Kevin was a 48 year old father of three. After an early meal he thought he was suffering from indigestion. Little did he know that his heart muscle was starting to complain about a lack of blood supply. He collapsed in pain a few minutes later. His wife, a trained nurse called the ambulance and he was rushed to his nearest hospital. A cardiologist did an angiogram, which revealed multiple blocks in the arteries of his heart. This precluded stenting and so he was transferred to coronary care unit for stabilisation. Over the next few hours his condition deteriorated to the extent that an anaesthetist was involved in trying to stabilise his condition. A surgeon was contacted and a decision was made to attempt surgical re-vascularisation of his heart muscle as an emergency. In view of the complex nature of the disease, Surgeon A asked Surgeon B to help. The two started operating on Kevin’s heart at 2000 hrs. Kevin needed a valve replacement along with a triple coronary artery bypass graft procedure. At 0300 hrs Surgeon B left, thinking that the operation was nearly over. Surgeon A was unable to wean Kevin’s heart from the artificial pump and called surgeon C at 0600 hrs, as he was the expert at mechanical heart assist. Surgeon C put Kevin’s heart on a mechanical assist device that helped move Kevin out of theatre back to intensive care by 1400 hrs the following evening. If Kevin were to die which surgeon should be responsible for his death?
Since 2005 heart surgeons in the UK have been giving permission for their surgical results to be published in the press. The background of this has been a suspicion of medicine in general and surgery in particular on the back of the sad case of Dr Harold Shipman and the less than acceptable results in Bristol for a specific children’s heart operation. Understandably many changes needed to be made to protect unsuspecting people from the infrequent but damaging effects of carers that stop caring. One of the quick wins noted by the people, then in power, was to ask cardiac surgeons to publish their results. This was easy because, Cardiac surgeons across the country had developed a voluntary database of individual results in order to collaborate and compare results and hopefully pick up good practices that might become obvious in recurring good results. This sort of practice lead to regular visits by surgeons to watch each other to pick tips and tricks that improved individual results. This was best illustrated by Prof. Mark DeLeval, from Great Ormond Street, going to visit Mr. William Brawn at Birmingham, after he had a few unexpected deaths, with a particular procedure. He subsequently had a streak of unmatched success with the procedure, which he duly published in a reputed journal. Incidentally the surgeons in Bristol had also done the trip in their own time to improve their outcomes. The Society of Cardiothoracic Surgeons of Great Britain and Ireland were asked to consider releasing this data into the public domain. The initial reaction was varied among surgeons. There was a group that felt that this would show how good they were compared to their peers and the floodgates of private referrals would be opened in their direction. There was another group that was against it for the clear reason that it would disadvantage surgeons who offered their services to the highest risk patients. Following a long consultation period a decision was made to publish a risk adjusted version taking 3 years work into consideration in order to protect surgeons from the possibility of a “bad run”. There were a few dissenting voices but these were squashed by a request under the freedom of information act for the publication of results. This led to the regular publication of results. Surprisingly none of the surgeons stood out of the agreed statistical limits of competence. This led to a big sigh of relief from many quarters and life moved on. Today most patients are unaware of the surgeons results prior to undergoing their operation and prefer to have their operation soon and as close to their loved ones as possible, rather than wait for a surgeon with a slightly better result further away from their home town. So despite its lofty ideals why is, surgeon specific results not the right thing for patients?
The first problem comes when you try and understand the issues around cardiac surgery results. Unlike in the early days of cardiac surgery when technology was in its infancy, today the results are predominantly affected by the state in which patients are brought into the operating theatre. The preoperative treatment, intra-operative procedure and the postoperative care are all equally important in reducing both death and complications. This involves a whole team of professionals. Trying to place the result on a single person’s “name” is unfair on the contributions of all other team members and can often lead to unnecessary arrogance among individuals. The prediction of risk in cardiac surgery is as flawed as in banking and space exploration. The best model of risk profiling is only 78% accurate and so is only 28% better than flipping a coin. This means that surgeons are getting increasingly nervous of taking on high-risk cases as these are most often not accurately reflected in the risk scores. On the other side there is no clear mechanism of monitoring patients being turned down from life saving high-risk surgery. Paradoxically the patients who benefit most from surgery are often the ones with the highest risk. A surgeon today is faced with two choices when asked to take on a high-risk patient. He can turn it down, not be censured in any way, get home early, and look good in the newspapers at the end of the year. The other option is to take this patient on, with a lot of effort and quite a lot of involvement in the post operative care manage to get this patient through, but in the process develop a reputation for taking on high risk cases. Soon this surgeon will be inundated with many demands for high-risk operations. The law of averages will dictate a higher death rate for this surgeon. There is no financial incentive to salaried staff but the disincentives of poorer work life balance, and higher death rates will soon produce a risk-averse behaviour in even the best-intentioned individuals. The sad loser in this whole unhappy situation is the patient who has most to loose and most to gain.
What do most surgeons feel about this. Most privately think it is a bad thing but feel that this is required in the era of openness. Trying to resist it is often seen as being secretive and the Society of Cardiothoracic surgeons sees this as the crucial contribution they are making to make the world a safer place. I feel it is bad for surgeons in the long run. As soon as a surgeon is appointed to a post his initial aim is to get to the three-year mark without being an outlier. If he is referred a high-risk case he is likely to turn it down to keep his numbers looking good. Traditionally, new surgeons are often bailed out by senior surgeons, who act as unofficial mentors. Now most senior surgeons are trying to keep their mortality down and mentoring a new colleague has a limited attraction. Across the country there are many consultants in their early years who have been investigated for poor results partly due to lack of mentoring. Today in a busy cardio-thoracic surgical unit, surgeons cover their own patients night and day and on weekends in the belief that another surgeon will not care for their patients to the same extent as their own. There is evidence that patients operated on before a surgeons holiday have a much higher chance of dying than those done while he is still around. With surgeons allowed four to six weeks of holiday this is a worrying trend. Surgeon specific results leads to unnecessary competition rather than collaboration among surgeons of different skill mixes and experience. What a patient would really benefit from is the combined experience and mix of those in the institution rather than one individual. Surgeons like all other human beings are not always good at everything on every day. As we become experts at increasingly complex aspects in each of our fields, we need to rely on more than one individual to offer the best care for complex patients. This is not helped by the current system.
For an institution named surgeon specific results are bad for the morale. The pathway of a patient involves many people doing a lot of amazing things in order to produce a good result. Singling out one individual belittles the contribution of many. It breeds a group of increasingly arrogant individuals, who use the excuse of “their name in the newspaper at the end of the year” as a reason to get what they want. Results need to be institutionalised. What patients need to know is what their risk is of surviving or dying if they are admitted to one hospital or another. Individuals come and go in shifts or on holidays or on lecture tours. The unit that produces the best result is most likely to improve its weakest link in order to achieve this. Unit-specific results produce a sense of pride in the whole unit. It does not matter which surgeon operated on which patient, as they all are scrutinised together. This will foster team working. This will give patients the best deal. This will lead to the unit policing its results in real time. If there is a problem individual they will uncover it sooner than the three years it takes the current system. Most importantly it will help in eroding into the self-propagated arrogance that cardiac surgeons are often caricatured with. Cardiac surgeons will be forced to recognise and value their role in the whole team.
So what happened to Kevin, fortunately he did not become a statistic. Kevin’s heart actually got better over the next few days. Surgeon C was able to wean his heart off the assist device. Surgeon C and B together managed the patient and discharged the patient home along with a lot of input from nurses, perfusionists, physiotherapists, anaesthetists and cardiologists. This is what it takes to get someone like Kevin home. To give all the credit or all the blame to one surgeon is oversimplification. With technology changing rapidly a patient is increasingly best served by a combination of a senior surgeons experience and judgment along with a junior surgeons skills and exposure. Team working for complex cases has to be encouraged and surgeon specific results, does not make it conducive.
In United Kingdom we need to look once again at the situation. We need to publish real-time unit specific results putting the focus on the whole package of care. We will be better served by looking at how patients with certain diseases survive in the short and long term. Surgery after all is often just one of the many options available in the management of chronic diseases. The congenital heart surgery teams are already looking at this model to help improve services in the their speciality. The current system of surgeon specific results is not working. Adult cardiac surgery needs to take stock of the situation and quickly react if it wants to stay ahead of the game of delivering the best for our paymasters, the patients.
