenter was talking about using statistics, designing and interpreting randomized clinical trials and their use in designing evidence-based standards of care. Again, a tantalizing subject. And well presented. So I will wait with my question until the next time.
Then one of the discussant, a well-experienced surgeon, noticed, that regardless of the results of clinical studies, we always will apply their results with personal bias. This is true, and was not stressed enough.
There is a big difference between surgical and medical clinical trials. Surgical clinical trials assume that all surgeons participating in a given study have the same experience and manual skills. We know that’s not always the case. When we do a clinical trial on a specific medication, let’s say, the strength and the quality of the pill is standardized and for all purposes the same. In surgical studies, this factor of providing the care is delegated to a surgeon. Not all surgeons deliver the same level of care. I know that. I spent close to 50 years in the operating room. The results of carotid endarterectomy done by surgeon A may not be the same as the procedure done by surgeon B. It’s enough to ask the OR and ICU crew. For some surgeons, even years of practice are not enough. When I, as a patient, ask a surgeon what is his mortality and morbidity on a planned surgical procedure, and he gives me numbers taken from the national study, it’s not enough and doesn’t mean much. I would like to know his mortality and his morbidity. Big study numbers are frankly not that relevant, particularly for surgeons in the beginnings of their careers. The major criticism of the VA coronary artery bypass study was that mortality and morbidity in VA hospitals at that time was much higher, the same values in community and major center academic hospitals.
Different results for different surgeons can explain different confidence levels in recommending a particular surgical procedure for their patients. And that can be one of the factors creating personal bias.
The difference between the results of national studies and one’s personal results is comparable to the difference between classical physics and quantum physics. One refers to the particular results, the other to the probability of results. Concepts may be close, but not the same.
But the best part of the conference is at the end. When everyone is rushing to the OR, their offices or to make rounds and I am still sitting and smiling. I don’t have to rush to do it anymore. I can have my cup of coffee and go to do some reading and writing. And later on go to the gym.
Life simple pleasures.
