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In making this choice on behalf of their patients, neurologists should first consider some necessary but not necessarily sufficient qualifications in their preferred neurosurgeon.
The neurosurgeon you choose should indeed be a properly qualified neurosurgeon. In some jurisdictions (the USA, for example) it is not legally required that one be certified by a specialty board in order to practice neurosurgery. In the USA, the American Board of Neurological Surgery requires at least a year of practice after graduating from an accredited training programme and passing its written examination before the final oral examination can be taken. Therefore, in the first few years after graduation a properly qualified neurosurgeon may be ‘Board eligible’ rather than ‘Board certified’. Board certification should be obtained within 5 years of graduation.
The surgeon’s license and hospital privileges should be in good standing. It is possible to practice with limitations on privileges or some form of supervision. This fact is unlikely to appear on the surgeon’s website and an inquiry of the hospital and licensing agency is required to uncover it.
The surgeon should have colleagues; a neurosurgeon in solo practice can too easily get out of touch with modern techniques and does not have the regular oversight of partners whose own reputations and practice are impacted by the performance of their entire group.
And then what about their quality? Some surrogate indicators include the following.
Regular participation in quality improvement activities such as audits or mortality and morbidity conferences that expose his or her practice to the review of others.
Regular participation in continuing education activities (preferably those sponsored and developed by professional organisations rather than travel agencies).
Held in esteem by referring physicians. This is a slippery one, as there are many things that can induce loyalty unrelated to quality of outcome, but lack of regular referrals from physicians who see the outcomes of the neurosurgeon is surely a worrisome thing.
There are a few other indicators of quality for which there is some evidence.
Surgical volume: a surgeon should operate regularly. The exact parameters (how many cases per year, how many hours of operating) are not known but most competent operators seem to maintain skill by doing something in the range of 200–400 operations per year.
Familiarity with the disease: there are conditions that are relatively common and straightforward such as hydrocephalus and subdural haematoma that fall into the range of practice of any neurosurgeon. For less common, more technically demanding conditions, such as cerebral aneurysm or vestibular schwannoma, special interest and unusual volume are important indicators of quality.1
But other indicators are of questionable value.
National or international prominence: this can be an indicator of excellent marketing (make no mistake, much of what is presented at neurosurgical professional meetings is more about marketing than about science) but does not necessarily correlate with excellent outcomes.
High surgical fees: what induces people to pay outrageous fees for services that can be obtained in equal quality for far less have more to do with means, status, location and marketing than with excellent outcomes.
Patient endorsements: while it is not a bad thing if a neurosurgeon’s patients are pleased with their experience of a frightening and dangerous episode of surgical care, they are hardly objective observers of outcome. Almost everyone has the experience of a kindly well meaning and incompetent doctor with a large and loyal patient following because their communication skills are excellent.
Number of professional liability allegations: useless. The correlation between patient injury and the filing of a professional liability claim is weak.2 In the USA it is nearly impossible to practice neurosurgery and avoid such lawsuits. In many other countries the frequency of such claims is so low that it is not a useful measure of quality.
And finally there are a couple of difficult questions.
Does technical expertise trump personality? My personal answer is “absolutely not!” Technical expertise in neurosurgery is not such a rare commodity that anyone should have to put up with abusive or insensitive behaviour. In my experience, the surgeon who cares so little for his patients that he treats them this way is likely to focus so intensely on the technical aspects of surgery that critical preoperative and postoperative care issues are given short shrift or left to others.
Do you want a fighter pilot on the other end of your aneurysm clip? The practice of neurosurgery requires the ability to make difficult decisions rapidly with incomplete information, high degrees of technical skill and concentration, and a lot of high cost, high tech equipment purchased by someone else and loaned to you with the expectation that it will be wisely used. On the other hand, do you really want a ‘top gun’ personality making the decision between a technical tour de force that leaves no visible meningioma on your 65-year-old mother’s carotid artery or leaving a bit behind to be followed and possibly treated with radiosurgery 10 years hence? Personally, I want skill tempered with good judgement.
Personally, I want skill tempered with good judgement
In summary, I would look for a properly qualified neurosurgeon in good standing who operates a lot, specialises in the disease of interest and cares about neuroscience. He or she should communicate well with patients and doctors, and temper confident skill with humble judgment. Let us hope that in the future we will have validated and adjudicated patient outcomes to supplement these surrogate markers of excellence in the practice of neurosurgery. At the moment there are no useful outcome measures.
Competing interests The author is a neurosurgeon!
Provenance Commissioned; not externally peer reviewed.