The problem with Shouldice or The most dangerous phrase in the English language- “We’ve always done it this way.”

I have just been chastised online for daring to criticize the Shouldice clinic on Twitter.  So I’m going to outline some of my problems with the Shouldice clinic, which is held up around the world as a great Canadian healthcare success story.  I am not going to comment on specific cases, just generalities here.   I have never worked at, or been involved with the Shouldice clinic, so this blog comes from my own professional opinion as a general surgeon/hernia fixer and defender of evidence based medicine and socialized healthcare, discussions with many patients who have gone or are considering going to the Shouldice clinic, going to a talk some years back given by a surgeon who worked there, and the Shouldice clinic website.

The Shouldice Clinic is a private clinic operating in the Toronto area which has been open for decades.  It was originally founded during World War 2 to allow for young men to have their hernias repaired before going off to fight.  It was then allowed special licence by the Ministry of Health to continue operating.  It has been repairing hernias for decades.  It was recently taken over by a private company and is no longer in the hands of the original Shouldice family.  The clinic sits on luxurious grounds and offers one thing and one thing only.  Hernia repairs at the Shouldice are done with local anesthetic, no mesh insertion, and with a long stay in their hospital to recover.

Now as a confession of a conflict of interest here, I am a general surgeon who does lots of hernia repairs at a hospital about an hours drive from the Shouldice.   I think 3 or 4 tomorrow in fact.   The standard of care when the Shouldice was formed was a primary (suture) repair and lots of days in hospital recovering from the pain of having your own tissues reamed together to repair the hernia.  I really don’t want to get into a lot of detail about the complex world of hernia repair here, but the world surgical community has moved on from primary repair with lots of inpatient days and the Shouldice has not.  Is this because Shouldice thinks this is good care?  Is it because they make lots of money off the patients and the taxpayers?  Or is it because, here it comes, that dangerous phrase “We’ve always done it this way”?  Likely some of all three.   Another confession, I also make money doing hernia repairs, but I don’t make nearly as much as the Shouldice does off their patients.  The “standard of care” now is to do hernia repairs with mesh, a plastic like substance which allows for less pain (if inserted properly), earlier return to work, and decreased recurrence rates.  If I was doing the Shouldice repair with no mesh and keeping my patients in hospital for 5 days after hernia surgery, I would probably have my competence questioned, and with good reason.  I would also, I hope, be getting angry calls from our hospitals administrators asking what the hell I was doing keeping patients in hospital for so long after such a simple procedure.  Groin hernia repair is a day surgery procedure in Ontario (anywhere but the Shouldice clinic) with no overnight stay required, unless complications arise or in very frail or sick patients.  I cannot recall a patient ever having been in hospital for 5 days after elective hernia repair.  The Shouldice clinic admits patients the day BEFORE their surgery.  I find this mind boggling- this approach was abandoned in the rest of medicine decades ago.  I honestly cannot recall the last time I admitted a patient the night before surgery, except when I was a clinical clerk, and that is going back a long time now.  The vast majority of procedures are day surgery, or what we call same day admits, where they are admitted (usually after a lot more major surgery than hernia repair) after their operation.  Being in hospital has its own set of complications, with hospital acquired infections, pneumonias, blood clots in the legs or the lungs, and other problems.  But my main problem with this approach as a taxpayer is that this is a huge waste of healthcare dollars.  The Shouldice clinic charges patients for a private room for up to 5 days (this adds up to many hundreds of dollars).  Sometimes this cost is paid out by private insurance companies if the patient has a health benefits plan, or by the patients themselves.  The Shouldice then also bills the Ministry of Health for each inpatient day a patient stays overnight.  So yes, that is you, the taxpayer, footing the bill for unnecessary care being provided by a private company.  Now some of the Shouldice clinic patients come from out of country and should be paying for all of their care but what this percentage is, I do not know.  Shouldice also does not require a doctor’s referral to see patients and bill the Ontario health care system.  As a specialist, I am not allowed to bill OHIP to see patients without a referral from another doctor, and so we see the double standard growing.

Now the Shouldice clinic does do something I agree with in part.  Patients are required to be within 20 % of their ideal body weight, and are refused surgery at the Shouldice if they do not meet this criteria or lose the weight.  The average North American is gaining 1-2 lbs per year, and obesity is a clear risk factor in hernia recurrence.  The more you weigh and the more weight you gain after hernia repair, the more your risk of recurrence rises.   Now I do on call, a lot, at a smaller hospital, and it is not my practice to refuse hernia repair to overweight patients, unless it is a very large, recurrent hernia, in a very obese or frail patient, where there is little risk of bowel obstruction.  Odds are, I am going to be the one digging out a blocked or gangrenous piece of bowel from this hernia in the middle of the night if I do not fix it electively.  So while I agree with patients having to lose weight for some surgeries, I cannot on a practical level be that picky about it. Shouldice of course sends most of the patients it sees back to where they came from, and does not have to worry about complications or ongoing issues from their repairs.  They do not have to do emergency general surgery, ever, how convienient.  Most general surgeons will tell you that they cannot get patients to lose weight before surgery, and that has certainly been my experience.  Shouldice effectively skims off elective procedures in a very healthy, wealthy, and slim segment of the population that is extremely motivated to get their hernias repaired at this private clinic.  This makes any numbers they publish about their recurrence rates completely out of touch with the reality of what myself and other general surgeons are dealing with in our practices.  The other thing about hernia repairs is that recurrence rates have always been very hard to measure.  You have to follow patients for decades to know your real recurrence rate, and patients also are not likely to go back and see the same surgeon (or a clinic) once they have had a recurrence.  This makes anyone’s numbers on hernia repair difficult to interpret, but the Shouldice’s number in particular should be viewed with a grain of salt.  One patient told me he didn’t want to go back to Shouldice with his recurrence because he couldn’t afford it.  I wonder if they know about him, or does he go into their success pile?

Now patients will generally think that more care is better care.  So five days in hospital must be better than no days in hospital, right?  We know that asking patients about their satisfaction with their care has nothing to do with the quality of care provided.  In fact, the most over investigated, over treated patients are likely to think they have great care, when the opposite is the truth.  The Shouldice clinic is a good example of that.  I am also not a fan of the idea of “Centres of Excellence.”  The idea that high volumes of doing one thing only makes you better at it.  I went into general surgery because it’s well, general.  I love doing a variety of different procedures in patients of all ages, sexes, shapes and sizes.  It’s one of the great things about my job.  If I was doing only one operation, the only thing I would be is bored. There is some evidence that using generalists is a cheaper, better way to run a health care system and I believe that.

This is a microcosm of what happens when you introduce private interests into a socialized health care system.  In Australia, the introduction of private healthcare has resulted in exactly what has happened here, albeit on a much larger scale.  A skim off of the healthy and the wealthy to the private system, leaving the public system to deal with the emergency, unhealthy, and poorer patients.  I do not believe in the argument that the Shouldice doing so many repairs allows for more hernias to be repaired in our public system.  The amount of money being drained away by this clinic from the public system is opportunity cost, not just for hernia repairs, but all healthcare spending.

So one last confession.  I had two hernias repaired in November last year.  I got a colleague to do it, with mesh, and a general anesthetic, as day surgery, in one of our local hospitals. I went back to work in less than 48 hours and I am very happy with my scar.  I would recommend this approach (and frequently do) to anyone, including my patients.