Risky surgery, risky surgeon, and risk-taking surgeon

INTRODUCTION

Surgery is a high-stakes profession. Inappropriate decisions and actions can lead to adverse outcomes. Despite scientific advances enabling improved preoperative planning, safer surgery and anaesthesia, and better postoperative care, many surgical procedures remain complex, with uncertain outcomes. Differentiating between risky and risk-taking surgeons is, by and large, essential to ensure ethical, effective, and patient-centred care.

The WHO noted that 0.5%–5% of patients die and 25% develop complications after major surgery.¹ Even in high-income countries, nearly half of all adverse events in hospitalized patients are related to surgical care, and of these, at least 50% are considered preventable. One in 150 patients dies of general anaesthesia alone in some parts of Africa.¹

The definition of ‘risk’ assessment is a relative term to both the patient and the surgeon. According to Chand et al. ‘The risk of 5% mortality may be unacceptably high for a patient undergoing a fundoplication, whereas 50% operative mortality may seem acceptable to a patient with a ruptured aortic aneurysm’.²

RISKY SURGERY

High-risk surgeries are procedures where the probability of complications, morbidity, or mortality are increased due to patient factors, disease complexity, or technical challenges. Though the exact definition of ‘high-risk surgery’ is still vague, a team of American surgeons attempted to develop a list of 227 operations that carry a 1% or greater operative mortality in patients aged 65 years and older and designated them as ‘high-risk’ operations.³ Preoperative risk assessment tools, such as the American Society of Anaesthesiologists (ASA) physical status classification, the National Surgical Quality Improvement Program surgical risk calculator and the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) system help stratify patients based on risk profiles.⁴ Innovations like artificial intelligence and predictive analytics enhance surgeons’ ability to anticipate complications and optimize outcomes.⁵ Surgeons must ensure informed consent and involve patients and their families in discussions about the potential risks and benefits of the procedure and alternative treatment options.⁶

High-risk surgeries often have the following features:

1. Intracavitary procedures: Involve major body cavities (e.g. chest, abdomen, brain).

2. Long duration/complexity: Long, technically demanding, challenging operations.

3. Potential for blood loss or organ damage: High potential for major blood loss or damage to vital organs.

4. Postoperative intensive care: Need for intensive care or prolonged recovery post-surgery.

Specific patient and procedural factors may also contribute to making a surgery high-risk. The patient is the most important and perhaps the most variable factor. Comorbid conditions such as diabetes, uncontrolled hypertension, chronic liver or kidney diseases, metabolic disorders like hypothyroidism, malignancy, immunosuppressed status, and bleeding disorders all add to the risk of surgery. Similarly, extremes of age add to the risk of surgery.

Some procedures are inherently high-risk because they are performed in high-risk circumstances. Thus, surgery for polytrauma, certain intracranial procedures, cardiac surgery, major cancer resections, transplant surgery, and surgery in burns are accompanied by high risk. Emergency procedures invariably carry a higher risk than elective ones. A simple hernia repair becomes high risk when accompanied by bowel strangulation. Surgery in sepsis is high risk, especially in infected necrotizing pancreatitis or in perforative peritonitis.

In essence, high-risk surgery refers to a surgical procedure that carries a major risk of complications, serious morbidity, or mortality, especially in certain patient populations.

RISKY SURGEON

‘A risky surgeon is one whose practices or outcomes deviate significantly from accepted norms, potentially jeopardizing patient safety. This concept should be applied carefully after evaluating evidence-based indicators of surgical outcome.

Contributing factors include poor adherence to clinical guidelines, overconfidence, impaired judgment, or systemic issues like inadequate training or supervision. While there may be occasional “rotten apples” in the surgical fraternity, most surgical errors are committed by well-trained, well-motivated surgeons’.⁷

According to Blasier ‘most surgeons reach their overall peak performance around 45–50 years of age, growing experience can and does compensate for diminishing physical skills’.⁸ Increasing age does make a surgeon ‘risky’ just due to physical decline but also an accompanying cognitive decline, fatigue and burnout, skill mismatch, and systemic failures like poor institutional support, inadequate resources, or ineffective peer review mechanisms. Alternatively, a surgeon early in her/his learning curve is a risky surgeon when she/he tries to operate beyond the ambit of his training.⁹

Surgeons performing a new surgical procedure for demonstration in a live surgical workshop are rendered ‘risky’ as they may be under a lot of stress, multitasking (explaining while operating), working in an unfamiliar environment, and also performing a procedure on a patient they have not met and planned pre-operatively. Working with unfamiliar assistants and operating equipment can add to anxiety. Finally, expert surgeons may not follow up with patients in a live surgical workshop, and the host team may not be familiar with the associated risks and complications.¹⁰

The package system in surgery, where the drugs, duration, and the days of hospitalization are prefixed by insurance companies and government schemes, makes even a good surgeon risky, as the surgeon has to discharge the patient based on the predetermined package system, and no deviation or changes are allowed.¹¹ Performing a new surgery after watching an online video or after attending a surgical workshop is also risky as the training or information available is limited.

The fear of missing out is seen with every surgical advance, whether it is magnification and microsurgery, laparoscopic surgery, laser surgery, or robotic surgery. Venturing into this world of advanced technology without proper training and mentorship makes for a risky surgeon. Planned retirement is still uncommon, but most appropriate for most surgeons across the globe due to ‘a lack of self-esteem, fear of death, and resistance to change.’⁸

Regular assessment of surgeons and surgical outcomes can flag risky surgeons. Measures like the surgical expertise validity evaluation project,¹² peer-reviewed outcomes data, hospital and system-level quality metrics, board certification, and continuing education can act as a guide to keep surgeons abreast of the latest evidence-based practices and also immediately highlight any major deviations of any surgeon from the norm.

In brief, the term, risky surgeon, though not a formal medical expression, is used to define one who consistently demonstrates unsafe judgment, high complication rates, including re-admissions and death, has a poor adherence to protocols, lacks communication skills and teamwork, or performs procedures beyond one’s competence or training.

RISK-TAKING SURGEON

A risk-taking surgeon can be defined as a surgical professional who demonstrates the ability and willingness to make bold, calculated decisions during complex or uncertain situations, where the potential benefits to the patient outweigh the potential harm. Most surgeons would likely prefer to be characterized as well-trained professionals who have to manage risk (and unknowns) than to be thought of as a ‘risk-taking surgeon’.

Judgment of the surgeon based on her/his clinical knowledge, training, skill, and experience allows her/him to better treat high-risk patients that other surgeons may refuse. They may accept patients with major comorbid conditions, poor prognoses, or advanced disease stages whom other surgeons might decline. Such surgeons may innovate to adopt or pioneer new techniques, cutting-edge technologies, or aggressive approaches that carry inherent uncertainties but hold promise for better outcomes. They must provide ethical patient-centred care, prioritizing informed consent and a clear understanding of potential outcomes and alternatives, and accept the possibility of adverse outcomes while maintaining accountability and learning from experiences to improve future practice.

Although not statistically significant, physicians’ risk-taking tendencies correlated with their tendency to gamble; male doctors, surgeons and anaesthesiologists tended to gamble more than senior doctors who also tended to be less risk-taking.¹³ Ethical dilemmas may arise when the line between calculated risk and recklessness blurs.

In summary, a risk-taking surgeon is a doctor who is more likely than most to perform challenging or high-stakes surgeries. This could be due to the complexity of the operation, the patient’s critical condition, or a high chance of complications. They are often driven by confidence derived from training and experience, and an ability to innovate in a calculated approach to help patients in difficult situations. However, this action must be supported by published evidence of benefit and clear communication with the patient.

CONCLUSION

Risk is an inherent component of surgery. Its management requires a nuanced understanding of patient factors, procedural complexities, and the surgeon’s capabilities. Risky surgeries demand meticulous planning and execution, while risky surgeons require accountability and continuous education. Risk-taking surgeons, when guided by evidence and ethics, play a pivotal role in advancing surgical practice.