‘The Naked Surgeon’ by Samer Nashef

Six months ago I attended a Royal Society of Medicine talk held by Mr Nashef. It was an event that I discussed in my previous blog post, which you can access here. The talk was based around his book ‘The Naked Surgeon’. I thoroughly enjoyed the event and the message Mr Nashef was trying to get across, therefore I made it my summer goal to read his book.

The book was aimed at discussing outcomes and how they are measured/achieved. Mr Nashef strongly highlights the use of statistics to track the progress of Trusts and also to act as a platform that encourages reflection on performance in order to bring about beneficial change.

However, the way these outcomes are measured can have an impact on how we perceive the information presented. In the book, Nashef mentions one of Sir Bruce Keogh’s quotes – “Do we make what’s important measurable or what’s measurable important?” – in other words when the process of measuring outcomes comes into play, should we opt for the easy option and only look at the data available to us and hence act upon that, or do we clearly set out what we are looking for and make those options measurable. The latter seems like the better choice as the numbers obtained are much more relevant to the initial question posed and hence they will naturally manifest into the answers needed in order to reach a valid conclusion.

Before setting out to begin measuring any form of outcome, the book suggests to ask the following questions:

  • What are you trying to achieve?
  • Is there a way of measuring this achievement?
  • What is the acceptable target?

These questions not only act as a great starting point for any quality improvement project but I think they can also serve as great reminders. For example, say you were in a situation where there is a lot of data presented to you, sometimes all the values can be overwhelming and hence it becomes easy to forget the purpose of the evaluation. Therefore, through initially noting down the answers to the three key questions above, it keeps the project grounded and does not allow the conclusion to sway from the initial aim/question hence making it more purposeful.

This concept of quality measurement and reflecting on figures has become a growing interest in medicine. Previously, it was done unofficially but now there are teams and QI projects set which get healthcare professionals to really think about their performance and how it is affecting the care they provide. Personally, I think it is a well timed and vital element of healthcare. In a field whereby scientific advances have a direct influence on the way medicine is practised, the constant layering of new knowledge would be of no use if the profession did not bother to review the statistics and determine whether the advancement is beneficial or not. By frequently reviewing the numbers, who knows, you could find that the expectation that a new method, drug or even a new piece of technology should offer better results, could be faulted, and in fact the previous/traditional routines and protocols still provide the more promising results. Nonetheless, the key thing to note here is that these projects are aimed at evaluating the old and new ideas to see if they are working or not. Depending on the validity and reliability of the data looked at, usually the numbers do not lie and hence only once they have been scrutinized can an individual discern what the best way forward is.

According to Nashef, a physician should aim to achieve one of two things:

  1. Improve the patients’ symptoms so that they feel better and it ensures a better quality of life
  2. Improve the patients’ prognosis to allow the patient to live longer

From our understanding of evidence based medicine culture, doctors can achieve one of the two aims through conforming to changes in hospital protocols and technique through applying the change to the way they deliver their care. Interestingly, Nashef raised a valid point as he had an alternative way of coining the culture which was ‘eminence based medicine’. In today’s practice he believes most professionals are resistant to change and fare best through following routine as they feel more comfortable and it helps them generate the results they need to look better amongst their colleagues.

The biggest lesson I took from this book is that progress and its outcomes only matter if it correlates with the patients’ wishes. In fact, the fact that we have to always keep reminding ourselves that behind every number lies a patient and a story, highlights why sometimes the change we want to bring about does not translate well in practise. It is all well to try and achieve a goal to ensure you beat the system of transparency and to maintain a reputation but ultimately if your goal is not in line with what the patient wants from being under your care, then it is irrelevant. It is one thing to always aim at being successful but it is another to actually be a doctor.

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