‘The Naked Surgeon’ RSM Talk

The other day I attended a talk held by the Royal Society of Medicine but delivered by Mr Samer Nashef. Mr Nashef is a cardiac surgeon at Papworth Hospital and is the author of the book “The Naked Surgeon”. In an era of medicine whereby the success of clinical outcomes can be measured, Mr Nashef’s work revolves around making use of data in order to improve surgical outcomes for cardiac surgery patients.

One of the most interesting aspects of this talk, was the mention of the Hawthorne experiment which was conducted in 1928. This link explains the experiment: http://www.economist.com/node/12510632. To summarize, the experiment showed that when the company varied conditions and factors within the workplace, the workers continuously performed well. At the time it confused the company managers but years later a sociologist discovered that the reason for the workers’ improved performance was not due to the change in conditions but actually due to the fact that they were aware that their performance was being monitored and hence it gave them incentive to work to the best of their ability. This became known as the Hawthorne effect and it underpins the work that Mr Nashef does, which is to track the performance of cardiac surgeons. This approach ensures that quality care is provided by the surgeons and also it enables the provision of feedback for surgeons who may underperform.

The way Mr Nashef measures the performance of the surgeons is through the use of cumulative VLAD (variable life adjusted display). This is a plot that is drawn to show the difference between expected and actual mortality rates post-operation hence showing whether a surgeon’s performance is above or below what is expected. In order to evaluate the actual outcome, Mr Nashef’s euroSCORE system is a risk model which provides a predicted outcome of the mortality rate for each patient before the procedure is undertaken. This is the risk model: http://www.euroscore.org/calc.html. The graph will show an increasing line when a surgeon is performing well but it will begin to decrease when a surgeon is causing too many deaths. The decrease will flag up to the seniors that there is a need for further investigation in order to determine where the surgeon is going wrong and hence allow action to be taken immediately before more patient lives are being put at risk. This is Papworth’s version of the Hawthorne effect, as it gives surgeons the incentive to continuously perform their best and hence ensure safer care for the patients.

The cumulative VLAD really highlights the power of graphs. As a visual representation of data which can otherwise be very cumbersome to go through if they were to be analysed individually, graphs have the ability to provide quick answers. As a result, it helps manage the progress of a hospital and even help save lives. When shadowing the medical director, one of his tasks involved going through a weekly update of the hospital’s mortality, infection and admission data through graphs. Depending on what the data shows, he would take action accordingly. Truthfully, I never enjoyed looking at graphs, however after this talk I recognise their importance and their ability to get important data across through clear-cut messages.

Outcome statistics guide decision making. For patients to decide what treatment option is best, they want risk factors and side effects explained in percentages. Similarly, for doctors to decide what treatment would be best for their patients, they need numbers to highlight the degree of success for each treatment. This definitely emphasizes the importance of data and graphs.

Nowadays, outcomes for all aspects of care are published on the MyNHS website. This was a decision NHS England and Jeremy Hunt made in 2014, in order to provide patients with the data required to compare the performance of their local NHS hospital with other services. This scheme was put in place after the Mid-Staffordshire enquiry led by Robert Francis in 2013. The poor conditions within this hospital and the inability of the Trust to measure its performance and ensure their staff were on the right track resulted in a high mortality rate. Therefore, to ensure this does not occur again, MyNHS has been set up to, once again, provide the hospital and its workforce with incentive to improve or maintain their numbers as they are under the watchful eye of both the seniors and the public.

However, Mr Nashef made a valuable point: is transparency i.e. publishing outcomes, a good move? There are clear benefits to this system as it encourages competition among hospitals and even members of the workforce and hence rewarding those who do well. However, sometimes the competition itself can cause hospitals and in this case surgeons to act misleadingly. Mr Nashef shed light upon this concept he called “category shifting”; in order for a surgeon to ensure their figures are high, they will either undertake low risk operations or even reclassify their high risk patients into other categories through the addition of unrequired procedures. This is because transparency becomes a sensitive issue as it now means reputations are on the line.

This talk has been a real eye-opener for me as it has made me realise the significance of data and the need to incorporate the measurement of outcomes in day to day practise. I am aware, through my work experience and shadowing, that this is a move that many NHS Trusts are making, in order to really keep on top of the progress of their services, so that at the end of the day the patients only receive the best and most efficient care. In many situations, such as in Mr Nashef’s case, this move has been a great success, and in the current era of evidence based medicine I am sure it will continue to ensure success. However, because it is such a new concept there is still a lot of work to be done around ensuring every factor is accounted for within the data and ensuring it is a well implemented system in every NHS Trust.

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