Surgeons' performance data: challenge and opportunity

Abstract

Last month, the Society for Cardiothoracic Surgery called for a rethink on the national policy of publishing performance data for cardiothoracic surgeons.¹ Such calls are not new, indeed publication of these data has been resisted from the outset in 2004. Publishing performance data is now routine and other specialties allow it too, but dissenting voices remain. Transparency is fair enough, say the critics, but surgeons are now avoiding high risk procedures because of intense public scrutiny of individual surgeons' 30-day mortality rates.

Publication of any data is problematic. Many readers or users will not understand limitations of data or how best to interpret them. Performance data are especially tricky since they appear to offer a judgment on a clinician's competence, and risk creating anxiety in both doctor and patient. If high risk procedures are avoided, one of the stated objectives of publishing performance data, to discourage occasional practitioners, might well be achieved. But another consequence is that surgeons may be losing the courage to fail, as John Pepper and Aman Coonar explain in their editorial.²

This dilemma, they say, “represents a considerable challenge but also a great opportunity.” The challenge is clear, to present data in an understandable way to patients and surgeons that satisfies both parties but ultimately improves outcomes and protects patients. The opportunity might seem less obvious. Pepper and Coonar propose that the way ahead lies in greater patient partnership, multidisciplinary working, a focus on Atul Gawande's concept of “rescue from failure” instead of failure itself, and better definition of outcomes. Greater transparency with better quality data is required to foster an environment of candour and partnership.

David Misselbrook, who begins a two part series on virtue ethics, might ask whether the publication of performance data is Utilitarian or Deontological?³ Is there a third way characterised by virtue ethics? Medical ethics dates back at least to the time of Aristotle, although this month's paper from JRSM's archive only asks you to travel back fifty years. JP Shillingford describes the performance and operational challenges of one of the first coronary care units.⁴

References

Boseley S. Surgeons ask NHS England to rethink policy of publishing patients' death rates. The Guardian: http://www.theguardian.com/society/2015/jan/30/surgeons-nhs-england-patients-death-rates-bruce-keogh-jeremy-hunt-health. Last accessed 5 February 2015.

Pepper JR and Coonar AS. High-risk surgery: the courage to fail. J R Soc Med 2015; 108: 44--46.

Misselbrook D. Virtue ethics -- an old answer to a new dilemma? Part 1. Problems with contemporary medical ethics. J R Soc Med 2015; 108: 53--56.

Shillingford JP. The intensive care of the coronary crisis. J R Soc Med 2015; 108: 79--82.