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AFTER BRISTOL: QUIS CUSTODIET?

The repercussions of the British General Medical Council enquiry into the deaths of babies undergoing cardiac surgery will continue. The Health Secretary has decided to hold a public Enquiry into the circumstances of the deaths and into why certain operations were not halted earlier and why patients and relatives were not told of the true risks.

Many questions relating to the principles of the practice of medicine are raised by this sorry tale which are important to Otolaryngologists as well as to Cardiac Surgeons. The most important of these is that patients are entitled to be told the true – i.e. personal / departmental – risks of surgical treatment. The children who underwent certain types of surgery in Bristol were much more likely to die than if they underwent the same procedures elsewhere in the country. Our patients are equally entitled to know how our own performance is measured and how it compares with national figures. How many of our readers quote their own success rate for stapedectomy based on their last 100 cases? How does a new consultant quote his own success rate? One method employed by American vascular surgeons is to say that new consultants have a series of 100 good results to begin with and then they add their own patients on top making 101, 102 etc. However the results of the latest 100 are what is quoted which allows all the notional initial cases to drop out after the consultant has achieved 100 personal cases.

If we are to compare our own figures with the national ones where do we find other peoples’ results? Clearly the best departments will publish in peer-reviewed journals but we must remember that by definition 50% of departments will have results below average; although comparing your results with the best is desirable, it may produce misleading and unnecessarily unfavourable conclusions.

What about the issue of stratifying for complexity of disease? We know that in the field of Head & Neck cancer, stage of the disease is the most important determinant of survival. But nutritional status also influences outcome. Cancer also allows surgeons to hide behind the disease as is the case with any life-threatening condition. It is easier to say the outcome was poor because the disease is so serious than because your operation or post-operative care was sub-standard. The aftercare of patients has also changed enormously over the past ten years: with the constant demand for team working and multi-disciplinary involvement, who carries the can if a major surgical case receives poor anaesthetic or intensive care? To unravel the strands of where in the chain of events the care of any one patient may have gone wrong is extremely difficult and occupies huge amounts of time in the law courts.

This journal wishes to encourage openness in the debate about professional scrutiny and accountability. I am willing to accept for publication abbreviated reports of Audit meetings in your departments if they will help to identify the true success rates of surgical procedures (e.g. fistula rate after laryngectomy or dead ear rate after mastoid surgery) or the outcomes of certain treatments. This would at least provide an accessible benchmark for others when looking at their own results. If you have information which may fit into this category please contact me to discuss publication.

THE LOST TRIBE (of trainees)

The changes in training surgeons in the UK are now well established. On page 74 of this issue the secretary of the Association of Otolaryngologistst in Training raises some worrying questions about the demographic time bomb that is just around the corner. It seems possible that there will be twice as many accredited trainees leaving the system as there are consultant jobs available in the years 1999 and 2000. In a country where all important health care decisions are made centrally, it is arguable that the decision that trainees must leave their training scheme after a set period will have to be reversed. Since the government is a monopoly employer it surely owes a duty of care to those in approved training posts that they will not be made redundant without a reasonable prospect of employment as a specialist. No doubt the medical trade union will have something to say about this in due course.