Two reasons why Publication of Surgeon Specific Mortality Data is Anachronistic and just anti-NHS

Since writing the post on the latest edition of the Bulletin of the Royal College of Surgeons of England, I have thought, pondered and cogitated on the subject of  publication of surgeon specific mortality data (SSMD) - the theme of the above mentioned edition. (containing 2 articles which all surgeons must read, here and here). And the more I cogitate the more I realize that publication of SSMD is not 'modern' or essential as Professor Bridgewater suggests but flies contrary to the way the NHS and healthcare generally is developing. All healthcare is a team sport, and this includes Surgery . The days of conspicuous individualism, the Sir Lancelot Spratt era are thankfully long gone. Ironically, proponents of publication of SSMD will argue that one of the functions of such publication is to deter 'have a go' surgeons. It certainly is achieving that in spades in cardiac surgery where an increasingly large number of surgeons are 'not having a go' (even though they should be !) A phenomenon, increasingly occurring because of the need to adhere to waiting time targets is for patients to be seen and listed by one surgeon and to be operated on by another. So, which surgeon's SSMD should the patient look up before coming into hospital ?
This relatively recent change is emphasised in the consent form which patients are asked to sign and which contains the statement that 'The NHS Trust cannot guarantee the surgeon who will operate on you'.
In this age of Multi-Disciplinary Team Working where the decision to operate is taken by groups of individuals, publication of surgeon specific outcomes is just SO yesterday.
Patients want to and are entitled to know what the chances of a successful outcome after their surgery are. Publication of SSMDs is just NOT the way to do it. 

The Stick and Bigger Stick Approach to Health Outcomes Publication

The Bulletin of the Annals of the Royal College of England (RCSEng)is this month dedicated to the thorny issue of surgical outcomes reporting. The editorial team should be commended for publishing 2 very opposing views of the reporting of surgeon specific mortality data.

Should we be Formally Testing Surgeons?

Two Major Breakthroughs In New Surgeon Rating Study - Forbes

This is fascinating stuff. In the United states, it is common practice to go and observe the surgeon you want to appoint, operate. In the UK, it is virtually unheard of - until recently that is.  I was representing the Royal College of Surgeons at a  appointments advisory committee to appoint a Consultant Heart Surgeon at a London Hospital. The medical director told me that it was common practice for him (the medical director - a non surgeon) and a senior surgeon to observe the potential appointee in their current workplace.

A formal assessment of surgical skills is made when trainees are interviewed for appointment to specialty training, both at ST3 level and at ST1 level. And yet, no formal assessment is made at the end of training when they are about to enter the scary real world or further on in their career as consultant when they are being assessed/appraised for revalidation. This paper suggests that there is value in doing so and I am sure the public would expect it.

See One, Do One, teach one - Measuring the Learning Curve.

One of the possible victims of public reporting of surgical outcomes of individual surgeons is Surgical Innovation.  When a surgeon is under scrutiny, he dare not innovate lest he fails. Learning a new technique means that initially the operative outcome will not be as good as when the surgery is performed by a surgeon already experienced in this new technique. But if the new technique carries potential advantages, it must be disseminated. So how is this quandary solved? How does a surgeon get over this so called learning curve? This paper by German surgeons on the training of minimally invasive mitral heart valve surgery turns the measuring of the learning curve into a quasi science. There are recognised ways of getting over the learning curve without harming or disadvantaging  patients - using simulation and operating with experienced 'buddies' to start with (so called buddy system) are 2 commonly used. Measuring the learning curve and knowing when a surgeon is ready to fly solo is therefore of crucial importance - which is why this paper from Leipzig is worthy of mention. 

Is this A Dangerous Precedent ?

I really cannot tell whether suspending paediatric cardiac operations at Leeds General Infirmary was the right or wrong thing to do - I just do not have the facts to make a judgement .
What I can tell for sure is that Sirs Bruce Keogh and Roger Boyle, both of whom I know and greatly respect, have set a precedent on how to deal with adverse surgical outcomes.
From April 1st,  Bruce Keogh promised that outcomes of a number of surgical procedures performed in England will be published. There will be surgeons and units with mortality rates that are double the national average.
Are we therefore going to see a whole host of closures and investigations started before the month of April is up?

Surgical Outcomes Reporting - why we are Missing the Point.

JAMA Network | JAMA Surgery | Failure to Rescue Patients After Reintervention in Gastroesophageal Cancer Surgery in EnglandFailure to Rescue in Gastroesophageal Cancer

Although cardiac surgery is very different from other surgical specialties (and cardiac surgeons seem alien to many!) there is a lot I, as a cardiac surgeon can learn from more conventional surgical specialties. I often browse through thoracic and general surgical journals. I even enjoy reading the Annals of my College - the Royal College of Surgeons of England. I stop short however of reading orthopaedic rags - I have never had ANY professional affinity with that lot - no offence boys/odd female!!
I digress. This paper in JAMA surgery (the journal formerly known as Archives of Surgery!) is fascinating. It confirms what has been previously publicized in yet another excellent piece by surgeon racconteur, Atul Gawande in this piece in the New Yorker. Gawande describes the findings of a research study from University of Michigan that demonstrated that a major reason for variation in mortality rates after surgical procedures between different hospitals was not the incidence of things going wrong or morbid events but the ability of the institution to rescue patients once things went pear shaped. This study from England looking at events occurring after (o)esophagectomy replicates these findings. If one thinks about the incidence of morbid events or death after surgery, these findings are perhaps not so surprising. We know from many studies in different surgical specialties that a major contributor to the spread of incidences of complications are the patients themselves - advanced age, co-morbid conditions etc.   But how much does the surgeon's ability contribute to variation in mortality between centres after surgery? In any one developed country, the vast majority of surgeons are trained to the same standards -standards which  do not vary greatly between schools of surgery. In addition graduates from each school end up working all over the country. Both these factors contribute to the uniformity and narrow standard deviations of surgical ability in any one country.  This  paper is therefore significant on a number of levels - it confirms the fact on both sides of the Atlantic that variation between surgical outcomes are due predominantly to systemic institutional factors. It is also important because Bruce Keogh, medical director of the National health service in England and ex cardiac surgeon has decided that many surgical specialties should follow the Cardiac Surgeons and publicly report individual surgeons' outcomes. There is a moral case for this - patients are entitled to know what the clinical outcomes of the surgeon who is about to operate on them, are. This paper above, other studies and common sense suggest however that Bruce Keogh and many of the colleges and professional societies who support this stance, are missing the point.

Surgical Self Flagellation

Sir Bruce Keogh is  in the news today because of his appearance on tonight's edition of ' The Report'  - a topical programme on Radio 4 which today deals with Surgeons under Scrutiny. 

Your Ideal Surgeon?

Does It Matter If Your Neurosurgeon Is A Jerk? onforb.es/QZPeS4 The point of the WHO briefing is to ensure no-one acts like a jerk
— Norman Briffa MD(@Chestcracker) September 10, 2012

I recently tweeted about an article that I read in Forbes journal on whether the character of an operating surgeon matters to patients.

Public Reporting of Outcomes - History, Ethics, Keogh and the NHS Reforms

I recently posted why I felt that reporting of the outcomes of an individual clinician was wrong. I believe very strongly however in the principle of outcomes reporting.

Individual Consultant Outcome Reporting is Poor Health Policy

The decision by the society of cardiothoracic surgeons of Great Britain and Ireland to publicly report individual surgeons' outcomes on a regular basis  was inevitable. No other avenue was open to them after the Bristol Paediatric heart surgery scandal and the efforts of Sarah Boseley who, in 2005, used the Freedom of Information act to obtain the death rates of every heart surgeon in the country. The Society president at the time of the Bristol imbroglio was none other than the current Medical Director of the NHS, Bruce Keogh.
Patient choice is an integral part of the NHS reforms. Patients will be able to choose their own consultant - hence the importance of publishing outcomes of individual consultants. I have always felt that the variation between outcomes after surgery is more likely to be due to deficiencies of process and pathways of institutions rather than differences in abilities of individual clinicians. It is more important and informative for patients to be able to choose the institution where they want to be treated based on published outcomes rather than individual consultant surgeon. This article from an American cardiothoracic surgeon expresses the same sentiment. KevinMD.comCardiac surgery is a team sport

NUDGE NUDGE

Secondary Prevention After Coronary Artery Bypass Graft Surgery: Findings of a National Randomized Controlled Trial and Sustained Society-Led Incorporation Into Practice -- Williams et al., 10.1161/CIRCULATIONAHA.110.981068 -- Circulation
Until relatively recently, reporting of outcomes (especially in cardiac surgery) was perceived as being the key towards quality improvement. The past 6 to 12 months has seen a shift towards ensuring that the

SPINNING GOOD NEWS.

BBC News - Boost for UK over heart surgery performance
This is obviously a good news story - how can it be otherwise. For months, we have been told how poor cancer outcomes are in the UK compared to Europe (which they incidentally are!) Now, here is something we're better at (which we incidentally are!)
There is however a disingenuous spin to the story and how it is being reported. It suggests the reason English heart surgeons have better survival than their European counterparts is because their outcomes are publicly reported. Well what tosh. Public reporting of individual surgeons' outcomes is hugely controversial. Cardiac surgeons were sort of bounced into it . For years after the Bristol Children Heart Surgery tragedy we were the whipping boys of the government and the press and it was inevitable that our outcomes would eventually get reported. As a cardiac surgeon, I am very much in favour of outcome reporting. It is only fair that patients who will be going through what would be the toughest and most dangerous period of their lives need to have some idea of what to expect. Whilst outcomes from institutions are fair game for reporting, I believe that reporting of outcomes/results of individual surgeons is wrong because of 2 simple reasons. Firstly contrary to popular myth, cardiac surgeons are human and the most human of reactions to increased death rates is to avoid operating on patients who you might think have a higher than average chance of dying - i.e. risk averse behaviour. The spin meisters will tell you that does not occur - well if you believe that you'll believe anything!
The second reason why reporting of individual surgeons' outcomes is unfair is because there are many people apart from the named surgeon who contribute to a successful or unsuccessful outcome - anaesthesiologists, nurses, etc. So why should you as the surgeon take the rap for the deeds of your anesthesiologist, Dr. Shipman! We are always being encouraged to work in teams and reporting of individual doctors' outcomes mitigates against that. It is not surprising that despite the efforts of many, reporting of outcomes of institutions and/or individuals has not really spread beyond cardiac surgery in the UK.
If somebody shows me evidence that before public reporting, outcomes in England were worse than they were in the rest of Europe, then maybe (and only maybe) I would be inclined to believe in the spin of the article. This report does not provide that evidence.
Outcomes after heart surgery are better in the UK than in Europe and probably have always been. There are a LARGE number of reasons why this may be so - maybe better trained surgeons, better anesthesiologists, better processes to ensure patients are taking the right drugs etc etc. Whatever the reasons for better outcomes are,  public reporting of them is not one of them.