The Naked Surgeon, page 1
THE NAKED SURGEON
SAMER NASHEF, who qualified as a doctor at the University of Bristol in 1980, is a consultant cardiac surgeon at Papworth Hospital, Cambridge, and a world-leading expert on risk and quality in surgical care. He is the creator of EuroSCORE, which calculates the predicted risk of death from heart operations and is the most successful risk model in medicine; it is used worldwide and is credited with saving tens of thousands of lives. The author of more than 200 publications, Nashef’s research has been widely cited, and he has been invited to lecture in more than 30 countries. He is a clinical tutor at the University of Cambridge, and is also a dedicated teacher and public communicator, having appeared in NHS Direct videos, at the Wellcome Trust foundation, and in Channel 4’s The Operation. Outside the world of medicine, he is a regular compiler of cryptic crosswords for The Guardian and the Financial Times under a pseudonym.
To my mother
and
Neil Armstrong
(and to all the other patients who died after heart surgery)
Scribe Publications
18–20 Edward St, Brunswick, Victoria, Australia 3056
2 John St, Clerkenwell, London, WC1N 2ES, United Kingdom
First published by Scribe 2015
Copyright © Samer Nashef 2015
Foreword © Terence English 2015
‘Storm’ © Tim Minchin 2008. Quote used with kind permission.
All rights reserved. Without limiting the rights under copyright reserved above, no part of this publication may be reproduced, stored in or introduced into a retrieval system, or transmitted, in any form or by any means (electronic, mechanical, photocopying, recording or otherwise) without the prior written permission of the publishers of this book.
The moral right of the author has been asserted.
National Library of Australia
Cataloguing-in-Publication data
Nashef, Samer, author.
The Naked Surgeon: the power and peril of transparency in medicine / Samer Nashef.
9781925106664 (Australian edition)
9781922247933 (UK edition)
9781925113808 (e-book)
1. Heart–Surgery. 2. Surgery–Decision making. 3. Surgery–Risk factors. 4. Diagnosis, Surgical. 5. Surgical indications. 6. Evidence-based medicine.
617.9
A CIP record for this book is available from the British Library
scribepublications.com.au
scribepublications.co.uk
Contents
Foreword by Sir Terence English
Prologue
1 Out of the Dark Ages
2 The Benchmark Operation
3 How Not to Lie with Statistics
4 Accurate Predictions
5 Better Out of FIASCO
6 Decisions, Decisions
7 The Trouble with Ratings
8 Curious Influences
9 Surgeons and Risk
10 The Future of Medicine
Acknowledgements
Appendix A: Still Nobody Told the Parents
Appendix B: A True Haunting
References
Further Reading
Primum non nocere
(first, do no harm)
There are three kinds of doctor:
those who can count …
and those who can’t.
Foreword
I had the pleasure of being a colleague of Samer Nashef after his appointment as a consultant at Papworth Hospital in 1992. It soon became apparent that we had added an unusually gifted and stimulating surgeon to our team. He already had a wide experience across the field of adult cardiac surgery, and was a fine technical surgeon and wise clinician. He also had the habit of questioning received wisdom, which encouraged us to look critically at procedures and see how these could be improved.
In due course, the latter propensity became a driving ambition to help cardiac surgeons to become more transparent about their results. This in turn led to creating the EuroSCORE model for predicting the outcome of heart operations, so that individual and national groups of surgeons could compare their results. The model became widely applied across Europe and beyond, and acted as an important stimulus for improving the results of cardiac surgery, thereby saving many lives.
Nashef’s book gives interesting examples of his investigations into factors affecting outcomes, such as whether surgeons should operate immediately after a death on the table, and whether the risk-propensity of individual surgeons is measurable and can affect their results. He has a gift for making complex issues understandable, and presents the means by which patients can use mortality data to help them come to informed decisions about the risks and benefits of treatments offered them. At a more general level, he provides powerful arguments against some of the ill-conceived targets and rankings created by non-professionals that hospitals have been subjected to, and shows how these can mislead patients and demoralise doctors.
The Naked Surgeon is altogether a very stimulating read and one that will be of great interest to both patients and doctors. It should also receive the attention it deserves from health politicians, hospital managers, and health economists.
Sir Terence English, KBE, FRCS, FRCP
Past President of the Royal College of Surgeons of England
Prologue
As a medical student in 1977, I had a profound dislike of surgeons. They tended, I thought, to combine arrogance with a stunning ignorance of most aspects of medicine to which they could not take a knife. Many of my fellow students felt the same. While this was initially due to youthful prejudice on my part, over the course of my training I stumbled upon some disturbing facts about the practice of surgery that revealed my bias to have been based in truth.
In British medical schools in the ’70s, students were attached to ‘firms’ for varying periods, usually of a few weeks. Firms were hospital sub-units made of a pair or a trio of senior doctors, or ‘consultants’, working in one specialty, such as general surgery, or general medicine, or general surgery with an interest in urology, and so forth. We medical students tagged along on the firm’s ward rounds, sat in clinics, sometimes asked questions, and other times tried to answer them. Occasionally, we were directly taught at the bedside or in a corridor, if the opportunity arose and if the busy and harassed doctor we were trailing felt inclined to teach. In exchange for this ‘medical education by osmosis’, we were expected to help the junior doctors with ‘clerking’ duties (endless paperwork and form-filling), but our most crucial and useful task consisted of taking an impossibly large number of daily blood samples from patients. These were for the tests needed to make a diagnosis and manage the patients’ progress during their hospital stay. And so we went, from firm to firm, trying to learn, enjoying the hospital environment, and, vampire-like, taking countless blood samples.
My next firm was to be the professorial surgical firm, distinguished by being ‘academic’: in other words, some of its senior surgeons, in addition to being consultants, had university positions with titles such as ‘lecturer’ or ‘professor’. These were somewhat more prestigious and grand surgeons who, in addition to operating on patients, were expected to be keen and dedicated teachers and researchers. During a two-month stint, students on this firm did all the usual clerking work and blood samples, but were also given an additional assignment. We were each allocated a topic to read about, and we were required, on the last Friday of our attachment to the firm, to give a short talk on the chosen topic to a small and select assembly consisting of the firm surgeons, professor, and lecturers, as well as our fellow students.
My assigned topic was ‘emergency arterial surgery’, which sounded pretty exotic. Not much surgery was done on arteries in those days, so such operations, and emergency ones to boot, promised to be an eye-opener.
I managed to find two examples of such surgery. The first was a ‘femoral embolectomy’, the removal of a blood clot from the main artery to the leg. This is what happens: A patient with a problematic heart gets a blood clot in it. As the heart beats, the clot becomes detached (in medical parlance, it becomes an ‘embolus’, or roving clot) and travels out of the heart and down the body until it gets stuck in the femoral artery, the large blood vessel that feeds the leg. The leg becomes cold, white, and painful, and, unless the clot is quickly removed by femoral embolectomy, the leg dies and drops off, or has to be amputated. Now that is drastic surgery, but it is quite tame when compared with the second example I found: repair of a ruptured ‘abdominal aortic aneurysm’ (or ‘triple A’).
The aorta is the biggest artery in the body, with the calibre of a large hosepipe. It comes out of the top of the heart, curves back like an old-fashioned walking stick, and descends through the chest towards the belly and the legs, giving branches along the way that feed every single part of the body. Sometimes, the wall of the aorta, as it passes through the belly, is weakened by age and disease. Under the relentless high pressure of the blood within it, it begins to stretch out into a balloon, or ‘aneurysm’. Eventually, it suffers the inevitable fate of most balloons: it bursts. When this particular balloon bursts, the patient either dies suddenly or becomes very sick, in shock, with lots of blood and clots in the belly, and, unless an emergency operation is done immediately to replace the blown bit of aorta with a watertight plastic tube, death is certain.
I began my research by visiting the library to find out more about ruptured triple A: what causes it, who gets it, what its symptoms are, how it is fixed, and what percentage of patients survive. I quickly discovered that, despite treatment by emergency surgery, about half the patients died. It occurred to me that I might find some individual patient stories with which to enliven my talk, and to look at the experience with this operation locally. At the time, not much had been written about this rare condition, so, being rather ambitious, I resolved to study all cases of ruptured triple A treated in the hospital in the previous ten years.
It was a daunting task. In those days, there were no electronic clinical databases. All patient data were on paper in the medical records department, where old case notes were chaotically stacked high and wide in the vast, windowless, and musty basement of the hospital. There was an opaque card-filing system, which was poorly organised and not fully understood even by the clerk who presided over that shadowy underworld. This was going to be a tedious trawl. After spending every spare hour in that basement for more than a month, I eventually emerged with the case notes of 46 patients with ruptured triple A.
I summarised all the patient features, the findings at operation, and the outcomes of these operations. I then analysed the results with an eye to what determines a successful outcome: survival. I was taken aback to discover that all of my hypotheses for important factors in survival were simply wrong. I had assumed that unduly delayed diagnosis would lead to death. It didn’t. I had guessed that unduly delayed treatment would lead to death. It didn’t. I had thought that older and sicker patients, or those whose kidneys had shut down, were more likely to die. They weren’t.
Two factors alone predicted the outcome. The first was how badly the patient was in shock on arrival at the hospital: those who arrived cold and clammy with a fast heart rate and a low blood pressure did badly, and those who were pink at the edges with good circulation and a normal blood pressure did well. The second factor was who did the operation. To my astonishment, the best results had been achieved by a pair of surgeons with a special interest in breast and thyroid surgery, and the worst results by the firm that actually specialised in arteries, which was — you guessed it — the very firm of surgeons to which I was attached. As for the causes of death, they were varied, but, on post-mortem examination, more than half were found to have had technical problems, such as bleeding from the stitch lines.
This was dynamite! How was it possible that the surgeons who should have been the best at this operation were actually the worst? What was going on?
Convinced that I was onto something big, I double-checked my results and presented them in a brief written report. I also summarised the findings on some overhead transparency sheets, the last of which listed all the surgeons by name against their success rates. That night, I went to the pub in a celebratory mood. At the very least, I had an excellent talk to give. At best, there would be a scientific paper of enormous interest to surgeons: not at all bad for a third-year medical student.
The last Friday of the attachment finally arrived. It was a beautiful sunny day when we all trooped into the small lecture theatre clutching our overhead transparencies. My talk was at the end of the programme, so I waited and listened politely, albeit with a little impatience, while my fellow students delivered their reports and answered questions from the consultants. At long last, it was my turn. I rose to the podium, placed my first transparency on the overhead projector, and began talking. The audience appeared moderately interested as I reported on patients, told their stories, quoted the numbers, and explained my analysis. The level of attention rose perceptibly as I started talking about outcomes and factors associated with survival. Towards the end of the talk, I began to speak about the link between surgeons and outcomes, when a palpable coldness permeated the atmosphere in the room. I placed my last transparency on the overhead projector.
On the left-hand side of the projected transparency was a column of survival rates, in descending order, from around 70 per cent to around 25 per cent. On the right-hand side was a list of surgeons’ names, covered with a blank sheet of paper. I then asked the audience if they wanted to see the names. There was total and absolute silence. Nobody coughed, shifted, or even audibly breathed.
The talk was not going well.
After what seemed an interminably long time, a senior lecturer (who later went on to become a famous professor of surgery) looked around him and said: ‘Well, I’m not particularly interested. Is anyone?’ The few mumbled grunts and coughs that followed clearly indicated that nobody else was particularly interested either. As I gathered my bits of paper, the audience filed out of the room. There was to be no feedback, no praise, and certainly no paper to publish. When the grades for that attachment were delivered, I was awarded a C minus — a borderline pass — with a bonus feature: a personalised handwritten addendum describing this particular student as ‘arrogant and unaware of his own deficiencies’.
Two years later, we were approaching the end of medical school, and the time had come to apply for jobs as house officers — the most junior doctors in a hospital. All new graduates had to work for six months as a house officer in a surgical specialty and another six months in a medical specialty before they were given full registration with the General Medical Council and let loose on patients. I had no difficulty in securing a good house job in a medical specialty at my own teaching hospital, but, when it came to the surgical house job, it was a different story. Frustratingly, most of my applications to posts in the region were rejected even before the interview stage. After a prolonged and anxious wait, I was relieved to be asked to attend an interview for the post of house officer to a consultant surgeon in a district general hospital some 40 miles away from my medical school. I dug out my regulation charcoal pinstripe suit, sober tie, and worn but serviceable black shoes, and arrived at the interview with three other candidates.
I walked into the office and saw the surgeon, an elegant, slim, and smartly dressed young consultant whom I recognised immediately: he had been a senior trainee surgeon in the academic surgical firm two years previously.
‘Oh, it’s you’, he said, as he looked up from his papers and saw me.
‘I’m afraid it is’, I said, trying to sound cheerful.
‘Terrible business, that was, terrible business …’ he added, as he escorted me back to the office door. ‘Anyway, if it makes you feel any better, I have kept a copy of your study, and have read it and referred to it more than once. Next candidate, please.’
The interview was over. It suddenly dawned on me that, as a result of my medical student project, I was being blacklisted (either officially or unofficially) for surgical jobs in the region. I had crashed headlong into surgeons’ arrogant refusal to examine the results of their operations.
After that, I hated surgeons.
1
Out of the Dark Ages
It is remarkable to think that, until a couple of hundred years ago, medicine and its myriad forms of treatment were administered to patients almost as an act of faith. Much of early medicine had no basis in science or fact, and only in modern times have our treatments been supported by at least some hard evidence that they actually work. Once we have discovered effective treatments, an obvious next step would be to find out how well they are administered. Yet this is a question that had not even begun to be asked until the last couple of decades or so, when the scrutiny of medical outcomes began in earnest.
Today, most medical treatment is supported by scientific evidence, and most doctors claim to practise medicine that is ‘evidence-based’. We are therefore abundantly justified in beginning to ask the question I posed to my peers as a medical student: how well do those who treat us actually treat us?
I am now a heart surgeon, and proud of the fact. I know that I do many patients a lot of good (and a very few untold harm), but the net effect of my interventions, like that of most of my colleagues, is overwhelmingly positive. That said, I would not have been proud to be a surgeon, or indeed any kind of medical doctor, a hundred years or more ago. Many, if not most, of the medical treatments dished out with tremendous authority and style by my ancient predecessors to long-suffering patients over the centuries were not only useless, but actually downright harmful.
