Public Accountability

"If I was going to have surgery I would be keen to know the key outcome rates for the hospital and surgeon I would be going to."
"I think it's almost inevitable that we're going to be reporting this more and more."
 Andreas Laupacis, physician, health-policy analyst

"It drives a culture where you act with the patient's best interest first and foremost, which hasn't always happened in British medicine. It's made people, everybody, focus on tidying up on every little thing, making sure you go the extra mile on everything."
"At first, people didn't like it, people felt it wasn't right, being under that kind of scrutiny. [Now] it's kind of tolerated, if not widely embraced."
Ben Bridgewater, University of Manchester surgeon

Nathan Denette/The Canadian Press/Files    Dr. Teodor Grantcharov, a surgeon with Toronto’s St. Michael’s Hospital, with a mock patient in an operating room. 

 

When thoughtful and concerned people decide to shop for something in particular, many of them do some diligent research. To determine the best product available at the very least cost; quality for a reasonable financial expenditure. Armed with that knowledge, they set out to acquire the object, be it a refrigerator, a car, a house. These purchases are important to our quality of life. They are regarded as necessary, and their acquisition complements the kind of lifestyle we imagine for ourselves.

That being so, why is the far more vital, certainly incomparably more important life-issue of finding a competent, experienced surgeon, through a research tool available, for example, on line, to ascertain the surgical success rate of that surgeon's professional accomplishments not available? If the surgical specialist has to his credit, as an example, successful outcomes for the patients he/she undertakes to operate on, as opposed to others whose outcomes are more on the iffy side, who wouldn't want to make that selection, forearmed?

In Canada, at the present time, even on those occasions when a medical regulator imposes on a surgeon's license restrictions reflecting complaints and poor outcomes, that information is not accessible to the public; the public being those people who might find themselves wondering about the level of expertise and operating success of a surgeon they may have been referred to by their family doctor or a specialist in internal medicine.

It would be immensely helpful if basic performance statistics for surgeons' success rates were publicly available. Recently in Canada a federal agency began providing a list of basic statistics in performance reflecting success of individual hospitals; rates of patients re-admitted following heart surgery, or complications following joint replacement. If this can be done with hospitals, to alert patients, and in the process encourage hospitals to mount better practises, why not with doctors?

It's being done in the United Kingdom, where hospitals now expect surgeons to report on their vital statistics, how patients fare after operations. A program exists making publicly accessible success rates for thousands of surgeons available for anyone to examine, and in the process compare one surgeon's success rate against another's, as an aid to helping them determine who they would prefer to operate on them in what could very well be a life-and-death situation.

It's been almost a decade since Britain has pioneered this public service. And since that time, they've seen their overall mortality rates drop significantly. Some doctors are suspicious about the process, claiming that to protect themselves, unintended consequences could surface where surgeons deliberately avoid taking on the most difficult patients with a seeming guarantee of a questionable surgical outcome.

"If you came in with a really high-risk condition, I'd hate to think a surgeon would run for the hills because they didn't want to take a thump to their numbers", explained Dr. Dave Ross of Edmonton, president of the Canadian Society of Cardiac Surgeons. Doctors are people like any other in any other professions, some with excellent skills, others just getting by; their competency levels nothing to write home about.

Interestingly, a University of Michigan study published last year  highlighted the performances of bariatric (weight-loss) surgeons whose surgeries were videotaped and then screened and rated by colleagues. Those with the least expertise had higher rates of complications and patient deaths, was the general consensus. Other similar studies over the years have confirmed that patients whose doctors have performed a specific procedure frequently tend to suffer fewer complications. Experience matters.

"In surgery, once you graduate, you can do whatever you want, and nobody monitors you", commented Teodor Grantcharov, who operates out of Toronto's St. Michael's Hospital. His interest in patient safety spurred him to develop an operating-room "black box" recording system. And there is the instance where patients who were suing an Ontario obstetrician-gynaecologist for serious complications they suffered under his care, had no knowledge that the College of Physicians and Surgeons had previously red-flagged him resulting from earlier complaints.

In the 1990s, New York State took the initiative to pioneer public reporting of individual surgeons' performance by publishing mortality rates for cardiologists specializing in artery-unclogging angioplasties. A spate of heart-surgery deaths of babies at the Bristol Royal Infirmary in Britain led to an inquiry, and then a British newspaper obtained and published the numbers of such deaths in 2005. They've been routinely posted on the Internet through the specialists' society by cardiac surgeons themselves since then.

Canada has started to publish some hospital-level data. The Canadian Institute for Health Information began making a range of statistics publicly available in 2012, including the rate of C-sections, the uptake speed of hip fracture surgery and the percentage of patients returning to hospital following treatment of a variety of conditions, and rates of medical error. That list is set to be expanded soon with the addition of statistics for hospital-acquired sepsis and outcomes in nursing homes.