One of the more intriguing idioms is the expression, “the devil is in the details,” which means that mistakes are usually made in the small details of a project. Usually it is a cautionary tale, involving the need to pay attention to avoid failure, an expression of the concept that many things seem straightforward on the surface, but difficulties, problems, and obstacles are later discovered while trying to implement or execute a task or plan.
Although it seems somewhat of a cliché these days, it still has universal application, including our oncology practices where the details and nuances of our relationships with patients, their families and other health care providers can lead to difficult circumstances. On the other hand, and in a purely clinical context, careful attention to detail and nuance, especially in view of new findings from the literature, can have impact on how we interpret results on a renal mass and determining the extent of risk.
Our main article in this issue suggests how “the devil is in the details” can raise implications for what we do in managing renal cell carcinoma. Yes, all of this may seem intuitive but the implications are significant. As the article on ethical questions illustrates, “the need to disclose physician-specific factors (experience, previous outcomes, training), is controversial. Studies have correlated surgeon volume and objective ratings of surgeon skill with patient outcomes; these findings suggest that disclosure of these surgeon-specific factors may be relevant to patients’ informed decision making. A survey of patients supported this, as a majority of respondents found information on surgeon volume and outcomes essential.”
The issue of disclosure of surgeon experience is very relevant to the surgical management of renal cancer, as Dr Eric Singer and Dr Parth Modi point out. Laparoscopic and robotic-assisted partial nephrectomy have become popular and widely utilized interventions for small renal masses. Several studies have demonstrated a learning curve with the use of these surgical modalities and surgeon experience has been shown to independently predict patient outcomes. So the question arises: to what extent are physicians obligated to disclose their experience? Yes, the devil is in the details. I urge you to discover them by reading this article covering a broad range of ethical issues in renal cancer.
These are troubling and significant questions and in the case of medical ethics have even been described as dilemmas. Since the devil is in the details, we must, by the very nature of our practice be concerned with confronting difficulties, problems, and obstacles on a routine basis and preventing these details from complicating the course of care at a much later time. It is a challenge that reflects the essence of providing high quality value based care.
Robert A. Figlin, MD