Ensuring the continuing competence of surgeons: a bridge too far, a sacred cow or burying your head in the sand

Should you have an effective system for detecting and dealing with those of your colleagues whose performance is below an acceptable standard? Should you make public the death and disability rate of each surgeon in your specialty measured against an expected range based on patient characteristics? By ‘you’ in each of these questions, I do not mean each of you individually. I mean you collectively, through each of your specialist societies. I have no doubt that any public poll would yield an unqualified yes to each of these questions. What do you say? Though you have known for some time that these questions are being asked,1 your specialist societies have, with one exception, ignored both of them.2 The exception, as you will know, is the Australia and New Zealand Society of Vascular Surgeons. It has, for many years now, had a system for detecting and dealing with vascular surgeons whose performance is below an acceptable standard. It seems to have worked well. Yet no other specialist society has sought to follow this lead. Why is that? In England, since 2005, the Society of Cardiothoracic Surgeons has published, annually, the mortality data of each of its members. Its lead has since been followed by nine other surgical specialties. Yet no specialist society in Australia has sought to disclose the mortality rates of its members. Why is that? I turn specifically to those questions. Here I'd like to make three points. First, that there are, among you, some incompetent surgeons. Second, that a culture of silence by your profession protects them. And third, that your profession's failure to identify and deal with those incompetent surgeons will be remedied, but not, apparently, by you. No profession, including my own, can deny that it has some incompetent members. I am confident that each one of you knows of at least one of your operating colleagues who should not or should no longer be operating at all or should not be performing specific operations of a kind, which he or she is performing. The worst examples of this may reach the criminal courts. But I am not talking about criminal negligence. I am talking about those surgeons whose performance, either generally or in a specific procedure is, in one way or another, sub-standard and which therefore gives rise to an increased risk of consequent injury, disability or death. Statistical surveys here,3 in the United States4 and elsewhere have shown the extent of sub-standard surgical performance. It is unnecessary for me to attempt to analyse or even discuss these. But they show that those errors, which are reported to the Health Quality and Complaints Tribunal, are likely to be just the tip of the iceberg. My points here are that surgical error occurs at an unacceptable level; it is sometimes the result, not just of a single error by an otherwise competent surgeon, but of incompetence; it sometimes has serious consequences; much of it is preventable; and one means of prevention is to identify those surgeons who err, correct their tendency to err, for example, by retraining, or prevent them from further performing operations of the kind in which they err. I have discussed this before and you are all, I assume, familiar with it. It is the Australasian Vascular Audit referred to earlier. It answers the first question, of taking action in respect of sub-standard surgeons, and appears to have responded to it effectively. Moreover, it was initiated by vascular surgeons themselves, without any pressure from government, and with the full support of practising vascular surgeons. It does not respond to the second question and some would say that it could not have operated effectively if the names of inadequately performing surgeons had been made public. I shall return to that question later. The question is, if I may repeat it, why have no other specialties followed this lead? For more than a decade now, there have been audits conducted in hospitals in Australia of deaths occurring in or after surgery. Surprisingly, these have not, until relatively recently, been uniform throughout Australia, nor, until recently, has participation by surgeons in these audits been a compulsory requirement for continuing certification to practise. I say surprisingly because, even without identifying any surgeons who have erred, these surveys have nevertheless had a remarkable effect in reducing deaths and in changing practices in or following surgery. The Annual Report of the Western Australian Audit of Surgical Mortality in 2012 showed that, over the 10 years of its operation, deaths under the care of surgeons had fallen by 26% notwithstanding that, over that period, patients had got older and sicker, and a recent survey of surgeons showed that 78% of recipients said that involvement in or feedback from these audits had changed their practices.5 On the other hand, audits of injury or disability occurring in or after surgery, morbidity audits, are still neither uniform throughout Australia nor, in practice, a necessary prerequisite to continuing to practise; and there remains, it seems to me, a continuing reluctance by many surgeons to participate in them. Moreover, I don't see that the Morbidity Audit and Logbook Tool will change that because, as I understand it, it will not provide for any effective obligation to participate. If audits of surgical mortality have been so beneficial, even when de-identified, why the apparent reluctance to implement uniform audits of surgical morbidity and to participate in them? There is no convincing excuse. The most rational explanation is concern about the possibility of adverse actions, civil or administrative, against erring surgeons. Even with full implementation and participation, both kinds of audit will, without radical change, continue to be de-identified, thus preventing the kind of investigation conducted by the Society of Vascular Surgeons. How can that be justified? The statistical surveys prove, if proof be needed, that a significant proportion of deaths, injuries and disabilities in surgery are caused by surgical error. Without identification of those surgeons who have erred, if only for the purpose of rectifying errors, insufficient can be done to ensure rectification of their conduct and prevention of continuing error-prone surgery. Several reasons have been advanced for the need for de-identification. The first is that it encourages disclosure and frankness. This may be true. But that means, put bluntly, that you consider self protection from action against you more important than patient safety. And, regrettably it seems to me, that is also the main reason for your reluctance to implement audits of the kind adopted by the Society of Vascular Surgeons. A second given reason is the difficulty in identifying and applying accurate criteria for surgical error which requires correction. It is no doubt true that this poses some difficulty. But the British cardiothoracic surgeons, and those nine other surgical specialties, which followed their lead, all found criteria, in an expected mortality range based on patient characteristics, sufficient to permit publication of individual death rates. Over the years during which death rates have been published in England, those rates have dropped notwithstanding that, over those years, patients have got older and sicker. And continued publication has comprehensively dispelled the myth that it would cause surgeons to refuse to operate on high-risk patients. The Australian Orthopaedic Association has, for many years, maintained this registry, which records and analyses all joint replacement operations. It enables each surgeon to assess his or her performance against peers. It thus contains data, which would enable the Association to identify those surgeons who are performing these operations at a level below an acceptable standard. But the Association does not have access to this information, even on a confidential basis, in order to deal with error-prone surgeons. No satisfactory explanation has ever been given for this. The most likely explanation is, again, concern about the possible liability of erring surgeons. Nor has any satisfactory explanation been given for the apparent reluctance of other orthopaedic surgeons, for example, spinal and shoulder surgeons, to submit their data to such a registry. I understand that the Western Australian Department of Health has, for some time, been offering premium payments to hospitals that will collect data, which it can use to assess the performance of individual surgeons against the agreed standards adopted by the specialist societies in England. So while your specialist societies still refuse to assess their members, it seems that, sooner rather than later, you will be assessed by government. And possibly those assessments will be made public. The experience in England since 2005 makes opposition to publication of death rates almost unarguable. Death rates have dropped since publication commenced and no one has suggested that there has been any other cause for the drop. Nor is there any evidence that surgeons have avoided high-risk cases in consequence of publication. And though there were early concerns about the criteria for publication, these seem to have abated. If publication of mortality rates of individual surgeons is in the public interest, why not also the publication of morbidity rates of individual surgeons, similarly based on an expected morbidity range taking into account individual patient characteristics. There is, I believe, a compelling argument that a prospective surgery patient has a right to know these rates before choosing a surgeon. What is the core business of your specialist societies: the health and safety of surgical patients or the protection of its members? What is your role in this? If the core business of your specialist societies were the health and safety of patients who came under your care, they would ensure the continuing competence of all surgeons in your specialty. You know that there are some surgeons in your specialty who are performing below an acceptable standard, and that their sub-standard performance risks injury, disability or even death. These surgeons are identifiable and should be identified for retraining, restriction of practice or termination of practice. You cannot otherwise ensure the continued competence of all surgeons whom you put forward to the public as competent to practice your specialty. Your specialist societies have failed to do this. Moreover, those who are about to undergo surgery have a right to know if their surgeon is competent to perform the operation. Publication of failure rates would help to answer that question. Your presence here today marks each of you as a surgeon who is concerned about the health and safety of patients who come under your care. You should demonstrate that concern by ensuring that your specialist bodies remedy their failure to act. Otherwise are we, the public, to infer from this failure that you are more interested in protecting your incompetent colleagues than you are in the health or safety of surgical patients?