It is unnerving as a surgeon to recognise that half the surgical workforce is, statistically speaking, below average. No surgeon would like to think they fall into this half and the overwhelming majority do everything they can to perform well. As a patient, it is more unnerving yet, to think that you might be operated on by someone ‘below average’.
Of course, it’s not as simple as this. By what measure do we reasonably assess a surgeon’s performance? It is not straight forward. Outcome measures in medicine and surgery are various: some are more meaningful than others and the context hugely affects which ones.
“Make the important measurable, not the measurable important.”
Consider the outcome measure of gross tumour resection. More is better, one might reasonable think. But this is not necessarily the case. A targeted debulk that achieves the aims of decompressing a critical structure, brings the patient minimum risk and maximum symptomatic benefit, is clearly the sensible and preferable option for someone in their 80s, with a relatively short life expectancy. This may be quite different for a young adult, where maximal resection of tumour brings potential lifelong benefits. The risk/benefit analysis is different and personalised. Such decisions are commonplace in surgery. Making the right call is rarely straightforward. People vary in terms of physiology, outlook, expectations, risk appetite, and more. For a surgical plan to not cater for this nuance means defeat from the outset, almost regardless of how technical proficient and complication-free an operation may be.
All of this said, if we actually could hypothetically distil all useful surgical outcome measures, we would yet be left with the unarguably fact that half of surgeons will be below average. Some might be better communicators, some might be better technicians, some might cope better or worse under pressure. But half would still be – overall – below average.
The answer to this issue is very simple. Reduce variation and increase mean level of performance. If variability is reduced and, on average, we all perform better – there will be improved outcomes for patients. Tools and training and mentoring and coaching and honest audit of outcomes – all are ways of driving performance in the right direction. At eoSurgical, we consider our simulation tools to be one cog in this machine of ongoing global health improvement.
Consultant Neurosurgeon and Honorary Senior Lecturer, Edinburgh