Surgeon Volume vs Hospital Volume: Which Matters More?

To the Editor.—  In the editorial¹ discussing the provocative study of the relationship between volume and mortality by Hannan et al,² Garnick and colleagues¹ pose many important questions yet to be considered. They do conclude, however, that "directing patients toward higher-volume surgeons and hospitals for certain procedures has the potential to improve overall patient outcomes." It should also be considered whether so directing patients has the potential for worsening patient outcomes or for worsening the relationship between physician and patient.Being a practicing surgeon who has worked in two very different settings, a large, high-volume clinic and a full-time academic position, I see the potential for harm in somehow directing patients to surgeons who are already "high-volume" practitioners. There is a point beyond which time becomes the enemy and shortcuts to conserve time erode the quality of both technical surgery and the relationship with the patient. The