[HN Gopher] Outcomes after surgery performed by associate clinic...
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Outcomes after surgery performed by associate clinicians vs doctors
(2021)
Author : barry-cotter
Score : 69 points
Date : 2023-05-06 09:15 UTC (13 hours ago)
(HTM) web link (jamanetwork.com)
(TXT) w3m dump (jamanetwork.com)
| semenko wrote:
| This title has little to do with the article (and keeps
| changing).
|
| This piece compares _non_ -surgeon MDs with _non_ -MDs (medical
| assistants) performing minor surgeries in resource-limited
| settings.
|
| Its a bit of an odd comparison, as the non-MDs have specifically
| trained in a 3-year program to perform minor surgeries
| (CapaCare).
| scott00 wrote:
| The comparison makes sense in the context of Sierra Leone,
| where the study was done. The full article mentions that there
| are very few surgeons there, and that basic surgeries are
| usually done by general MDs or ACs, the types of training
| compared.
|
| Certainly relevant to Sierra Leone and other poor countries,
| probably not relevant to rich countries that generally have
| surgeons do this type of surgery.
| psychphysic wrote:
| Wow they really butchered the meaning here then. Thanks for
| clarifying.
| loaph wrote:
| A minor clarification, it compares MDs to ACs. It says ACs are
| associate clinicians who have an amount training somewhere
| between a nurse and a doctor.
|
| At least the way it's used in the US (I know hacker news is not
| only the US) a medical assistant is someone who has less
| training than a nurse and is often doing administrative work.
| derbOac wrote:
| Fair point, but then the article is demonstrating that people
| trained to do specific types of care actually might have better
| outcomes than generalist education.
|
| This still seems significant to me.
|
| Most of the comments so far seem focused on the fact this was
| done in a resource-limited setting, and comparing specialists
| to generalists. I think that's important to keep in mind, and
| maybe the title was misleading (I didn't post the article).
|
| However, a study like this would be difficult to do in less
| resource-limited settings due to all sorts of issues, some of
| which are due to prudence, and some of which probably less so.
| It's typical of medical research in developed countries to not
| lower the standard of care, so this sort of study might never
| get done otherwise.
|
| So, if you take it for what it is, it's suggesting that a type
| of procedure classically pointed to as a reason for strict
| medical licensing forms in fact does not necessarily work the
| way you think in terms of training background and outcomes. It
| doesn't point to getting rid of licensing, it just suggests
| that a particular type of educational and training background
| does not necessarily result in better outcomes.
|
| This type of finding isn't uncommon in different areas of
| medicine, and the research is often fighting against double
| standards, in the sense that you're not just comparing training
| models, you're comparing time with training program experience
| as well: the alternative training tracks are often newer and
| involve less opportunities to have worked out problems, improve
| certain issues etc.
|
| The irony is that this sort of thing is playing out in the US
| anyway, under the radar. For example, medical schools are often
| reducing coursework to a 1.5 years or even 1 year, meaning that
| a PA with an additional 2-3 years of training post degree often
| has as much experience in the clinic as a new MD. If you took
| them and gave them 3-4 years of additional training, they'd
| probably look similar in outcomes to someone coming out of a
| residency. I might be wrong about that, but healthcare
| administrators are increasingly voting with their dollars and
| apparently don't really see a significant difference in
| outcome.
| renewiltord wrote:
| The truth is that much of medicine is about access to baseline
| care that a highly trained technician can do. You don't need an
| MD for it. And people in the world will suffer for lack of
| access.
|
| In the First World, people get either perfect care or none. The
| discourse is dominated by "tell that to the guy who is paralyzed
| by a bush doctor" and "tell that to parents who lost their kid to
| a charlatan".
|
| Outcomes are everything and a comprehensive public health process
| allows for making tradeoffs in access and quality to ensure
| outcomes.
| thisancog wrote:
| Hernia surgery is not only routine, but quite straight forward.
| Mesh implants are easy to handle and offer a good long-term
| outcome. It's one of the first interventions a beginner in the
| field would learn to master. Also, I am not sure about Sierra
| Leone, but in Europe and the US it is commonly done as a keyhole
| surgery, so it requires some dexterity with the tools. The study
| chose to examine open surgery, which is easier to perform but
| leads to more post-operative complications. Also, they only
| looked at elective surgery, so only at cases when the hernia
| didn't cause further problems demanding a more timely treatment,
| such as bowel constriction or even inflammation or incarceration.
| These can be much more challenging to treat properly.
|
| All that being said, the authors purposefully sought to compare
| performance for a type of surgery that doesn't offer many
| obstacles for somebody new to the job. I guess it helps to
| identify tasks that highly-skilled MDs are freed up from doing
| when they are already scarce in a given location. But it's hardly
| an indicator that much what they do could be done by others, as
| some would probably like to believe.
| George83728 wrote:
| [flagged]
| mberning wrote:
| I have seen quite a few people sewn up after surgery and with few
| exceptions the work that is visible has always looked sloppy to
| me. Crooked incisions, odd spacing of stitches, knots that look
| like 4+ half hitches stacked on top of each other, loose ends
| dangling, etc. I realize the point is not to make your surgery
| look pretty, but damn, I have seen packs of steaks tied up nicer
| than my wife's c-section sutures.
| projektfu wrote:
| There's a number of good reasons and also bad reasons for the
| appearance of incisions.
|
| Crooked incision: flank incisions rarely end up perfectly
| straight and I understand the cesarian in the conscious patient
| is not optimal from a surgical positioning standpoint, though
| good for the patient and baby.
|
| Odd spacing: in live tissue, even when you measure 6mm or
| whatever the tissue seems to move. In addition, there is often
| a bit of subcutaneous tissue that is hidden better with one
| placement over another.
|
| Half hitches: these are bad knots, and one of the failure modes
| of the square knot. If surgeons are leaving lots of these they
| might be careless. However, monofilament suture has more
| likelihood to form them and it's preferred on the skin.
|
| Loose ends: monofilament suture is a little unforgiving and the
| last throw often does not stay in place. This is why 4 throws
| of the square knot is preferred.
|
| Speed: how long do you want your patient to wait for you to
| finish the cosmetic portion of the incision? A model might have
| a plastic surgeon on hand to finish the job.
|
| The layers you cannot see are the important ones from the
| standpoint of no hernia or infection. Hopefully they are all
| done flawlessly, but there cosmesis is not the goal.
| tomatofoot wrote:
| Often times the reward given to a medical student, after
| observing a surgery, is being allowed "close" the incision. Not
| saying it's the case here, but possible.
| [deleted]
| fideloper wrote:
| So should I google "inguinal hernia" or nah
| caycep wrote:
| This reminds me of this Russian patient back in school..."you
| know, back in Russia, you'd be lucky to get a doctor, the nurse
| would usually take out your appendix". Never was sure she wasn't
| pulling my leg...
| doubled112 wrote:
| And if you're a Russian in Antarctica, you might need to do it
| yourself.
| philstephenson wrote:
| I understand the HN mods changing titles of sensationalist
| clickbait, but can we agree that maybe titles of articles in
| scholarly journals should not be changed?
| fn-mote wrote:
| As many commentors note, this is a comparison based on Sierra
| Leone MDs and assistants. Sierra Leone (as the article notes) is
| nearly at the bottom of the international "human development
| index", so very poor - there are not enough surgeons or even MDs
| to treat everyone.
|
| The surgery studied is an elective hernia surgery. In a wealthy
| country this could be done in a "hernia repair factory" and I
| recall, but won't find, a study showing that is the best case:
| the more practice the surgeon has, the better the outcomes. I
| would expect the same results here: if the MDs do not specialize
| in hernia repair, they will be beat by the specialist (even if
| not an MD).
|
| Very importantly, this was a RANDOMIZED clinical trial. That
| means that counfounding variables should be equally distributed
| by the randomization. You generally do not have randomization
| when you are comparing outcomes, e.g., between the Cleveland
| Clinic and the Mayo Clinic in the US. That is a great feature of
| the study. It gives me much more confidence that what they detect
| is a true difference, not caused by a factor like selective
| recruitment.
| nico wrote:
| Great explanation. Thank you!
|
| Maybe we need to start training non-MD specialist to perform
| only specific surgeries.
| amelius wrote:
| I guess this holds until there are complications.
| mortehu wrote:
| There were only 5 MDs and 6 ACs. How confident can we be that
| they are measuring the effects of the groups, and not just the
| individuals? For example, you might get the same result of you
| compare one group of 5 MDs against another group of 5 MDs.
| bookofjoe wrote:
| [flagged]
| wageslave99 wrote:
| In Sierra Leone, please do not edit the titles.
| MontyCarloHall wrote:
| But it's OK to edit them in Guinea or Liberia?
| cwillu wrote:
| In Soviet Russia, title edit YOU.
| ChuckNorris89 wrote:
| Same in current Russia.
| heywhatupboys wrote:
| how many articles here are US specific, but make no mention of
| them being so? Why is it only a problem when it is outside NA?
| Moto7451 wrote:
| The problem is the title is being edited from what it
| actually is. Repeatedly apparently.
|
| "Outcomes After Elective Inguinal Hernia Repair Performed by
| Associate Clinicians vs Medical Doctors in Sierra Leone" is
| the original title.
| 2devnull wrote:
| Just wait: gpt + 3d printing and soon we won't even need the
| medical assistants. Drive thru robo-surgery in the comfort of
| your own motor vehicle.
| jimnotgym wrote:
| I suppose someone who does the same thing every day will get good
| at it.
|
| The balance is probably something about not pushing the
| boundaries of understanding, or developing new techniques due to
| the lack of theoretical knowledge.
| matwood wrote:
| Practice improve performance - obviously. The question I have
| is what happens when a routine surgery has complications?
| Avicebron wrote:
| I would imagine it gets elevated to an MD on call, similar to
| how I would expect a dental assistant to be more proficient
| at routine teeth cleaning than the dentist, but I would
| expect a dentist to be more proficient at something like a
| filling.
| [deleted]
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