Mortality rates for common forms of cardiac surgery have been made public in the United Kingdom for several years now. This information is individualised. If you are considering having a particular surgeon perform a common form of cardiac operation on you, you can make a better-informed decision by getting on the internet and finding out how many times that cardiac surgeon has conducted that operation, how many of his or her previous patients have survived such operations and how often they have not survived. You can also find out how your prospective surgeon compares to other surgeons performing similar operations. Although the publicising of cardiac surgeons’ performance information was controversial when it was first introduced, it has attained a broad level of acceptance in areas in which it has been introduced, in large part because this form of transparency has been effective in reducing mortality (see Justin Oakley and Steve Clarke ‘Surgeon Report Cards’, in Patient Safety First: Responsive Regulation in Health Care, edited by Judith Healy and Paul Dugdale, Sydney, Allen and Unwin, 2009, pp. 221-236). For discussion of a range of ethical issues related to the disclosure of surgeons’ performance information see Informed Consent and Clinician Accountability: the Ethics of Report Cards on Surgeon Performance, edited by Steve Clarke and Justin Oakley, Cambridge, Cambridge University Press, July 2007.
In a recent report on data collection, the United Kingdom’s Society for Cardiothoracic Surgery has called for other surgical specialties to follow the lead of cardiac surgeons and collect and publicise performance data, with the aim of improving performance and improving safety (http://www.guardian.co.uk/society/2011/mar/21/heart-surgeons-push-specialist-data). While poorly performing practitioners of other surgical specialities might not like the idea of having such performance data made public, if practice in these other specialties can be significantly improved by the publicising of performance data then there is a strong consequentialist argument in favour of publicising such data.
There may be practical difficulties involved in extending the publicising of surgeons’ performance data far beyond the scope of cardiac surgery and doing so effectively, however. One crucial fact about cardiac surgery is that there is a significant chance of mortality for common operations – an average of roughly 1-3% – it is very clear what counts as mortality and everyone agrees that this is the most significant performance indicator for cardiac surgery. In other specialties however, mortality is much rarer and people’s primary concerns, when faced with other surgical procedures, are often focussed on other factors, including recovery times, chance of a full recovery, quality of life in the event of a less than full recovery, seriousness of scarring and so on. All of these factors have a subjective element to them, unlike mortality. It is not entirely obvious what counts as full recovery, quality of life is an almost purely subjective matter and the degree to which scarring bothers people is highly subjective. One person, who has been used to being admired for their smooth skin may be highly harmed by the presence of post-operative scarring, whereas another who is relatively unconcerned by matters of appearance may feel almost completely unharmed even by severe post operative scarring.
Despite the above concerns I agree with the Society for Cardiothoracic Surgery that other surgical practitioners should go ahead and develop and publicise performance information for common operations in their respective specialties. In specialities where mortality is not a significant factor this will involve identifying those factors that are of most concern to patients and attempting to ‘operationalise’ these by developing objective definitions that capture what most patients are concerned about. The degree to which different patients are concerned about the size of post operative scarring may vary considerably, however most will have some interest in an objective indicator of scar size and the provision of such information can help them make better, more informed decisions about surgery. The same goes for recovery time, quality of life after recovery and so on. Furthermore, the publicising of such information will motivate practitioners to improve performance, as has already happened in the case of cardiac surgery.
Other outcome measures that are measureable are adverse events (very objective). T start with interested surgeons can audit themselves. SurgicalPerformance.com is an anonymous, secure project where people find out how well they do compared to others. Being a surgeon myself, it gives me a great deal of security, limits my vulnerability because I know what my data are. It also gives me a database of my patients that I own. Subscription costs are minimal.
Steve I think this is a very good idea in principle although it is fraught with perils. There is a well-documented tendency in the NHS (and elsewhere) for indicators that are well intentioned and even sometimes well designed to be nonetheless distorting factors in people's behaviour, leading to poor or inefficient performance. It is also very difficult to design research and collect data that will give real insight into the relative performance of. say, orthopaedic surgeons performing hip replacements. However the alternative, that numerous surgeons continue to practise substandard medicine without any sanction, is unacceptable. Perhaps we need to look at something like TripAdvisor, where people grade their service and provide brief commentary, with the hotel or restaurant having a right of reply. It has an organic feel to it, although no doubt there has been a lot of design work behind the scenes. The strength is that patients are able to give their views unfiltered, the weakness is that the measurements are not objective or susceptible to numerical analysis.
Andreas do you think it would ever be possible to do anything like this, or is it simply not practical, or does it demean the professional standing of surgeons, or am I totally missing the point? By the way, my background was in professional liability insurance, although in the US, not the UK.
Bearing in mind patient confidentiality, is there a concern about the reliability (as oppposed to the subjectivity) of "something like TripAdvisor"? Could surgeons' (or their family, friends, etc.) write fake reviews about other surgeons and/or themselves? Could disgruntled (or happy) employees or former (or current) spouses/partners write fake reviews about surgeons?
Presumably TripAdvisor works because of the law of large numbers: even if there are fake reviews etc it's umlikely to massively distort the figures. Perhaps sample sizes would be too small for this to apply in the case of surgery? There's also something that feels inappropriately frivolous about it, although on the whole I'm all for crowd-sourcing. But the self-reporting suggested by Steve seems like a good idea.
I respectfully take a different view of self-reporting and many alleged applications from the law of large numbers. Many studies (from different but seemingly analogous areas) document that men will receive better reviews than women, that professionals who meet conventional beauty standards will rececive better reviews than comparable professionals who do not meet those standards, that professionals with certain kinds of names will receive better reviews than professionals other kinds of names, that many patients with unrealistic hopes and expectations about outcomes will give inappropriately low reviews even when the(ir) relevant professionals performed the best work possible, and so on. For just one example, ordinary people need positive illusions (subversions of rationality studied in the heuristics and biases traditions of social psychoogy by people such as Shelley Taylor) to maintain certains kinds of happiness and mental health. Such illusions can (and very often if not regularly do) cause people to blame problems on perfectly competent professionals – problems that results from their own (responsible or irresponsible) behavior (as opposed to that of surgeons or other professionals). In other terms (which could be based on other kinds of concerns/research), I have no more confidence in the self reporting of patients about the performace of their doctors than I have confidence in the (decades on record of) self reporting of philosophers about the alleged ubiquity of intuitions regarding contrast cases in philosophical arguments. Is there good empirical support for the reliability of self-reporting that anyone can cite and argue is relevant here in the case of surgeons (and/or doctors/other professionals)?
No need for respect, David, you have clearly thought about it much more than I have!
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