The Question Patients Cannot Answer

Physicians who earn their living performing procedures are trained, above all, to intervene. Their work unfolds in a visible theater where success is measured in terms of witnessed dexterity, decisiveness, and outcomes. Yet, beneath the technical stage of the procedure room lies another theater, less visible but often just as important. It is a moral and relational one bound by personal ethics, professional judgment, and the capacity to defend, withstand, or reconcile institutional pressures.

This, however, is the subject of a different essay.

Proceduralists are rarely one thing. First and foremost, they are technicians, of course, and patients understandably would like to choose them on that basis. Often, patients express the desire to choose their doctors based on published results of technical successes. Strangely, however, only a handful of surgical fields offer robust, publicly accessible risk-adjusted outcomes data that patients can use to compare institutions. Even fewer allow meaningful comparisons among individual physicians. Cardiac and thoracic surgery is the clearest example. Others include bariatric surgery, orthopedics (for joint replacement), transplant surgery, and oncology care through cancer registries and hospital rankings. Each offers varying degrees of transparency and accessibility to individual patients.

A few recent observations of physician practices in my own specialty, which is interventional pulmonology, prompted me to write this introductory essay. In recent years, rapid growth, driven in part by technological progress, has enabled earlier diagnosis of diseases such as lung cancer and improved the ability to palliate, and sometimes cure, patients with benign and malignant central airway obstruction (tracheal and bronchial tumors). The procedural repertoire is growing, and with it, the promise of even more meaningful clinical impact.

Yet the specialty still lacks a national, publicly accessible outcomes registry.

This absence is easy to explain. Considering the difficulties encountered in standardizing outcomes and adjusting for risks, the challenges are substantial. Clear endpoints, such as mortality and procedure-related complications, must be defined. Sufficient procedural volumes to make statistical analyses meaningful are required before even contemplating the creation of such a database. Risk adjustments must account for the heterogeneity and severity of diseases and the frequent coexistence of other medical disorders. Standardized techniques must also be identified, even as innovation continues to reshape clinical practice. Perhaps interventions such as bronchoscopic ablation of an airway tumor, or airway stent insertion using a particular device are good places to begin, as both are performed in academic and community-based practice alike. Most importantly, embarking on such an endeavor demands coordinated leadership and the enthusiastic support of the medical specialty’s professional societies.

As of now, however, patients who require these often life-altering or life-saving procedures have little knowledge about how to best choose their doctors.

I find it increasingly puzzling, therefore, that a profession that prides itself on evidence-based decision-making, statistical rigor, and life-long learning after prolonged apprenticeship-style training, is unable to provide patients with what they want most — the answer to their question:

“Who is the best interventional pulmonologist for me?”

This essay is the first in a short series exploring how patients choose procedural physicians, and what current systems of measurement fail to capture.