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Ann Thorac Surg 2005;79:1092
© 2005 The Society of Thoracic Surgeons
Department of Surgery, Medical University of South Carolina, 96 Jonathan Lucas St, Suite 409, Charleston, SC 29425
(E-mail: sader{at}musc.edu).
Dr Kumar makes a cogent and useful suggestion. There is a well-established tradition in surgery of experienced surgeons assisting those who are less experienced. In the case of Mrs Barefoot, were Dr Wisdom to help Dr Click, they would accomplish two goals: provide the patient with a greater likelihood of a good outcome and elevate Dr Click's experience and competence for that particular operation. Such an option certainly should be considered in cases such as Mrs Barefoot's.
There are, however, potential limitations on this option. Assisting a colleague in one's own institution, as Dr Kumar has done in the past, is a frequent practice and is unproblematic, but the institutions in the case report were separate and locally competing hospitals. On the one occasion when I have exercised this option, the patient insisted on remaining close to home for a complex operation I performed only infrequently; the leading expert was in a distant city. The expert, who was also a personal friend, traveled to my hospital and assisted me in doing the procedure; everyone benefited. In the case of Mrs Barefoot, however, she could simply go across town and have the operation performed by the expert himself in his own environment.
Dr Click already had done 13 Ross procedures, and although two deaths is a high proportion (15%), statistical confidence limits are wide and the mortality rate is not likely to be significantly different from Dr Wisdom's results. In addition, we do not know the risk factors of Dr Click's patients who died or those of the rest of his operative cohort; he may not need or benefit from the help Dr Wisdom could provide.
Dr Kumar comments that Drs Click and Wisdom could share the professional fees, but this would be both unethical and illegal, as it constitutes fee-splitting. Dr Wisdom would be entitled to no more than an assistant's fee.
Dr Kumar also says that if Dr Wisdom refused to help, he would be "guilty of putting his personal interests before those of the patient and the profession." This is not necessarily true, as there could be many valid reasons to refuse, such as scheduling incompatibilities or unsuitable hospital- or surgeon-related factors.
My coauthors and I [1] are indebted to Dr Kumar for bringing this potentially useful option to our attention.
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