Chance can turn a surgeon into a killer

Risk-adjusted 30- to 90-day outcome data for selected types of operations done by specific surgeons and hospitals are now being publicly posted online by England's National Health Service.

According to the site, "Any hospital or consultant [attending surgeon in the UK] identified as an outlier will be investigated and action taken to improve data quality and/or patient care."

After cardiac surgery outcomes data were made public in New York, some interesting unexpected consequences were noted.

Surgeons and hospitals resorted to "gaming the system" by declining to operate on patients who were high-risk and tinkering with patient charts to make those they did operate on seem sicker. This can be done by scouring the charts for all co-morbidities and making sure none are overlooked when they are coded. An article from New York Magazine explains it in more detail.

Interpreting outcomes data can be tricky.

In a post three years ago about a report that nine Maryland hospitals had higher-than-average complication rates, I pointed out that whenever you have averages, some hospitals are going to be worse than average unless all hospitals perform exactly the same way or, like medical students, are all above average.

A much more sophisticated way of looking at this subject appeared in a fascinating 2010 BBC News piece by Michael Blastland, who is the Nate Silver of England [or maybe Nate Silver is the Michael Blastland of the US], called "Can chance make you a killer?"

Blastland set up a statistical chance calculator for a hypothetical set of 100 hospitals or 100 surgeons performing 100 operations each. The model assumes that every patient has the same chance of dying and that every surgeon is equally competent. The standard is that a mortality rate 60% worse than the norm set by the government for any hospital or surgeon is not acceptable.

You are assigned one hospital. Using a slider, you may choose an operative mortality rate anywhere from 1% to 15%. After you do this a number of times and recalculate for each mortality rate, you will notice that the number of unacceptably performing hospitals or surgeons changes randomly for each percent mortality and your hospital may appear in the underperforming group strictly by chance alone.

The whole concept is explained in more detail on the site. I encourage you to try it for yourself. The link is here.

So it may be difficult for the NHS to separate the true outliers from the unlucky surgeons who happened to fall outside the established norms.

What do you think about this?

Improving the M&M conference

"Surgical pathology works more than 80 hours per week, has no regard for your gender or your life situation, and can be devious and sneaky in its presentation."

The following is a guest post by Dr. Leo Gordon, a surgeon from Los Angeles.

A recent paper in Annals of Surgery found that 24% of graduating surgical residents "were unable to recognize early signs of complications." One possible solution is a redesign of the morbidity and mortality (M&M) conference .

I have spent a significant part of my professional life in an effort—at this point it is a crusade—to change the nature of the M&M conference. For 11 years, I moderated 495 conferences, 1485 presentations, and 30 written examinations based on the error and complication-reducing points raised during the discussions.

If properly implemented, a redesigned M&M conference can satisfy the ACGME core competencies, the suggestions of the Institute of Medicine, and the public's demand for a reduction in medical errors.

What I have dubbed the "M&M Matrix" converts the weekly conference into a vibrant educational effort and creates a constantly updated patient safety curriculum for the resident and attending staff.

If the M&M Matrix is such a valuable idea, why hasn’t it been widely adopted?

Here are the reasons:

What goes on at a real morbidity and mortality conference?

f you’ve read my reviews of the new medical TV show “Monday Mornings” [here, here and here], you’ll know I’ve been critical of many things about it. I was particularly disappointed with the way the show handled one of its central themes—the morbidity and mortality (M&M) conference.

I thought it might be useful to tell you how most real M&M conferences are run. M&M conferences generally take place at hospitals with residency training programs and are rather specific to surgical disciplines.

It is possible that they may be held in large non-teaching hospitals, but time constraints and the fact that direct attending surgeon to attending surgeon criticism in an open forum is difficult to do.

Unlike the TV version, real M&M conferences feature presentations by residents, not the attending staff. The resident who performed the operation prepares a summary of the case which these days is usually on PowerPoint. Pertinent history, physical exam findings, lab results and images are shown. A radiologist or pathologist may be on hand to help educate the attendees. The conduct of the surgical procedure and the patient's hospital course are described.

The resident is asked questions about the way the case was managed and what she knows about the disease process and the surgical literature. The resident may have prepared a brief review of recent papers on the subject.

The attending surgeon who was involved with the case might add some more details. At least one person asks a question that was already addressed in the presentation. An attending surgeon or two will describe a similar case they had 10 years ago that went wrong and state that now he does things a different way, never mind the evidence to the contrary.

Comments from other surgeons and the chairman are made. Often a consensus may be reached about whether or not the complication or death was preventable. The idea is that the discussion informs the whole department, and everyone does not have to make the same mistake. In theory, the complication might be averted the next time.

However, not all complications or deaths are due to errors. Sometimes despite everything being done correctly, outcomes are bad.

In the old days, residents were blamed for everything that went wrong. Public humiliation was common. A famous chairman allegedly once said to a resident who presented a case that resulted in a patient's death, “Why didn’t you just take a gun and shoot him?”

Although this is said to still happen in some hospitals, the conference is much more civil in most places.

Unlike the “Monday Mornings” version, M&M conference is not where attending surgeons are browbeaten, tricked or fired. Of course, the real conference is far less dramatic (most of the time).

There can be raised voices and sometimes arguments occur, but the focus of the conference is usually more on education and quality improvement.

It's too bad about the show. It could have done a lot of good if it tried to realistically portray how self-critical we are. Unfortunately, it went all Hollywood on us, like every other medical TV show.

Operative Mortality Rates and Sleep Deprivation

To add some spice to the never-ending debate on the effects of sleep deprivation on surgeons are two recent papers published in respected journals.

“Prospective evaluation of consultant surgeon sleep deprivation and outcomes in more than 4000 consecutive cardiac surgical procedures” was published ahead of print in Archives of Surgery in May. This was a prospective study of the sleep patterns of six consultant [senior attending] cardiac surgeons in Canada over a six-year period. Of the over 4000 cardiac operations performed, there was no difference in the rates of mortality or complications whether the surgeon had less than 3 hours of sleep, 3 to 6 hours of sleep or more than 6 hours of sleep.

“Association of operative time of day with outcomes after thoracic organ transplant” appeared in the Journal of the American MedicalAssociation on June 1. This was a retrospective study of over 27,000 heart or lung transplant operations divided into two groups based on whether their procedures were performed from 7 am to 7 pm (days) or 7 pm to 7 am (nights). Almost exactly 50% of the operations were performed during each time period. Mortality rates at 30 days and one year were not statistically significantly different whether the procedure was done during days or nights.

Even the most ardent crusader against “tired surgeons” would have to admit that these are well-executed studies of rather complex operative procedures. In addition, there are not enough transplant or cardiac surgeons around to allow for shift work. As shown by the data in the transplant paper, half of all such procedures occur at night. Someone has to perform these operations when the organ and the recipient are available, not the next day.

The transplant paper was the subject of a New York Times blog and it drew the usual number of ridiculous comments. I don’t know why I read them because they are so infuriating. Here are some of the more inane ones:

“This is part of the "doctors are superhuman" myth that is simply unsupported in the real world.” Never mind the data.

“Are the ‘qualified surgeons’ in the business of eliminating possible competition, for example?” In response to the fact that there are not that many transplant surgeons.

“A heart transplant in the US costs roughly $145,000. Figure the chief surgeon makes $100K and 9 "helpers" make $5K each for a 5-hour operation. That works out to be $10,000/hr for the doc and $1,000/hr. for each assistant.” And the hospital does not receive any payment?

“Surgery requires superb eye-hand coordination which deteriorates with fatigue. Airline pilots have co-pilots and extensive mechanical controls on the plane and on the ground. Transplant surgeons do not.” Never mind the data.

Feel free to add your own comments [preferably not infuriating, and ...watch your math].

Frivolous Musings on Obesity from the New York Times

“Plus-Size Wars” in the August 1, 2010 issue of the New York Times magazine documents the travails of obese women looking for fashionable clothing and designers and manufacturers attempting to make clothes that fit. The article also mentions the burgeoning movement of the obese accepting their bodies and resisting the societal pressure to lose weight. If only the problem of obesity was limited to lack of suitable couture.

As a practicing general surgeon, I would like to point out that while obese people are coming to grips with their body images, they are also killing themselves. Just about everything involving medical care is exceedingly more difficult in the obese patient from the simple acts of having blood drawn, IVs inserted and blood pressure measured accurately to undergoing and recovering from even basic operations such as appendectomies.

Obesity is linked to decreased life expectancy and higher rates of diabetes, cancer, lung disease, hypertension and death from all causes. Finally, the cost of medical care is significantly higher for the obese. Compared to health, the clothing issue is of miniscule importance.