Is publishing ‘league tables’ of surgeons’ performance good for patients?

I read today that from later this summer, survival rates for the patients of surgeons in the UK will be made available to patients. The idea is, then, that patients can choose who treats them. According to Health Secretary Jeremy Hunt: The Health Secretary said: “Transparency and participation must be the operating principles of the NHS. They can lead to more effective healthcare, better outcomes, greater accountability and efficiency.”

Regular readers of this blog will know that, generally speaking, I’m all for transparency and patient empowerment. However, while the publication of surgeon mortality statistics may seem like an eminently good idea on the surface to some, I have to say I have some considerable concerns about it.

Is it always wise to place doctors in ‘league table’ of survival performance? Just imagine you take 100 surgeons, and all have very low and quite similar mortality statistics. All of them may be perfectly able and technically sound surgeons with acceptable mortality rates given the known risks of surgery. However, once put in a ‘league table’, half of them will be automatically ‘below average’, with all the stigma and judgment that may bring. Even the person last in the list could, technically speaking, be a perfectly adequately-performing surgeon. He or she, however, looks awful.

I had a conversation recently with a friend who is a cardiothoracic anaesthetist, and he told me that he was aware that a hospital in the UK recently decided to audit the performance of its anaesthetists. One anaesthetist stood out as having significantly worse outcomes than the rest. However, within the department, he was recognised as the most skilled and experienced anaesthetist. The probable explanation? That the surgeons were specifically seeking to have him as their anaesthetist when operating on the riskier cases were complications and poorer outcomes were more likely.

So, a surgeon’s mortality statistics may actually not accurately reflect his or her skill or expertise. Poorer statistics might reflect, for example, the fact that the surgeon attracts sicker people and riskier cases. Maybe, that surgeon is prepared to take on cases that other surgeons reject because they are view as ‘poor candidates’ for anaesthetic or surgery?

The statistics on surgeon’s performance are ‘risk adjusted’, which essentially means allowances are made for surgeons operating on more difficult and riskier cases. However, I wonder how reliable this process is, and even if it is reliable, I suspect some surgeons will have the league table system affect them (either consciously or unconsciously) in terms of their decision-making and the care they offer.

So, while these league tables may be designed to allow patients to make a more informed choice about who they have operate on them, this works both ways of course. Because, surgeons are quite within their rights to choose who they operate on too.

Put yourself in the shoes of a surgeon for a moment, and imagine you know your mortality statistics are to be published. You’re sitting in a clinic and see a patient who ‘needs’ an operation, but who in your view is a poor candidate. Do you think the fact that your mortality statistics are going to be published in any way might affect whether you take this patient on or not?

You can perhaps see what the problem might be here. And the end result might be doctors will be increasingly less inclined to take on challenging cases who may possibly end up being ‘left out in the cold’.

The league table idea is not new. In fact, in the UK, statistics for cardiothoracic surgeons has been available for several years. My friend (the cardiothoracic anaesthetist) works with some of them. He told me that one of his colleagues (by all accounts a very good surgeon) has said that he used to love his job, but now hates it. He feels under immense pressure. If ones of his patients dies that is beyond ‘the norm’ he gets a letter from his professional society. Another death within a year apparently triggers ‘a visit’. The risk is that he might be singled out for ‘observation’ and ‘retraining’. A my friend explained, none of the apparent problem with this surgeon’s performance may have to do with the surgeon’s performance, though. He just may have taken on more challenging cases, or maybe the aftercare was a problem, or maybe he was just unlucky (it can happen).

I can see the logic behind the publication of mortality statistics, but it’s clear that for some surgeons, this initiative will take the joy out of fixing people. And I reckon that if there’s a profession where being happy in your work is fundamentally important, it’s medicine.

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12 Responses to Is publishing ‘league tables’ of surgeons’ performance good for patients?

  1. Chris 4 June 2013 at 5:28 pm #

    If it is any consolation to your mates colleague I think a great many people are trending from being previously happy in their work to loathing it.

    A lot of this has to be down to being increasingly judged by a narrow band of metrics which completely fail to do justice to the complexities and variables pertaining to performance and outcome. There is nothing like the introduction of a statistic or two to debase the good sense that could well have prevailed before.

    In the clamour to make better use of resources I never cease to be amazed by how much time and effort can go into ‘proving’ that somebody who does a difficult job under difficult circumstances could do that job better, in less time, with fewer resources, and a truncated budget. We need more people ‘doing’ and fewer people ‘judging’. Life would be so much happier an event.

  2. Stephen Rhodes 4 June 2013 at 7:52 pm #

    This yet another example of the ineptitude of our lords and masters in Westminster. As H.L. Mencken is supposed to have said “For every complex problem there is an answer that is clear, simple, and wrong.” and then Einstein “Everything Should Be Made as Simple as Possible, But Not Simpler”.
    It is simply not possible to encapsulate in league tables anything multifactoral especially where people rather than inanimate objects are involved. Schools’ performance is a classic and this is yet another complete waste of time and money. It would be possible to convey the competence of surgeons or schools but HMG have no intention of investing the intellectual effort or taxpayer monies in the process – and since we continue to elect them you might consider that most of us wouldn’t have the ability to properly evaluate the conclusions anyway!

  3. David 5 June 2013 at 11:17 am #

    There were suggestions that the Leeds unit at the heart of recent controversy were risk averse.

  4. Robin Dowswell 5 June 2013 at 12:28 pm #

    Very good points made by all above.
    Before I became self-employed my previous employer, a big bank, introduced a 64 point appraisal system. An 8*8 matrix of effort vs output (or something like that – I really didn’t care about the details at the time).
    As Chris pointed out there are too many jobs involving using metrics. Measurement is an art to be used very carefully. It is the basis for much scientific progress, but misapplied it is a total waste of everyone’s time.

  5. TJ 5 June 2013 at 5:41 pm #

    As retired orthopaedic surgeon, I agree completely with the article, and amazingly with the points made by the writers above. How does one compare the drunk druggie at three in the morning with a smashed hip after a motorcycle wreck and a clean hip fracture after a fall at home? They are classified exactly the same.
    These kind of metrics only work for one type of person: the bureaucratic paper pusher!

  6. Chris 7 June 2013 at 8:29 am #

    Trawling similar depths prompted by Robin ..

    .. who outside of management and recruitment consultants, who use them to cloak themselves in gravitas, think psychometric tests can describe a persons traits objectively?

    Our thoughts and behaviours result from a complex blend of influences that, according to the contemporary thrust in psychology, we rarely notice nor understand, so we wind up with a head full of false narratives and/or preference sensitive beliefs that bear upon our actions. ['You Are Not So Smart'; David McRaney is worth a read on this].

    If management consultants, recruitment consultants, estate agents, and the designers of psychometric tests are ever proven to be exempt from harbouring false narratives along with preference sensitive beliefs and behaviour I’d like an assisted passage through the door marked ‘EXIT’, please.

  7. Robert Park 7 June 2013 at 10:54 am #

    Twenty three years ago I had a quadruple by-pass which the surgeon estimated as being possibly about 80% successful. The average life expectancy for cardiac by-passes at the time was 5 years. Around 7 years ago I came across a site on the Internet providing the so called ‘success rate’ of cardiac surgeons at the hospital where I had the operation and the surgeon who performed it was at the bottom of the list! Subsequently, I was seriously ill for the following 5 years only to discover that the medication being administered by my GP was what was almost killing me yet there are no success rates kept on family GPs which is presumably why Dr Harold Shipman (UK) was able to eliminate more than 450 of his patients. On discovering the cause of my ill-health I ceased taking the prescription medication and now in my 80s I feel top of the form. Interestingly the GP never enquired why I ceased taking the medication.

  8. Sandy 7 June 2013 at 11:06 pm #

    As a retired surgeon, I also agree that mortality league tables are almost impossible to interpret without having a lot more information on case mix and factors related to postoperative care. The recent data on mortality related to which day of the week surgery is performed highlights this dilemma.
    That having been said audit is vital. Surgical complication rates give a much more accurate indication of a surgeon’s performance. Proper use relies on the recognition by individuals or their peers, that a particular surgeon should not be undertaking certain procedures. Would that it were so easy with so many egos involved!
    Interestingly, private medical insurance companies have used length of hospital stay as a surrogate for complications to determine which surgeons would be authorised to perform procedures under their policies. Unfortunately the same non-reimbursable surgeons can carry on doing the procedure in the NHS.

  9. Jilly 8 June 2013 at 1:13 pm #

    Robert Park, do you mind telling us what was the medication prescribed by your GP and why do you think it was harming you.

  10. Robert Park 8 June 2013 at 6:38 pm #

    Regrettably, I cannot now recall what the name was of the medication but for five years I was in a serious state of health; I felt constantly tired and slept most of the day which did not disturb my nocturnal sleep, indeed, I felt so awful that I thought I would not make it through each day. The GP said the medication would strengthen my heart beat. My feeling of self-confidence dispersed, I became afraid of heights, had what is best described as electrical discharges or short-circuiting in my brain accompanied by mini-blackouts. My energy levels plummeted. After five years I decided to read the literature about the medication and was appalled by the numerous adverse side-effects catalogued. This lead me to read extensively about pharmacy when I discovered selegiline at 5 mg solved the neurological symptoms and CO-Q10 at 100 mg daily restored my energy levels. Later I was to discover that there were other substances which cleared plaque from arteries which would have prevented surgery and which was known to the medical profession yet I was not informed. It is only in the past few weeks that I have been able to ween myself off the selegiline but, of course, I am being careful about it. It will be appreciated that I had to battle with GPs to convince them to prescribe selegiline. Originally I purchased it from other pharmacies outside the UK which was prior to the days of the Internet. It has been a battle and a constant one but the war is has not been won, at least, not yet.

  11. Carole_W 14 June 2013 at 6:38 am #

    Shipman was not incompetent, has was a psychopath, and if league tables has been in place, he would have found some other outlet for his horrific compulsion. You cannot legislate for isolated bizarre experiences without causing significant repercussions for the vast majority. This is put extremely well by Tim Cantopher (a psychiatrist whose main client base these days are public servants – and a bureaucratic blame culture fostered by politicians is the cause:

    “What these professions now have in common is that they are all victims of the craze so loved by recent governments for regulation and its attendant bureaucracy. Politicians need to be needed and for us to believe that they can stop things going wrong. They can’t, of course, but they have to be seen to be doing something, or their opposite number will call them complacent.

    One person gets one thing wrong with terrible consequences. Here’s how it goes. First, set up an inquiry; second, find and punish a scapegoat; third, introduce a whole ream of bureaucratic structures and paperwork to increase the profession’s/industry’s regulation; and lastly, set up auditing systems to monitor the regulation you have set up. Oops, I’ve destroyed the service in the meantime – never mind; at least I’ve made sure nothing can go wrong again and we all feel better because those originally to blame have been punished.

    It’s a high price for society to pay for our politicians’ naivety and arrogance, though. Instead of one catastrophe, we now have an environment that stops people from doing their jobs, leading to a downward spiral of mediocrity and disillusionment.”

    As a medic, subject to endless costly, ineffective and soul-sapping hoop-jumping, I couldn’t agree more.

  12. Robert Park 14 June 2013 at 11:54 am #

    Let us forget about Shipman for the moment. About 40 years ago I had an aunt 74 who was seriously ill with influenza and her sister who lived with her called out the family doctor (a normal practice then). Upon arrival he apparently gave her an injection and departed. The sister then entered the room to find this aunt dead but no enquiry as to why. Consider too, why there are no waiting lists for hospices. There are too many questions going unanswered. Is Shipman’s case then an isolated one?

    I subscribe to your other views.

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