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Good theatre: what really happens when you're under the knife


Moral duty: Author Samer Nashef

Moral duty: Author Samer Nashef

The Naked Surgeon

The Naked Surgeon


Moral duty: Author Samer Nashef

This book takes a scapel to the medical profession and asks if patients get the standard of care they have the right to expect from their surgeons.

At first glance, a book with a quirky, familiar-sounding title about quality management in surgery might look to be very far away from a holiday read. But any book that lays bare a profession, as this does, is worth a second look, especially as this reading is intended not only to influence doctors' practice, but also to be a valuable resource for patients, in helping them to ask questions about their course of treatment and make informed decisions about their care.

In this book The Naked Surgeon, Samer Nashef draws on his experience as a cardiac surgeon at Papworth Hospital Cambridge, the UK's largest specialist heart and lung centre, to advocate for a greater focus on transparency and quality measurement in medical and surgical practice. He stresses the importance of publishing outcome data so that doctors can continuously learn and identify areas for improvement.

Responding to data on death rates in English hospitals a number of years ago, Professor Sir Bruce Keogh, medical director of the NHS in England, outlined the vital role of senior doctors in taking personal responsibility for the accuracy of data relating to their practice.

Keogh explained that "Surgeons have a moral and professional duty to know what they are doing, how well they are doing it and to use that information to help them improve - otherwise they have no right to be doing it at all."

In my view, medicine is not a pure science; it is a practised art based on science and supported frequently by scientific hypotheses. Successful outcomes cannot be absolutely predicted and death or injury can and do occur through no fault whatsoever. In saying that however, risk management is now a cornerstone of medicine, and creates a systematic approach aimed at enhancing both the performance of doctors and patient safety.

While medicine has advanced exponentially in recent years, the focus on data and outcomes in medicine has been slower to progress. According to Nashef, in the timeline of thousands of years of medical practice, the concept of quality management "was born only yesterday".

George Bernard Shaw once said that "all truths begin as blasphemies". Nashef describes "some ostrich-like behaviour" among doctors and surgeons when it comes to appreciating the benefits of quality management, monitoring and learning from mistakes.

He argues that surgeons are "natural risk takers", and as such, he argues, the culture of self-examination that is in place in other industries, such as aviation, has not yet taken hold in surgery.

The overwhelming majority of surgeons are, as Nashef notes, "passionate about providing good patient care". Nashef explores in detail the reasons for this, looking at surgeons' attitudes to risk and attitudes to quality measurement, as well as resistance to change.

The move towards greater transparency in publishing outcome data must ensure that the correct measurement tools are being used, taking into account risk factors to explore if differences are real, or due to chance.

In my view, activity and outcome data collection is vitally important for doctors. It confirms effective treatment, increases learning and identifies areas for improvement. It also increases public trust, as patients will be more confident in the care they receive if they see that their doctor is focused on continuous improvement, making sure that outcomes of procedures are in line with international standards.

It does not have to be complicated.

While reading Nashef's development of systems for quality accreditation, I was reminded of the log book I used in the 1980s to manage data, detailing all patients, anatomic and operative details, including outcomes and deaths. The point is that it's not complicated for doctors to measure the outcomes of their work, and this book describes several systems which could be used by doctors to provide international comparisons for their own work.

Ultimately, I believe that activity and outcome data collection maintains the independence of the medical profession by allowing it to advocate on behalf of patients, and to direct structured change.

This is highlighted in an appendix to the book, written by Dr Steve Bolsin, a British anaesthetist, whose work in collecting outcome data relating to heart surgery at Bristol Royal Infirmary was crucial in prompting action at a hospital where fundamental failures in medical professionalism, a failure to place the patient first and frank dishonesty, were rife.

Children undergoing cardiac surgery at Bristol died in circumstances where they could have survived had they been operated on elsewhere. The book highlights the 'club culture' encountered by Bolsin at the hospital, where high mortality rates were known about but not acted upon.

The parents of children undergoing cardiac surgery were, meanwhile, unaware of the higher-than-average risks their children faced by being operated on at the hospital. The devastating, and avoidable loss experienced by so many families at Bristol Royal Infirmary brings into stark relief the importance of doctors looking closely at their work and making sure their practices and the outcomes of their work are in line with international standards.

Bolsin's work led to fundamental change in the UK, prompting a government inquiry and sweeping changes in medical practice. His account in this book is one which should be learned from by health professionals throughout the world, so such events are prevented from occurring in other health systems. Every doctor should know what they do, how much they do, how well they do it and to use that information to improve patient care and service.

The famed war surgeon, Ambroise Paré, defined the role of the doctor as: "To cure sometimes, to relieve often, to care always."

I do not think there is a better way for doctors to express that care than by monitoring the quality of their work and sharing that information with patients.

Prof Freddie Wood is Medical Council President

Indo Review