Surgeon Perceptions Research Articles

Preoperative quantification of perceptions of surgical frailty

BackgroundFrailty has gained recognition as an objective measure of a patient's physiologic reserve that ideally can replace the subjective biases of surgeons. In this study, we sought to examine the concordance between patient and attending surgeon perceptions of the patient's “fitness” before surgery. We then correlated these ratings with the patient's objective frailty scores. MethodsPatients were prospectively enrolled from urology, general surgery, and surgical oncology clinics. Patients were asked to rate their ability to withstand the physical stress of the scheduled surgery on a visual analog scale. The operating surgeon then independently rated his assessment of the patient's ability to withstand surgery blinded to the patient's self assessment. ResultsA total of 203 patients were included. Median patient age and body mass index were 62 (range = 21–87) years and 28.1 kg/m2 (18.0–53.1), respectively. The majority of patients were white (67%) and male (60.6%). A patients' self-assessment showed no correlation with their age; however, surgeons' ratings showed a positive correlation with patients' age. Patients' self-rated scores showed a positive correlation with their frailty score, although surgeons' ratings showed a stronger correlation. However, when stratified by age group, the positive correlation and predictive ability were lost (P value = 0.198). ConclusionsAlthough age is an established risk factor, our data demonstrate surgeons may place an overreliance on a patient's age in place of an objective measure of physiologic reserve. Conversely, patients tended to overestimate their ability to withstand the stress of surgery, possibly leading to unrealistic expectations of their recovery and outcomes.

Development of a Physical Simulator Model for Developing and Evaluating Endoscopic Endonasal Surgical Skills

Introduction: Endoscopic endonasal surgical approaches are becoming an important option in skull base surgery, but require the development of a unique skill set in the context of a team approach. There is a need for developing and evaluating endoscopic endonasal surgical skills outside of the operating room for training purposes and for proficiency assessment as has been done in other surgical disciplines. In this study, we test the ability of five simulated surgical tasks to discriminate between surgeons based on skill level and also investigate surgeon perceptions of workload and validity.

Discordance in Current Procedural Terminology Coding for Foot and Ankle Procedures Between Residents and Attending Surgeons

Because of the importance of current procedural terminology (CPT) coding in both resident education evaluation and practice management, this study was undertaken to evaluate the correlation and interrater reliability between residents and attending physicians in CPT coding for orthopedic foot and ankle surgeries as well as to determine attending surgeons' and residents' familiarity with and confidence in the coding process. CPT codes from resident case logs were compared with those submitted by attending surgeons, and Pearson's correlation coefficient and interrater reliability were calculated to examine coding congruency. An online survey was also used to examine attending surgeon and resident perceptions and habits regarding CPT codes and the coding process. CPT codes recorded by 20 residents (1164) were compared with those recorded by 3 attending foot and ankle surgeons (1259). Correlation between attending and resident codes was poor (r = -0.015). Interrater reliability demonstrated a kappa value of 0.04, indicating poor agreement. Compared with attending CPT coding, residents concordantly coded 42% of the time, with an individual resident range from 2% to 65%. Additionally, 43% of residents reported being uncomfortable about foot and ankle CPT coding, and they reported rarely or never discussing CPT codes with attending surgeons in the perioperative period. Resident and attending surgeon concordance in CPT coding for foot and ankle procedures is poor, and residents have a low level of confidence in logging CPT codes, possibly because of a lack of training and preparation in coding. Because CPT coding is used not only for practice management but also has implications for evaluating institutions by accreditation bodies, educational initiatives to improve resident confidence and accuracy with CPT coding may be warranted.

Comparison of Patient and Surgeon Perceptions of Adverse Events After Adult Spinal Deformity Surgery

Survey based on complication scenarios. To assess and compare perceived potential impacts of various perioperative adverse events by both surgeons and patients. Incidence of adverse events after adult spinal deformity surgery remains substantial. Patient-centered outcomes tools measuring the impact of these events have not been developed. An important first step is to assess the perceptions of surgeons and patients regarding the impact of these events on surgical outcome and quality of life. Descriptions of 22 potential adverse events of surgery (heart attack, stroke, spinal cord injury, nerve root injury, cauda equina injury, blindness, dural tear, blood transfusion, deep vein thrombosis, pulmonary embolism, superficial infection, deep infection, lung failure, urinary tract infection, nonunion, adjacent segment disease, persistent deformity, implant failure, death, renal failure, gastrointestinal complications, and sexual dysfunction) were presented to 14 spinal surgeons and 16 adult patients with spinal deformity. Impact scores were assigned to each complication on the basis of perceptions of overall severity, satisfaction with surgery, and effect on quality of life. Impact scores were compared between surgeons and patients with a Wilcoxon/Kruskal-Wallis test. Mean impact scores varied from 0.9 (blood transfusion) to 10.0 (death) among surgeons and 2.3 (urinary tract infection) to 9.2 (stroke) among patients. Patients' scores were consistently higher (P < 0.05) than surgeons in all 3 categories for 6 potential adverse events: stroke, lung failure, heart attack, pulmonary embolism, dural tear, and blood transfusion. Three additional complications (renal failure, non-union, and deep vein thrombosis) were rated higher in 1 or 2 categories by patients. There was substantial variation in how both surgeons and patients perceived impacts of various adverse events after spine surgery. Patients generally perceived the impact of adverse events to be greater than surgeons. Patient-centered descriptions of adverse events would provide a more complete description of surgical outcomes.

International surgical clerkship rotation: perceptions and academic performance

BackgroundConcerns about international training experiences in medical school curricula include the effect on student learning. We studied the educational effect of an international elective integrated into a traditional third-year (M3) surgical clerkship. MethodsA 1-week surgical elective in Haiti was available to M3 students during the conventional 8-week surgical clerkship each year for the 4 academic years 2008 to 2011. The authors collected student and surgeon perceptions of the elective using a mixed-methods web-based survey. Statistical analysis compared the academic performance of participating M3s relative to nonparticipating peers. ResultsTwenty-eight (100%) students (41 trip weeks) and 3 (75%) surgeons responded. Twenty-five (89%) students believed the elective provided appropriate clinical training. Surgeon responses were consistent with students' reported perceptions.Strengths included unique clinical experiences and close interactions with faculty. Criticisms included recurring overwhelming clinical responsibilities and lack of local provider involvement.Academic performance of participants versus nonparticipants in the same clerkship term were statistically insignificant. ConclusionsThis study demonstrates the feasibility of integrating global health experiences into traditional medical student clinical curricula. The effects on less tangible attributes such as leadership skills, fostering teamwork, and cultural competency require future investigation.

Work Breaks during Minimally Invasive Surgery in Children: Patient Benefits and Surgeon's Perceptions

We recently reported that 5-minute work breaks every 25 minutes during long lasting laparoscopy in children (intermittent pneumoperitoneum [IPP] scheme) decrease the surgeon's stress markers such as saliva cortisol and heart rate and improve time-concentration scores significantly. Data on the impact of breaks on the patient and on the surgeon's perception of breaks, however, are still lacking. We present the comprehensive biometry data of a randomized trial including 26 patients operated with (IPP) and 26 patients without breaks (continuous pneumoperitoneum [CPP]). Moreover, we analyzed the surgeon's perception of the break scheme using behaviorally anchored 10-point rating scales. There were no significant intergroup differences in the pooled patients' hemodynamics including cardiac output, blood gas readings, and temperature during and after the operation. Infants <1 year of age undergoing IPP versus CPP produced significantly higher urine volumes (1.60 ± 1.8 vs. 0.67 ± 1.00 mL/h/m2, p < 0.05). The overall area under the curve (AUC) of their cardiac output was 106.7 ± 41.1 (IPP) versus 78.0 ± 41.3 (CPP). This difference became significant during long operations (p < 0.05 for AUC 150 to 270 minutes). Surgeon's break perception and acceptance: team communication shifted from an implicit "mute communication" to an explicit way "issues are outspoken" by +4.7 ± 2.6 (p < 0.05) with improved coherence between operator and assistants (+3.9 ± 2.1). However, when questioned whether there was one particular welcome (5.1 ± 1) or extremely disturbing (6.4 ± 2.4) break during the entire procedure, the latter yielded a higher score (p > 0.05). Acceptance varied according to the surgeon's own esteem of his/her work style. Operators with high self-ratings for "fast" were inclined to put up with shorter breaks ("fast" vs. "slow" = 3.5 ± 1.4 vs. 5.5 ± 0.7, p < 0.05). Overall the scheme was approved (5.9 ± 3.2). A break scheme has no detrimental effect on patient physiology and is beneficial in infants. It needs careful tailoring to both the surgeon's work situation and self-esteem to gain acceptance.

Surgeon perceptions and patient outcomes regarding proximal ulna fixation: a multicenter experience

Our objective was to determine surgeon- and patient-based perceptions concerning proximal ulna fixation, including rates of implant removal and overall satisfaction. Orthopedic surgeons were surveyed about surgical experience managing proximal ulna fractures and their perception regarding implant removal/revision. A retrospective chart review identified all patients who underwent fixation for proximal ulna fractures and osteotomies between January 2004 and December 2008. In total, 583 surgeons responded to the survey (80%). Of these, 67% believed that their implant removal rate was the same as other surgeons whereas 31% believed that their rate was lower. Seventy-one percent believed that patients required hardware removal less than 30% of the time. Ninety-eight percent believed that they were the same surgeons to remove the implant. In total, 138 consecutive patients were surveyed about their proximal ulna implant. Plating was performed in 80 (58%), and tension banding was performed in 55 (40%). The overall rate of implant removal was 64.5% (89 of 138) at 18.8 months. A second surgeon performed the removal in 68 patients (76%). Of the 49 patients without implant removal, 11 (22%) reported satisfaction with the implant and 19 (39%) reported a functional impairment because of the implant. If guaranteed a safe surgery, 36 (73%) would have the implant removed. Surgeons underestimate the rates of proximal ulna implant removal and patient dissatisfaction. Because 76% of the implant removals were performed by a second surgeon, in sharp contrast to the surgeon-perceived rate of 2%, we challenge surgeons to become more aware of this problem in their practices.

Disparities between resident and attending surgeon perceptions of intraoperative teaching

Background This study aimed to assess attending surgeon and resident recall of good and poor intraoperative teaching experiences and how often these experiences occur at present. Methods By web-based survey, we asked US surgeons and residents to describe their best and worst intraoperative teaching experiences during training and how often 26 common intraoperative teaching behaviors occur in their current environment. Results A total of 346 residents and 196 surgeons responded (51 programs; 26 states). Surgeons and residents consistently identified trainee autonomy, teacher confidence, and communication as positive, while recalling negatively contemptuous, arrogant, accusatory, or uncommunicative teachers. Residents described intraoperative teaching behaviors by faculty as substantially less frequent than faculty self-reports. Neither sex nor seniority explained these results, although women reported communicative behaviors more frequently than men. Conclusions Although veteran surgeons and current trainees agree on what constitutes effective and ineffective teaching in the operating room, they disagree on how often these behaviors occur, leaving substantial room for improvement.

Whatʼs New in Orthopaedic Trauma

The field of musculoskeletal trauma continues to benefit from advances in basic science, improved methods of treatment (both operative and nonoperative), innovation in surgical devices, and more sophisticated research methodology, with emphasis on comparative clinical trials and appropriate assessment of outcomes. The emphasis on evidence-based management continues in the literature and in presentations at academic conferences. For this year’s summary of advances in orthopaedic traumatology, the authors again reviewed all issues of Acta Orthopaedica, Clinical Orthopaedics and Related Research, Injury, The Journal of Bone and Joint Surgery (both American and British volumes), Journal of Orthopaedic Trauma, Journal of Shoulder and Elbow Surgery, and The Journal of Trauma . Selected articles from other journals were also included. Finally, presentations from the annual meetings of the Orthopaedic Trauma Association (OTA) and the American Academy of Orthopaedic Surgeons (AAOS) were reviewed. Articles and presentations that represent Level-I and Level-II evidence are reviewed in this article along with other articles of clinical importance in the opinion of the authors. The rigorous documentation of outcome, especially from the patient’s perspective, has been one of the major advances in orthopaedic surgery over the past decade. Two studies investigated differences between patient and surgeon perceptions of outcome after orthopaedic trauma. One study evaluated patients six months after they had sustained a “major” fracture1. Surgeons were more satisfied with their patients’ progress than the patients themselves were. The only factor associated with surgeon satisfaction was fracture-healing. Objective injury and treatment factors were not associated with patient satisfaction in terms of progress. Attributing blame of the injury to others was associated with patient satisfaction in terms of progress, whereas blame, the use of a lawyer, and female sex were associated with patient satisfaction in terms of recovery1. The Lower Extremity Assessment Project (LEAP) investigators reported …

Disparities between resident and surgeon perceptions of intra-operative teaching

Disparities between resident and surgeon perceptions of intra-operative teaching

Differences in Nurse and Surgeon Perceptions of Teamwork: Implications for Use of a Briefing Checklist in the OR

The quality of teamwork among health care professionals is known to affect patient outcomes. In the OR, surgeons report more favorable perceptions of communication during procedures and of teamwork effectiveness than do nurses. We undertook a quality improvement project in the Veterans Health Administration to confirm reported teamwork differences between perioperative nurses and surgeons and to examine the implications of these differences for improving practice patterns in the OR. The Safety Attitudes Questionnaire, which measures safety culture, including the quality of communication and collaboration among health care providers who routinely work together, was administered in 34 hospitals. Perioperative nurses who participated in the survey rated teamwork higher with other nurses than with surgeons, but surgeons rated teamwork high with each other and with nurses. On five of six communication and collaboration items, surgeons had a significantly more favorable perception than did perioperative nurses. To increase the likelihood of success when implementing the use of checklist-based crew resource management tools, such as the World Health Organization's Surgical Safety Checklist, project leaders should anticipate differences in perception between members of the different professions that must be overcome if teamwork is to be improved.

Surgeon Perceptions and Reported Complications in Spine Surgery

Systematic review. To define the term "complications" from the spine surgery literature and contrast this with definitions from other federal institutions, to summarize the incidence of adverse events in cervical, thoracic, and lumbar spine surgery, to include the factors that contribute to these events, and to determine the relationship between complications and patient centered outcomes. Efforts to understand and reduce complications in medicine, and spine surgery in particular have been hampered as a result of the lack of a meaningful and universally acceptable definition. The complex field of spine surgery has been a particularly challenging area for the development of a consensus to constructively describe these "undesirable/unanticipated developments arising during or out of the delivery of health care." Furthermore, an overall understanding of expected complication rates after major spine surgery is lacking. A systematic review of the English literature was undertaken for articles published between 1990 and December 2008. Electronic and federal databases and reference lists of key articles were searched to identify articles defining complications and reporting rates of spine surgical complications. Two independent reviewers assessed the level of evidence quality using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria and disagreements were resolved by consensus. RESULTS.: The definitions for complications in the spine literature and federal agencies are inconsistent and at times conflicting. Mortality rates for cervical spine and lumbar spine surgery are <1%. For thoracic spine surgery, rates range from 0.3% to 7%. Complication rates range from 5% to 19%, 7% to 18%, and 4% to 14% after cervical, thoracic, and lumbar spine surgery, respectively. Findings from a single study indicate that major complications may have an impact on 1-year self-perceived general health. However, minor complications may not. We define a complication as an unintended and undesirable diagnostic or therapeutic event that may impact the patient's care. Complications should be recorded and analyzed relative to disease severity, patient comorbidities, and ultimately their effect on patient outcomes. Further work needs to be done to develop a complication risk impact index that has the ability to help us assess and communicate the interaction of patient comorbidities and complication severity on patient centered outcomes.

The Eighty-Hour Workweek: Surgical Attendings' Perspectives

The year 2008 was a sentinel year in resident education; this was the first graduating general surgery class trained entirely under the 80-hour workweek. The purpose of this study was to evaluate attending surgeon perceptions of surgical resident attitudes and performance before and after duty-hour restrictions. An electronic survey was sent to all surgical teaching institutions in North Carolina. Both surgeon and hospital characteristics were documented. The survey consisted of questions designed to assess residents' attitudes/performance before and after the implementation of the work-hour restriction. In all, 77 surveys were returned (33% response rate). The survey demonstrated that 92% of educators who responded to the survey recognized a difference between the restricted residents (RRs) and the nonrestricted residents (NRRs), and most respondents (67%) attributed this to both the work-hour restrictions and the work ethic of current residents. Most attending surgeons reported no difference between the RRs and the NRRs in most categories; however, they identified a negative change in the areas of work ethic, technical skills development, decision-making/critical-thinking skills, and patient ownership among the RR group. Most surgeons expressed less trust (55%) with patient care and less confidence (68%) in residents' ability to operate independently in the RR group. Eighty-nine percent indicated that additional decreases in work hours would continue to hamper the mission of timely and comprehensive resident education. The perception of surgical educators was that RRs are clearly different from the NRRs and that the primary difference is in work ethic and duty-hour restrictions. Although similar in most attributes, RRs are perceived as having a lower baseline work ethic and a less developed technical skill set, decision-making ability, and sense of patient ownership. Subsequent study is needed to evaluate these concerns.

Surgeon Perceptions of Natural Orifice Translumenal Endoscopic Surgery (NOTES)

IntroductionIf proven feasible and safe, Natural Orifice Translumenal Endoscopic Surgery (NOTES) would still need acceptance by surgeons if it were to become a mainstream approach. MethodsThree hundred fifty-seven surgeons responded to a preliminary survey describing NOTES and were asked to rate the importance of various surgical considerations and (assuming availability and safety) if they would choose to undergo and/or perform cholecystectomies by NOTES or laparoscopy and why. ResultsThe risk of having a complication was considered most important. NOTES was theorized to be riskier and to require greater skill than laparoscopy but to potentially cause less pain and convalescence. Nearly three-fourths (72%) of surgeons expressed interest in NOTES training which correlated with younger age, SAGES membership, minimally invasive surgery specialization, and flexible endoscopic volume. Forty-four percent would like to introduce NOTES cholecystectomy into their practices. Among those not preferring NOTES, 88% would adopt NOTES if data showed improved outcomes over laparoscopy. Finally, only 24% would choose to undergo cholecystectomy themselves by NOTES, believing it to be too new and riskier than laparoscopy. DiscussionThe risk of having a complication is the greatest concern among surgeons, and safety will affect NOTES acceptance. ConclusionThe results of this survey seem to justify more focused future investigations.

Surgeon Perceptions of Minimally Invasive Spine Surgery

Background Interest in minimally invasive surgery (MIS) of the spine has driven the development of new and innovative techniques to treat an ever wider range of spinal disorders. Despite these new advances, spine surgeons have been slow in adopting MIS into their clinical practice. This study aims to provide a better understanding of the factors that have led to limited incorporation of these procedures into their practices. Methods Eighty-seven spine surgeons completed a questionnaire related to their perceptions of MIS. Respondents were asked to comment on their perceptions regarding the limitations and advantages of minimally invasive spine surgery. Survey results were then analyzed for both overall opinions and opinions based on the amount of MIS utilization in the respondents’ current practices. Results The top 3 identified limitations of MIS of the spine were technical difficulty, lack of convenient training opportunities, and radiation exposure. Of these respondents, spine surgeons experienced in MIS were concerned more with radiation exposure than the lack of training opportunities. In contrast, spine surgeons with little MIS experience cited the lack of training opportunities as the most significant limitation. There was little concern related to the limited proven clinical efficacy of MIS of the spine. Discussion Technical factors, training opportunities, and radiation exposure appear to be the major obstacles to MIS of the spine. Most spine surgeons believe that MIS leads to faster return to daily activities, better long-term function, and decreased hospitalization. This may explain why most surgeons did not cite a lack of proven efficacy as a major limitation to MIS. These findings indicate that the widespread adoption of MIS of the spine will likely be driven through relatively simple means, such as improved training programs that strive to decrease the technical difficulty and limit radiation exposure of these procedures. It is unlikely that extensive clinical data alone, without such improved training programs, will be sufficient to drive widespread use of minimally invasive spine surgery.

Surgeon Perceptions of Minimally Invasive Spine Surgery

BackgroundInterest in minimally invasive surgery (MIS) of the spine has driven the development of new and innovative techniques to treat an ever wider range of spinal disorders. Despite these new advances, spine surgeons have been slow in adopting MIS into their clinical practice. This study aims to provide a better understanding of the factors that have led to limited incorporation of these procedures into their practices.MethodsEighty-seven spine surgeons completed a questionnaire related to their perceptions of MIS. Respondents were asked to comment on their perceptions regarding the limitations and advantages of minimally invasive spine surgery. Survey results were then analyzed for both overall opinions and opinions based on the amount of MIS utilization in the respondents’ current practices.ResultsThe top 3 identified limitations of MIS of the spine were technical difficulty, lack of convenient training opportunities, and radiation exposure. Of these respondents, spine surgeons experienced in MIS were concerned more with radiation exposure than the lack of training opportunities. In contrast, spine surgeons with little MIS experience cited the lack of training opportunities as the most significant limitation. There was little concern related to the limited proven clinical efficacy of MIS of the spine.DiscussionTechnical factors, training opportunities, and radiation exposure appear to be the major obstacles to MIS of the spine. Most spine surgeons believe that MIS leads to faster return to daily activities, better long-term function, and decreased hospitalization. This may explain why most surgeons did not cite a lack of proven efficacy as a major limitation to MIS.These findings indicate that the widespread adoption of MIS of the spine will likely be driven through relatively simple means, such as improved training programs that strive to decrease the technical difficulty and limit radiation exposure of these procedures. It is unlikely that extensive clinical data alone, without such improved training programs, will be sufficient to drive widespread use of minimally invasive spine surgery.

1229: Surgeon's Perceptions and Injuries During and after Urologic Laparoscopic Surgery

1229: Surgeon's Perceptions and Injuries During and after Urologic Laparoscopic Surgery

The use of physical biomodelling in complex spinal surgery

Prior studies have suggested that biomodels enhance patient education, preoperative planning and intra-operative stereotaxy; however, the usefulness of biomodels compared to regular imaging modalities such as X-ray, CT and MR has not been quantified. Our objective was to quantify the surgeon's perceptions on the usefulness of biomodels compared to standard visualisation modalities for preoperative planning and intra-operative anatomical reference. Physical biomodels were manufactured for a series of 26 consecutive patients with complex spinal pathologies using a stereolithographic technique based on CT data. The biomodels were used preoperatively for surgical planning and customising implants, and intra-operatively for anatomical reference. Following surgery, a detailed biomodel utility survey was completed by the surgeons, and informal telephone interviews were conducted with patients. Using biomodels, 21 deformity and 5 tumour cases were performed. Surgeons stated that the anatomical details were better visible on the biomodel than on other imaging modalities in 65% of cases, and exclusively visible on the biomodel in 11% of cases. Preoperative use of the biomodel led to a different decision regarding the choice of osteosynthetic materials used in 52% of cases, and the implantation site of osteosynthetic material in 74% of cases. Surgeons reported that the use of biomodels reduced operating time by a mean of 8% in tumour patients and 22% in deformity procedures. This study supports biomodelling as a useful, and sometimes essential tool in the armamentarium of imaging techniques used for complex spinal surgery.

Discordance between the patient’s and surgeon’s perception of complications following hernia surgery

The study was undertaken in order to assess the degree of concordance between the patient's and surgeon's perceptions of adverse events after groin hernia surgery. 206 patients who underwent elective surgery for groin hernia at Samariterhemmet, Uppsala, Sweden in 2003 were invited to a follow-up visit after 3-6 weeks. At this visit the patient was instructed to answer a questionnaire including 12 questions concerning postoperative complications. A postoperative history was taken and a clinical examination performed by a surgeon who was not present at the operation and did not know the outcome of the questionnaire. All complications noted by the physician were recorded for corresponding questions in the questionnaire. 174 (84.5%) patients attended the follow up, 161 men and 13 women. A total of 190 complications were revealed by the questionnaire, 32 of which had caused the patient to seek help from the health-care system. There were 131 complications registered as a result of the follow-up clinical examinations and history. Kappa levels ranged from 0.11 for urinary complications to 0.56 for constipation. In general, the concordance was poor. These results emphasise the importance of providing detailed information about the usual postoperative course prior to the operation. Whereas the surgeon, from a professional point of view, has a better idea about what should be expected in the postoperative period and how any complications should be categorised, only the patient has a complete picture of the symptoms and adverse events. This makes it impossible to reach complete agreement between the patient's and surgeon's perceptions of complications, even under the most ideal circumstances.

Patient, Caregiver, and Surgeon Perceptions of Quality of Life Following Anterior Skull Base Surgery

To estimate the agreement between surgeons' and lay caregivers' quality-of-life (QOL) perceptions of patients undergoing major skull base surgery. Cohort survey of patients who had undergone anterior skull base tumor excision. University-affiliated medical center. Thirty-five patients and their lay caregivers participated in the study. A triple survey was performed: each patient and his or her caregiver were asked to answer 35 questions related to 6 distinct QOL domains: role of performance, physical function, vitality, pain, specific symptoms, and effect on emotions. The composite health-related QOL of the patients was also rated on an ordinal scale by 3 surgeons who participated in the operation and follow-up. An overall significant agreement was found between patients' and caregivers' scores at the group level (mean scores of each domain) and individual level (patient-caregiver pairs) (r = 0.76, P<.001). There was a minor correlation in the effect on emotions domain and no correlation in the pain domain. We found no correlation between the surgeons' and patients' ratings. The operating surgeons tended to overate their patients' QOL. The study results show that the surgeon's perception of his or her patient's QOL is not sufficiently accurate to correctly estimate patients' QOL status. These judgments should come from the patient or from the caregiver, whose perception can be used in clinical trials as a proxy for estimation of a patient's QOL.