A true measure of surgical risk

A true measure of surgical risk

February 2016

By T A Balasubramaniam

The Naked Surgeon

The Power and Peril of Transparency in Medicine

Samer Nashef, Speaking Tiger Publishing,

Paperback, INR 350; 201 pages

 Most medicine as practised nowadays is (or should be) evidence-based. There is so much medical research around, that a doctor should be armed with the facts and figures before deciding to use this or that type of treatment. The opposite of evidence-based treatment is practised by stubborn, yet famous, high-profile doctors. I call it eminence-based medicine and it is defined as ‘persisting in making the same mistakes over and over again, but with ever-increasing conviction.’ This is, of course, insane.”

Samer Nashef, the author of this book, is an experienced surgeon and an internationally acclaimed authority on risk and quality in surgical care. He ardently supports the modern trend of empowering patients with full disclosure (the ‘naked’ in the title stands for transparency) and statistical data, especially when they need to make life-critical choices about which surgeon and what hospital to approach for surgical treatment. One of his creations, the EuroScore model for predicting the outcome of heart operations, is now widely used in many countries, and it has saved countless lives. What he exposes in this lucid, honest and wry examination of what actually transpires in the world of surgeons is both startling and reassuring.

The reassuring aspect of modern surgery is that it is highly professionalised today, and, thanks to advances in medical science and technology, you can entrust your life to surgeons with a reasonable expectation of surviving even very complicated operations. However, compounding the problem of arrogance among surgeons is the difficulty that ordinary people, and even many expert analysts, have in interpreting statistical data. The problem with analysing records of the success rate of medical interventions is that the statistics can be manipulated in many ways to present a reassuring picture when the reality is quite different.

Nashef simplifies the data analysis and makes it intelligible through clear graphs and examples. He also goes to great lengths to take away the cobwebs that obfuscate our understanding of statistical complexities. His style is chatty and often marked with irreverence and wit, but he never plays down the serious nature of his investigations.

As an example, in the chapter titled, The Trouble with Ratings, Nasef patiently (pun intended), and with wry humour, explains the central paradox of risk in cardiac surgery: the more an operation is likely to kill you, the better it is for you. The reason for this paradox is that withholding an operation (because it entails high risk) is more detrimental for some patients than the associated risk of undergoing the operation. Many surgeons, however, are reluctant to go for the high-risk cases because it may affect their eminence (if they are not successful in their effort). “Our patient, if refused an operation, will die and become a statistic – but not a statistic that appears in the league table of heart surgery – and nobody will ever know.”

This is a compilation of surprising revelations that will help anyone understand the forces and compulsions that shape the profession of surgery today.

- TA Balasubramanian