The shaming of heart surgeons: how politics brought a proud profession low

During training and the early years of my consultant career, cardiac surgery was a pioneering profession. We developed techniques and technology to improve safety and broaden the scope of what we could achieve. We sought to help younger, older and sicker patients. Premature babies, nonagenarians, those at death’s door. There was no such thing as a work-life balance. We were a proud, charismatic specialty, trusted and admired – but not any more.

After multiple hospital scandals NHS England decided to publish surgeons’ death rates, ostensibly to improve confidence in the profession. Logically, you might expect the best surgeons to have the highest death rates because they act as a magnet for the most complex and sickest cases. That’s what happened in the US, when a handful of states were forced into the process by a hostile press. The rest refused to follow.

But this was not an exercise in logic. It was a punitive act irrespective of the fact that most investigations attributed the misery to ‘general failings in the NHS’. Mortality rates were published hastily. Surgeons were ‘named and shamed’ — a phrase destined to become enshrined in NHS folklore. Very rapidly the emphasis shifted from patient care to self-preservation. So many people contribute to the recovery of a heart surgery patient that the simplest way to stay under the radar is to avoid the sickest patients. Low risk translates into low mortality.

We are in the consulting room with two fictitious patients. An 81-year-old man strides in. Thin and wiry. A golfer who has never smoked. He has a narrowed aortic valve and is short of breath by the ninth hole. Normal coronary arteries. Good lungs and kidneys. The surgeon registers low risk of death or stroke and the patient is accepted for valve replacement before his wife has even found a parking space. Any questions? No. The family didn’t arrive in time but he strides off happy. The NHS is wonderful!

The next man is waiting anxiously with his wife and daughter. A 62-year-old diabetic who has suffered two previous heart attacks, his tired heart is scarred and dilated. He can’t do very much. They have waited for months for a cardiology appointment, another three months for the coronary angiogram, then two months to see the surgeon. Walking in to the surgeon’s office from the waiting room makes him breathless. He is overweight with fingers strained by nicotine. What is the surgeon’s first impression?

He reads the cardiologist’s letter: severe three-vessel coronary artery disease with moderately impaired left ventricular function. Then peripheral arterial disease with a 90 per cent carotid artery stenosis – a narrowing of the artery to the brain which could cause stroke during an operation.

He looks up from the correspondence. The family wring their hands and fiddle with a long list of medication. First question: ‘Are you a smoker?’ Answer: ‘No.’ ‘When did you give up?’ ‘After the angiogram.’ The surgeon’s frontal cortex registers: smoker for 50 years, diabetic with bad lungs. Damaged heart and risk of stroke. If I operate on 100 patients like this, at least five will die.

From now on, the dialogue is slanted inexorably towards declining surgery. Avoiding another death is the surgeon’s priority. Risk aversion also saves the hospital money, as sicker patients stay longer in an expensive intensive care bed.

I find this bitterly disappointing from every aspect, yet this is the reality of defensive practice — the outcome when politics interferes with medicine. To attribute all post-operative deaths to the surgeon is equivalent to blaming a pilot for a bird strike to his aircraft engines.

Why do patients die after heart surgery? Very few of the cases can be attributed to surgical error. The predominant cause is ‘failure to rescue’ the patient from a common post-operative complication, an event which, better managed, could have saved the patient’s life.

Much of this can be related to inconsistent team work — the presence of locum doctors or agency nurses who are unfamiliar with management protocols. The problem is worst at night and weekends. Publication of surgeon-specific mortality data has not improved patient choice, waiting times, team consistency, staffing levels or life-saving equipment. Most cardiac centres in Britain are still not funded for rescue circulatory support devices which might save half of those who die from heart failure.

This has all had a miserable effect on my profession. Currently only 40 per cent of children’s heart surgeons had their medical training in the UK. From the General Medical Council specialist register, we know that 68 per cent of trainees entering cardiothoracic surgery in 2000 were UK graduates. In 2013, this figure was 14 per cent. Of those who completed their training in 2014, just a fifth were UK graduates.

Don’t misunderstand my point here. We are very pleased to have overseas surgeons in our cardiac units. Without them, there would be no service.

But we are witnessing the demise of a proud speciality for a point of political principle. Graduates in Britain now feel that cardiac surgery is just not worth the hassle. In the final analysis a profession that dwells upon death is unlikely to prosper, undertakers and the military apart. When a surgeon remains focused on helping as many people as his abilities allow, some will die. But we should no longer accept substandard facilities, inconsistent teams and a lack of life-saving equipment, otherwise patients die needlessly.

I have always loved the NHS. I was born within two weeks of its inception in 1948. It remains a treasured resource for the British people. But I have never seen the staff under such duress and in frank distress. Between them NHS England and the GMC have created a perfect storm.

The BMA does not exaggerate when it warns that fewer medical graduates go on to practise, that junior doctors prefer Australia and that seniors are retiring in droves. There is general mistrust of the propaganda from the Department of Health and their recruitment drives from abroad. Instead, let us treat our own graduates with respect and revert to a supportive environment. Restore confidence in our precious health service before it’s too late.

Britain still leads the way in stem cell research and in developing technology that saves lives – our ventricular assist device is a world beater. Last week came the grim suggestion that survival for heart failure in Britain had not improved in 15 years. We can improve it now if the NHS will fund these home-grown advances.

Fragile Lives by Professor Stephen Westaby is out now


  • stevie gee

    Westaby is dead right. Every single day in every single hospital in the land a cardiologist and/or a cardiac surgeon is telling a patient ‘nothing can be done’ and it is an outright lie. It is just that a 50% chance of survival appeals far, far less to his doctors, than to the patient himself.

    The same thing happens in intensive care, neurosurgery, stroke, bowel cancer and so on

    The NHS puts resources first. It is not an ethical organisation and I still cannot believe that people ‘treasure it’. Westaby is only scratching at the surface.

    When politicians control healthcare, they do as good a job of it as they would if they controlled food supply.

    • Emma Badenoch-Jones

      correct!!

  • This is absolutely the truth. It’s obvious isn’t it? The guy with teh very best survival rate isn’t treating the sickest people. The other night on BBC2 I watched a heart warming film about the treatment of a 98 year old man for aortic stenosis. He was a wiry alert and happy fellow who could nolonger walk the four miles a day he had been used to walking until teh last couple of years. he had a family that cared about him. There was grave concern about whether he would survive the operation, which amazingly involved threading a new aortic valve through his femoral artery, and guiding it into the heart and through the bu ggered valve. To my horror, as the new valve was expanded into the narrowed valve he’d had for 98 years, allowing full blood flow, the poor old fellow had a stroke as a piece of calcified tissue broke away and was carried by the new strong pulse up to his brain. Then they managed to thread another gadget up his femoral artery and into his brain, tracking the progress on a screen, until they got hold of the clot and pulled it back out again. It didn’t look much, but it might have killed him. The film ended with the old boy marching vigorously out of the hospital a week or so later. Over cautious surgeons concerned about death rates would never have even looked at this old boy. The fact that some of them did was a good thing.

    It sickens me that venal swine like Hunt play to the tabloid message and rubbish the profession.

    • jeremy Morfey

      “he had a family that cared about him”. Perhaps the most neglected lifesaver of all?

      • That’s true. It was a heart warming programme atcually, even moved an old b@stard like me to see his beautiful grand daughter willing him to get better.

      • That’s me done for, then. Fortunately I have long since learned to live without them ;^)

    • Lola Sapola

      This article makes important points, especially the impact of ill informed politicking on how real people behave. That politicking includes the complaint industry and the menace of the GMC which, at the instigation of lawyers has become a Quango full of people with minimal relevant knowledge. They require that a patient is told every possible risk not just the main serious ones and as every procedure (even having corns cut by a chiropodist) can result in death if a series of things go wrong it becomes fairly easy to dissuade a patient from going ahead.
      However, there is another side to the argument because there are times when it is right to advise the patient against invasive treatment or drug reatment that will probably just make their final weeks even more miserable. Sure, the 98 year old’s case was a triumph (for the neuro radiologist rather than the cardiologist) but other cases in this series did not go nearly so well. In an earlier programme there was heroic “successful” surgery on a man with a non urgent dissecting aneurysm who eventually died after 6 weeks in ITU. A man with oesophageal cancer also had a “successful” operation but died 6 weeks later. I’m not saying they shouldn’t have been operated on , it’s easy to be wise after the event, just that these decisions are very complex and individual.

  • Debbie Massey

    Nice piece Steve. Enjoyed it very much. Have shared it.

  • Dave Massey

    In 1994, at the age of 42, with bacterial endocarditis and having just undergone a left femoral embolectomy to remove bits of my aortic valve from my thigh I ended up on Professor Westaby’s operating table and given a slim chance of survival. I’m still here.

    Professor Westaby is right. Thoughts about a surgeon’s reputation or position in a league table are completely inappropriate when it comes to life or death decisions. What matters are talent and dedication in the face of clinical need.

    The NHS (and other organisations come to think of it) is suffering from the curse of “Management Consultancy”. Too much management (administration really) and not enough leadership. And to quote Ken Kesey, “You don’t lead by telling people some place to go. You lead by going to that place and making a case.”

    • Also: Watch the American example. If America can do it, why can’t you?

      • Dave Massey

        Were you a citizen unable to afford health insurance in the US, I wonder if your view of the American health system would be as rosy? The point of the NHS is that it be free to everyone at the point of need. (Check for a pulse first, not for a wallet.)

        • You’re wrong on the facts. The poor and the elderly receive taxpayer- funded care as a matter of course. Without long waits, rationing, and substandard medicine as you getwith state-controlled health care.

  • Arrenby

    He’s right.
    That being said cardiac surgeons are without doubt an arrogant bunch and are not known for their “insight” into their own potential failings. As such, difficult as it is there needs to be some way of monitoring outcomes that avoids a 10 year debate that “it’s someone else’s fault” when there are, as there can be issues with an individuals competence.

  • Cristiano Amarelli

    Another fundamental point is the difference between perceived risk and our capability to predict and even modify the risk through the use of innovative solutions. If the pioneers had not taken the risk to operate aortic dissection we would not be able to save the 80% of patients with a so dreadful disease.

  • Thanks for the article. Sad and unfortunate. For myself — not that I need a heart surgeon or ever will, likely — I’m glad to be living in the USA. It’s still the best place on the planet if you are ill, and it’s very nearly the best place if you are well :^)

  • Sabyasachi Bal

    Results of Surgery, Comparative outcomes and the Shaming of Surgeons…

    For several days a particular article has been circulating
    in our medical forums; this one is by Stephen Westaby, a surgeon par excellence’,
    a great teacher and one of the doyens of British Cardiac Surgery and
    incidentally ..one of my heros. Unfortunately his article gives a very
    unreasonable and blinkered view of the issues involved.

    In his article “The shaming of heart surgeons: how politics
    brought a proud profession low” (https://health.spectator.co.uk/the-shaming-of-heart-surgeons-how-politics-brought-a-proud-profession-low/)
    Professor Westaby writes “After multiple hospital scandals NHS England decided
    to publish surgeons’ death rates, ostensibly to improve confidence in the
    profession. Logically, you might expect the best surgeons to have the highest
    death rates because they act as a magnet for the most complex and sickest
    cases. That’s what happened in the US, when a handful of states were forced
    into the process by a hostile press. The rest refused to follow.

    But this was not an exercise in logic. It was a punitive act
    irrespective of the fact that most investigations attributed the misery to
    ‘general failings in the NHS’. Mortality rates were published hastily. Surgeons
    were ‘named and shamed’ — a phrase destined to become enshrined in NHS
    folklore. Very rapidly the emphasis shifted from patient care to
    self-preservation. So many people contribute to the recovery of a heart surgery
    patient that the simplest way to stay under the radar is to avoid the sickest
    patients. Low risk translates into low mortality.”

    Prof Westaby has a very valid point. Bad results are often
    about choosing difficult cases.. .If you operate what most others would not
    want to do, your results will be poorer…

    On the face of it..all this is true. However, there is
    another perspective. I will give you an example…

    The Bristol heart scandal occurred in England during the
    1990s. At the Bristol Royal Infirmary, babies died at high rates after cardiac
    surgery. An inquiry found “staff shortages, a lack of leadership, … unit … ‘simply not up to the task’ …
    ‘an old boy’s culture’ among doctors, a lax approach to safety, secrecy about
    doctors’ performance and a lack of monitoring by management”. The scandal
    resulted in cardiac surgeons leading efforts to publish more data on the
    performance of doctors and hospitals.

    An investigation chaired by Professor Ian Kennedy QC was set
    up in 1998. It reported in 2001., It concluded that paediatric cardiac surgery
    services at Bristol were “simply not up to the task”, because of
    shortages of key surgeons and nurses, and a lack of leadership, accountability,
    and teamwork.

    Prof Westaby makes a very facetious comment…” Why do
    patients die after heart surgery? Very few of the cases can be attributed to
    surgical error. The predominant cause is ‘failure to rescue’ the patient from a
    common post-operative complication, an event which, better managed, could have
    saved the patient’s life.” This is a silly argument very akin to what we heard in childhood “The operation was
    successful, but the patient died” !!!!

    On the other side of the Atlantic exists the STS
    database(Society of Thoracic Surgeons). This year, it decided to publish
    Hospital base results for various thoracic surgeries. While doing this, it said
    “STS believes that the public has a right to know the quality of surgical
    outcomes and considers public reporting an ethical responsibility of the
    specialty.” Importantly, STS only publishes group and/or hospital level data…
    therefore individual reputations are NOT AT RISK !!! Quite contrary to what
    Prof Westaby argues…A comparison of STS General Thoracic Surgery Database and
    National Outcomes showed quite clearly that Lung cancer resection outcomes for
    STS General Thoracic Surgery Database (GTSD) participants are better than
    national averages . Thus, for the purposes of general thoracic public
    reporting, STS believed that it is appropriate to present a comparison of STS
    GTSD and national outcomes to demonstrate the high performance of GTSD
    participants. So its obvious, people who report their results and are willing
    for them to be published and be in the public domain are doing well for their
    patients…

    What is the moral of this debate?

    1.
    The public has a right to know the results of
    surgery in a hospital

    2.
    The results should take into account the
    seriousness of the condition because the best results are achieved in simple
    cases

    3.
    An excellent surgeon may have average results
    because he is taking up difficult cases which others have rejected to project
    superior results

    4.
    Individual names of poor performers are not
    necessary . However, internal analysis of results should lead to identification
    of poor performers and a root cause analysis of the poor results. As Prof Westaby
    rightly says “Much of this can be related to inconsistent team work — the
    presence of locum doctors or agency nurses who are unfamiliar with management
    protocols. The problem is worst at night and weekends.” But poor results could
    also be poor quality of surgical expertise and how would we know that if we
    were shifting blame on other and the system !!!!

    5.
    Once poor performers are identified, course
    correction is necessary…whether it is further training, supervised surgery or
    restricting privileges. The aim is to bring people up to acceptable standards,
    not to “Name & Shame”. And if someone cannot improve despite efforts, he
    can be told to go without acrimony or insult. Once this threat of loss of
    livelihood exists, even the worst will improve. The aim is to improve quality
    and consistency and not to be an authority whose sole aim is to be punitive..

    So declaring results of surgery and allowing them to be in
    public domain is good and should be welcome. It is important to understand that
    surgical outcomes are serious business and we all need to buck up and achieve
    results that match national and
    international standards because irrespective of how good we think we are…the
    proof of “the pudding” is in hard facts….believe me, figures don’t lie!!!