Britain has taken a giant leap in informing patients and thus transforming healthcare by launching publication of surgeon level mortality data. This is a historic event for surgeons not just in Britain but across the world as it signifies to us the direction of travel. It tells us that if we don’t set our house in order, public will take control of it and we will then be forced to do it.
For long, the world of surgery in India is plagued by too many low-volume, ill-trained surgeons performing too many (in terms of variety) procedures in a climate of little self-audit and non-existent external monitoring. Under these circumstances, surgeons themselves have no clue as to where they rank against their peers and patients simply have no chance at finding out who is a “safe” surgeon. I am against creating super-heroes and long queues outside the clinics of a few surgeons who know how to “market” themselves and in Indian context also know how to keep their colleagues in general practice and other specialties happy. But I do think we need mechanisms where patients can choose from a number of safe surgeons in town. And from the patients’ point of view, this is all you need to know; whether your surgeon is safe or not. Let us face it; you don’t need a globetrotter or a politician who chairs twenty committees or societies to look after you. In fact, you should wonder how this person gets time to look after his/her patients. There is no known correlation between surgical ability and political positions in professional associations.
Publishing surgeon level mortality data automatically implies that surgeons enter data for all their surgeries in a central database and then also enter their complications and mortality. In addition to the obvious benefits that it will bring to research and patient empowerment, it will also mean that surgeons will become careful in recommending surgery for those less likely to benefit and more likely to have complications, simply for monetary gains. Currently, many surgeons will not hesitate in performing an operation of dubious benefit on a terminally ill patient even if it means patient ends up spending his/her life’s savings on it!
Publication of surgeon level data will mean that surgeons will only perform procedures that they can perform to a certain standard with low complication rates and it will remove the current “free for all” that exists in Indian healthcare where any surgeon (or in many cases any doctor) can perform any operation. Professional associations and societies in India have generally failed to push reforms even in face of generally recognised facts that results are superior in the hands of high volume surgeons and in the West, complex procedures are generally centralized and surgeons disallowed from performing them if they don’t perform a certain minimum number annually. Such mechanisms have been impossible to implement in even public sector hospitals in India where there are no direct financial incentives, let alone the private sector. By publishing mortality level data, we will discourage surgeons from performing too few of each of too many types of procedures. This will indirectly encourage surgeons to refer patients to each other and allow development of specific expertise in the hands of individual surgeons, both in the private and public sector.
This measure has an obvious drawback that it will also discourage surgeons from taking on riskier cases but inevitably such riskier cases will then concentrate in the hands of very few national experts and even that, one could argue, will have its own benefits. Moreover, in a finance driven market, it will reduce unnecessary medicalization and we’ll see surgeons shying away from riskier cases where the risk versus benefit is not completely in patients’ favour.
Overall, I believe publication of surgeon specific volume, complication and mortality data is a great step for patient empowerment and will have profound implications for surgeons across the world. It will empower patients and improve accountability on the part of surgeons. It will however come with another challenge to ensure that the data is honest and accurate, as dishonest surgeons will otherwise get away with it and the honest ones might be penalized. In United Kingdom, this measure will come with an expectation that every unit has centralized mechanisms for data submission to national registries and in case of inconsistencies, both the registry controllers and individual units and surgeons should be able to clarify matters further. Deliberate falsification will of course be reported to the “General Medical Council” which as an institution is equivalent to the “Medical Council of India” but it is an institution that actually works and has the teeth to implement its directives.
Dr Kamal Mahawar is a practicing general and bariatric surgeon. He takes keen interest in wider healthcare organization and delivery and regularly writes on these issues. He is also the chairman of Webmed Limited (the company behind academic publishing portals WebmedCentral and WebmedCentral plus) where he works to provide voice to biomedical scientists from disadvantaged background.