The Naked Surgeon: The Power and Peril of Transparency in Medicine
By Samer AM Nashef
The ‘doctor as God’ trope is one that is still alive in many corners of the world, especially where patient awareness about medicine and medical procedures is nominal or absent. Consider how we, in India, hold a handful of cardiac, neuro or orthopaedic surgeons as legends, deservedly or otherwise. Juxtapose this with the West, more precisely with Europe, where patients with heart ailments, whose doctors advised surgery, first had a method to calculate whether the surgery advised—based on 17 items of information—will indeed be ‘life-saving’ or rather, unfortunately, the opposite. Before EuroScore—whose widely-ratified success has prompted its adoption worldwide—you just had to hold your cardiologist’s advice as the gold standard for treatment.
Things are changing fast. There is greater thrust on accountability and transparency in the medical profession—from within it and outside—now. The doctor is no more invulnerable, let alone a god of some sorts—and in the place of the meek, trusting patient, grasping at straws to stay afloat and alive, is a questioning, empowered patient. Who should know better of this than the guy who is one of the originators of EuroScore? Samer Nashef, a UK-based cardiac surgeon today, first propounded a risk assessment mechanism for vascular surgery as a student at a vascular surgery unit in a UK hospital in the late 1970s. He compared mortality rates for operations carried out by different surgeons in the department. He found that the lowest mortality rates could be credited to two surgeons whose expertise was not in cardio-vascular surgery. While presenting the study to senior cardiovascular surgeons who were to rate him as a student of the speciality, he asked the audience if they would be interested in the comparison of death rates of surgeons with the department. Predictably, nobody seemed willing. For his efforts, Nashef received the minimum passing grade and a remark about his ‘arrogance’. He had rocked the boat without realising it, and paid the price—even years later, his attempts to start practice as a surgeon at hospitals in the area would be resentfully stonewalled.
It is in this backdrop that Nashef’s new book, The Naked Surgeon: The Power and Peril of Transparency in Medicine—in which this inauspicious start to his lifelong quest for getting the surgeon’s community to be more accountable is penned as the prologue—becomes an important read. Mind you, Nashef is not on a Quixtotic adventure out to fight the ‘big, bad’ medical world. Though he sardonically states at the outset, after he has told the reader about his first fight for transparency, that “After that, I hated surgeons”, his ardour for assessing surgical outcomes comes from a desire to see the medical profession move away, in its own interest, from the false notions of infallibility often ascribed to it.
In The Naked Surgeon, Nashef uses data, peppered with anecdotes and case studies, to show how risk-adjusted surgical outcomes and similar assessment across specialities will shape the future of medicine and surgery. Even so, he also shows why an exclusive reliance on data comparisons and statistical models will not be as failsafe as one would assume. The author explains to the reader the statistical methods and the import of findings, talking of sample-size implications and all as easily as he teases apart complex surgical procedures for the layman to understand. He shows how adjustments are to be made to make comparisons and findings more watertight, and very importantly highlights how measuring outcomes can lead to these improving if the surgeon being assessed knows that he is being scrutinised. Nashef also speaks of how greater scrutiny also brings out risk avoidance among surgeons, who either seek to take on low-risk patients, or shift risk to a doctor treating a secondary or associated ailment whose treatment requires a different specialisation.
One of the most interesting parts of the book is the moving appendix written by Dr Steve Bolsin, the anaesthetist who blew the cover off the Bristol paediatric cardiac surgery scandal. During the 1990s, mortality after cardiac surgery was very high among babies being treated at the Bristol Royal Infirmary. Later, an inquiry found “(a) … unit … simply not up to the task” and “an old-boys culture among doctors”, apart from “a lax approach to safety, secrecy about doctors’ performance and a lack of monitoring by management” led to the deaths. The scandal resulted in a vigorous push for publishing of more data on the performance of doctors and hospitals. Bolsin’s account shows why Nashef’s crusade, that has expanded with many conscientious members of the medical fraternity joining in, is an important one.
Perhaps, the most seminal point The Naked Surgeon makes is how, while considerable sums are spent investigating causes of death such as aviation disasters or terrorism, such attention is never felt merited for the world of surgery, where patients often die needlessly, for reasons as trivial as poorly executed stitching after a perfectly executed delicate cardiac operation.