The Great Debate: Should surgeons disclose ‘complication’ rates?

In a major development for patients seeking access to a doctor’s official operating data – prior to providing informed consent for a medical procedure – surgeons “are being urged to disclose their rates of surgical complications to justify their premium fees and to help patients make informed choices on doctors”.

Triggering the front page headline ‘Surgeons Urged To Cut The Secrecy’, one of Australia’s most prominent surgeons “has broken ranks with the profession by publishing his surgical outcomes data for any potential patient, referring GP or colleague to scrutinise”.

Australian National University Medical School obstetrician and gynaecologist Professor Stephen Robson told The Sydney Morning Herald (SMH) bluntly: “Surgery is like sex – everyone talks up their performance.

“But getting the objective data to verify their claims is much harder to come by. When something is veiled in secrecy, it can feed mistrust and anxiety.”

Professor Robson has published a five-year audit of his surgical practice on his website, detailing the number of surgeries performed and benchmarking his complication rates against clinical indicators published by the Australian Council on Health Standards.

He explained: “I just thought ‘oh, bugger it’. It’s time for me to help patients make an informed decision about the quality of care they get and maybe I can inspire my colleagues to do the same.”

He also noted: “We don’t want a situation where patients go with the lowest bidder irrespective of the standard of care on offer.”

Support from Aust Chief Medical Officer

The UK’s National Health Service has published specialist league tables benchmarking specialists’ performance since 2014 and Professor Robson’s move was commended by Australia’s Chief Medical Officer Professor Brendan Murphy for dispelling the “mystique” surrounding doctor’s healing skills.

While Australian surgeons are required to conduct yearly audits of their surgical outcomes and submit them for peer review as a condition of their registration, Professor Murphy noted that of the more than 7,000 surgeons across the country, the number who publicly share this information was “likely to be in single digits”.

Professor Murphy told the SMH: “Any doctor claiming superiority has an obligation to provide the data to back that up.”

He added the strong resistance from the surgical profession was “predominantly rooted in fears about how the data would be interpreted”.

He explained transparency on surgical complications was both “incredibly important” and also “incredibly difficult” to get right and adjust for the level of complexity of different surgeries and patient prognoses.

But he emphasised: “We need to overcome these difficulties because the public has a right to transparent and accurate information.”

He said the ideal scenario would involve a “central register where surgeons’ outcomes were vetted, benchmarked and risk-adjusted against validate measures, so as not to disadvantage surgeons who took on a high volume of the most complex cases with a higher risk of complications”, but this was “a fair way off”.

Key part of ‘informed consent process’

Private Healthcare Australia chief executive Rachel David “applauded surgeons who took the brave step” to publish their outcomes for “dispelling a mystique surrounding the medical profession”.

She told the SMH: “Doctors who fail to share their data and hide behind the veil of ‘I’m the best’ – patients will move away from those practitioners.”

Victorian ear, nose and throat surgeon Dr Bridget Clancy has published her complications data on her website since 2015 – plus a plain English explanation for each adverse event.

Dr Clancy declared: “If you are a surgeon and you can’t explain your results to your patients, then you shouldn’t be operating. It should be embedded in every informed consent process.”

She understood that surgeons feared being “hung out to dry” for bad outcomes, despite patient care being the shared responsibility of the entire treating team. And she noted: “One colleague said to me ‘What if you have a bad year? What if you get a few bad complications in a row? Would you still publish then?’

“But the discomfort of not publishing and not being transparent outweighed the discomfort of publishing and worrying about what people would think.

“We could get very complex about it, with sophisticated data and analytics and weighting, and spend the next 15 years in sub-committees trying to work it out; or we could just start doing it and change the way we talk to patients about complications.”

It ‘can and should be done’

Economist Dr Stephen Duckett, health program director at leading think tank The Grattan Institute, said the move by individual specialists to self-publish their outcomes proved “it could and should be done”.

Duckett told the SMH: “For too long doctors have been saying it’s not possible and using statistical difficulties of risk-adjusting as an excuse not to do it.”

He suspected some surgeons opposed greater transparency because they “knew their results would not stack up against their peers”.

Dr Duckett said ideally surgical complications data “would be made publicly available by all public hospitals and individual surgeons operating in the private sector”.

He added there was also a “cost benefit for private health insurers if they disclosed surgeons’ complication rates to members, driving greater numbers of patients to the better performing surgeons”.

RACS warns ‘patients will misinterpret data’

The Royal Australasian College of Surgeons quickly rejected calls for doctors to publish their complication rates, warning patients would “misinterpret the data and that could unfairly tar doctors who take on the most complex cases and arduous surgeries”.

Spokesman Dr John Quinn told the SMH: “The College is in favour of transparency. But we are not in favour of league tables that rate doctors at the top and down the bottom.

“The public don’t understand the complexities involved. It’s not like motor engines, where everything is expected to work in a certain way. The different biologies of patients mean it’s not a valid comparison.”

He emphasised that clinicians who took on a high volume of the most difficult cases “could come off looking less skilled and trustworthy” because they have a higher rate of complications than their colleagues who deal with easier cases.

Others may “cherry-pick the least complex patients” that are most likely to have better outcomes, and surgeons at the beginning of their careers would also be “unfairly judged against consultants with decades of experience”. AMP