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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