I am a colorectal consultant surgeon and Senior Lecturer in Surgery at Imperial College London. Risk is an inherent part of my job, and over the years I have become adept at risk management. Despite this, I know that no matter how hard I try and no matter how hard my team work to keep patients safe, sometimes, my patients will have complications. All surgeons understand this and it is part of our job. But when complications occur (no matter how minor), it is hard. It is most difficult for the patient who must carry the burden of the pain, discomfort or change in the quality of their life. But these events also scar the surgeon and leave indelible marks on our clinical practice, personality and sometimes on our confidence.
The best surgeons will use these events to adapt and change, and the learning environment of the NHS is now thankfully geared to ensuring that this is part of standard practice. But, as part of the welcomed revolution in patient safety, all of my mistakes are public and are now posted on a website for anyone and everyone to see. If the very worst thing happens and someone loses their life while under my care, that too will be reported and it is referred to as a Surgeon’s mortality rate. The aim of this practice is simple; to inform patients and to give them choice about who they let operate on them. But it is also designed to drive up the standards of care through transparency and open reporting of data. Few could argue against this. However, what if I don’t fancy taking the risk on you because there is a high chance you may not do well and I don’t won’t my data to look bad? Suddenly, things become a bit more difficult and there is a real concern within the surgical community that surgeons may start avoiding difficult cases for this reason.
This is compounded by the fact that most surgical mortality is not related solely to a technical error made on the operating table by the surgeons. It may be due to a completely unpreventable medical complication, an anesthetic error, a nursing error, a prescribing error or all of the above. No matter, it’s all my mortality. So what is the answer? Well, that is not yet entirely clear. The cat is out of the bag and open reporting of surgeon’s data is here to stay. What we do need however is more meaningful statistics and a more granular approach to reporting of mortality after surgery. Many of the toughest decisions we now take in surgery are taken through multidisciplinary teams, which help improve the precision of our decisions and share the burden of risk taking. Surgery is a team sport, and this is one of the main reasons why I love it. When we have successes we always share in them, but we must also all learn together when we have failures.
My other job is to translate emerging technologies and treatments into the operating room to make surgery safer and our outcomes better. But herein lies a paradox; experimentation by definition means we introduce risk in to what is an already challenging environment. The major burden of this risk is once again carried by the patient and therefore I cannot begin to tell you how amazing our patients are. We utterly rely on them to perform our work, and we therefore increasingly work with patients as active partners in the design, development and delivery of our research programmes.
Naturally there is a methodology for risk assessing new technology, that entails a rigorous internal and external peer review, ethical review boards, Health Research Authority reviews, the Medicines and Healthcare Products Regulatory Agency and numerous other processes. This is designed to protect not just the patient but also the researcher. The most important tool for innovating in surgical environment however is effective leadership. Principal surgical researchers have to speak multiple languages (clinician, scientist and patient), communicate across organizations, manage budgets people and equipment. And they have to do this while simultaneously managing their clinical practice and all the time, ensuring that the quality of their clinical work is as good as it can be, their patients are safe and their standardized mortality rate is zero. Finally, this all has to be done in the austere environment of the NHS, where resource is scarce and where most clinicians just worry about having a bed for their patient rather than getting access to a new robot. This sounds tough, but the rewards are massive if it is done right. Ultimately, we are working on the surgical technologies that will be used by the next generation of surgeons to improve the lives of patients and make the NHS more cost effective and safer. Not many people get to say they do that for a living, and I am willing to risk it is worth it.
James Kinross is a colorectal consultant surgeon at St Mary’s Hospital, London and Senior Lecturer in Surgery at Imperial College London.