Please take a look at my latest post on Physician's Weekly. It's called "Why public reporting of individual surgeon outcomes should not be done."
Click here for the link.
"Man is least himself when he talks in his own person. Give him a mask, and he will tell you the truth." Oscar Wilde
13 comments:
Dr. Jha needs to stick to internal medicine, as his knowledge of surgery appears limited. I'm not necessarily against reporting data, as long as sample sizes are adequate and the public can be properly educated about results, neither of which would likely happen. The "teams" comments at the end of the piece ring true.
Thanks for the comments. As you could see from the post, I don't think confidence intervals will resonate well with the public.
This has been discussed in the UK. The point was; if a surgeon has a greater than 'average' number of bad outcomes, is he/she therefore a bad surgeon? A response was that this bad surgeon treated people that others would not because these patients were too frail. Further, as you note, surgeons would not take on riskier patients if it meant that their 'average' went down.
But I don't remember any agreement how such problems could be communicated to the public, or any advice given to them on how to choose the 'best' surgeon.
The goal with most quality measures and reporting seems to me to force the physician to be the person denying services instead of the government/insurance. If income is tied to quality/outcomes, then the surgeon says no to riskier surgeries and the politician/ insurance exec has less angry emails
Unknown, excellent point. You are correct. Have you ever tried to explain to a patient why he had to leave the hospital because insurance was refusing to cover another day? I have. The patient blames the messenger.
Scalpel, you mean you never tried "You can stay as long as you want, as long as you are willing to pay for it yourself from this day forward. The hospital requires a two day deposit (physician shifts blame from self to hospital)."
Psychiatry learned long ago to shift blame from an individual by creating the "therapeutic milieu."
Most all individual surgeons, in my experience, have been, technically, pretty darn good. The bad outcomes result from anatomical variation, unrecognized pathology, anesthesia complications, or breaks in asepsis.
It's simply not fair to hold the individual surgeon responsible for all that occurs in the perioperative milieu where most of the variables reside.
I respect surgeons but let's face it there are some really bad
actors out there. I remember a few years ago the place I worked retained the services a a surgeon who had left a very distinguished institution to work at my medical center which was less distinguished. I thought it odd. One week I was following one of his patients who was having a slow recovery after an abdominal aortic surgical procedure. He developed a fever and a tender abdomen and I finally convinced the surgeon to investigate.A CT scan showed that there was a vascular graft that had been placed right through the ascending colon. He was eventually let go but not after
a considerable passage of time. I agree that
outcome data reports are of dubious value but what can be
proposed to take their place?
Artiger, I never tried that. I think the hospital should be the one to deal with this type of problem.
Old, I agree.
William, that's quite a story. The quest for valid quality metrics (I hate that word) has been futile so far and smarter people than I have been working on it.
I've been reading Peter Baskett's History of Caesarean Births. He reports a series of cases which were described in the latter 19th century in the US. They were divided into three groups; in the first, the maternal mortality was 16.7%, in the second it was 28.6% and in the third 81.5%. Clearly the third group had a poor outcome.
The first group were 'self-performed' Caesareans, the second were the result of a goring by cattle, and the third were those done by physicians. Evidence-based medicine at that time would indicate that a D-I-Y Caesarean was the safest, and that physicians should abandon their efforts. The original author wasn't fooled; women in the first two groups were fit and healthy at the time; in the physician group, the women were exhausted and grossly dehydrated after a prolonged labour — the operation was a procedure of last resort.
Legislators however aren't trained physicians nor do they understand 'raw' statistics, and would have been duped by what, on the face of it, is incontrovertible. But are they any more informed today?
Korhomme, it’s not only legislators. Well-meaning patient advocates and even some doctors who should know better are also in the dark.
I wounder how this would affect us Acute Care Surgeons who almost never do elective surgery. Comparing 500 elective sigmoid resections for tumor or diverticulosis is not the same as 500 sigmoid resections for perforated diverticulitis or perforated stercoral ulcers with a belly full of poop.
Certainly I start out at a disadvantage in the latter group, and that's not even factoring in the CAD, COPD, present smoker at age 97, co-morbid conditions!
The good news is your patients don’t have the luxury of searching the Internet and finding another surgeon.
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