A few years ago, I was at a dinner party and got chatting to an engineer from overseas about mishaps and complications that happen in both our industries. During dinner, he turned to the host of the party (another surgeon) and asked: ‘So, what would you say your complication rate is?’ She replied, ‘Very low. ’ The engineer continued, ‘Less than 10 per cent?”. ‘Definitely, ’ she said. ‘Less than five per cent? ’ ‘Yes, maybe about one per cent. ’ The host’s husband, who had overheard the conversation, asked, ‘How about the lady you had to take back to theatre for a bleed? Or the patient with the deep vein thrombosis? And do you remember the patient with the infected port site?’ When reminded, the host remembered every one of these events. As surgeons, we sometimes don’t remember complications as factual events because they trigger an emotional response. They perhaps remind us that we are not as great, invincible and heroic as we would like to be.
Can reflection reduce complications?
We know that complications are the biggest killers of hospitalised patients. In Australia, complications kill twice as many patients as traffic accidents. Research also suggests that half of all complications that develop during a hospital admission are preventable. While doctors face increasing external pressures to be more accountable, many would also agree that external monitoring focusing on adherence to quality criteria misses the mark. This is because for independently minded, top-performing doctors the feeling of being ‘checked on’ does not create buy-in, but resistance.
My research shows that reflection can decrease complication rates by 30–40 per cent. Yet, how many surgeons reflect? And how many of us have the tools to help us do this effectively?
Self-reflection requires a specific mindset and willingness to look in the mirror, even when we anticipate unfavourable outcomes. Overweight people who are not willing to step on a scale are unlikely to lose weight. The issue with denial is that if we don’t recognise and take ownership of an issue, we don’t develop a need to fix it.
Why aren’t surgeons better at reflection?
The following are possible reasons that surgeons struggle with reflection:
Once doctors work independently and without the supervision of ‘bosses’ who keep an eagle eye on trainees, getting useful feedback can be challenging. Doctors can be geographically isolated, especially in remote communities, where there are only one or two specialists. Typically, gathering to exchange ideas and issues is difficult. Isolation can also be perceived. Some people are not comfortable sharing sensitive data with their colleagues because they associate complications with failure.
Lack of access to clinically meaningful data
Hospital data are not typically available to individual doctors. Even if it was made available, the quality of these data would be poor and meaningless for individual learning. Quality registries capture relevant data, but the primary goal of this activity is to inform health policy. It’s also easy to enter data into a registry, but it’s much more arduous to extract it.
Like my friend at the dinner party, we all prefer to hear about how great we are and avoid talking about our failings. Reflection requires an attitude that acknowledges our vulnerability.
Many surgeons say, ‘I know I’m okay anyway’. Some say they have a list of their patients, but never actually reconcile their patients with outcomes. Others, in conversation with colleagues, say that they record outcomes, when in reality, they don’t. Others again would say that if there was a problem, they would hear about it somehow.
Reflection also requires additional resources. The surgeon’s practice has to enter data into a database, which is time-consuming and creates an extra cost. Some question the return on this investment.
Patient-reported data are not available
‘It’s all about patients’ is easily identified as lip service if we don’t capture the patient perspective. One of the most common questions patients ask before surgery is, ‘What can I expect from surgery?’ This question is hard to answer because formal and quantitative feedback from patients about their post-surgery outcomes is virtually non-existent. Outcomes that are important to patients include pain, nausea, fatigue and the ability to perform normal daily activities.
What tools are available to help us reflect?
A few years ago, I felt overwhelmed by my complications in surgery for advanced ovarian cancer, and I was keen to understand how my complication rates compared with that of other surgeons. There were some tools available at the time, but they were insufficient to answer my question.
- Department-based audit. All patient data at our gynaecological cancer centre is audited for clinical quality indicators. Typically, the data is not stratified by confounders (complexity of the surgery, medical comorbidities) or the type of procedure. Surgeons who perform more minor surgery or procedures for benign diseases can expect lower complication rates compared to surgeons whose workload is predominantly cancer.
- Morbidity and mortality meetings. These meetings allow surgeons to discuss complications, near-misses or other events (such as omission of treatment) freely. The value of morbidity and mortality meetings is that they are constructive, not punitive, and learning points are developed based on selected cases.
- Patient survey. For many years, I have sent a survey to my patients six weeks post-surgery. The learning from those surveys has been invaluable. I ask my patients about how easy it was to contact my office, how friendly and professional they feel my staff is, how their anaesthesia went, and so on. The survey results indicate how well the patients felt treated, but no comparisons are possible.
- Data from my practice management system. Any practice management system collects massive amounts of data, but it cannot inform us clinically because virtually all of it is for administration and billing purposes.
I realised there was not one tool available that would accurately inform me about the meaningful outcomes that I care about as an active surgeon. I was looking for something that would give me confidential and secure access to information so that I can reflect without the threat of repercussion and so that I could interrogate my data at any time. I resolved to do something about it.
How SurgicalPerformance can assist with reflection
In 2012, with a team of software developers, I built a web-based database that is secure and fulfils all the criteria of a modern medical database; that is, it collects information to generate insights.
SurgicalPerformance.com is innovative because the information collected accounts for all parameters that could possibly have an impact on outcomes. Some of the patient factors are already routinely collected, others (such as the ASA score) needed to be added. To create the software, we had to document surgical procedures and break them down into small components so that our users can quantify them. Most importantly, we needed to record outcomes that are relevant to the surgeon. These outcomes have not been collected previously, because often they are specific to the procedure.
We then built a platform where users can quantify every data variable so that users can interrogate the database interactively and generate insights. Recently, we created a statistical algorithm to quantify the risk of a patient developing a complication, which allows us to report risk-adjusted complication rates. Again, this has never been done previously.
As a surgeon, I can now compare myself against others. Only I know my own outcomes, but I have more than 110 000 cases for comparison. Identifiable data are never shared with any third parties or the courts, but non-identifiable data are used for medical research. To date, we have written three scientific papers using SurgicalPerformance data.
The paper I am most proud of is the most recent paper, which is going to be published soon. It correlates familiarity of the surgical team (assessed by the surgeon) with surgical complications that were captured four to six weeks after surgery. In brief, the incidence of surgical complications following major gynaecological surgery was reduced by 30–40 per cent if surgical teams were familiar. As a SurgicalPerformance user, I can now check how the familiarity of my surgical team stacks up against others.
In collaboration with AGES, SurgicalPerformance has developed online morbidity and mortality webinars that run twice a year. O&Gs can anonymously submit a case for discussion, and we will develop learning points based on the case. By doing this, SurgicalPerformance is creating a community of users.
RANZCOG grants CPD points; 12 cases entered into SurgicalPerformance will earn 1 hour/1 CPD point. For my recent CPD cycle, I was able to collect all points through SurgicalPerformance.
SurgicalPerformance.com has just launched PROMS (Patient-Reported Outcomes) for gynaecology. PROMS allows to easily ask patients and gather feedback on outcomes that are important to them (such as pain, fatigue, mobility) after gynaecological procedures. A separate score will also inform users about how likely a patient is to recommend you to family or friends. PROMS is used in conjunction with SurgicalPerformance or as a stand-alone feature.
The future of insights
Without insights, working as an O&G or other surgeon in any country will become increasingly difficult in future. Insights are developed when we use analytical tools to reflect, inform us and lead to savvy decisions.
With SurgicalPerformance, we can use insights about where we are excelling (for example, ‘It seems I am pretty good at this procedure’); share quantified risk factors with patients; identify factors that could lead to better outcomes (for example, ‘My rate of XYZ is higher than I want it to be’); and simply quantify things we already thought to be true.
Today, we have the tools available to us to help us reflect without professional or personal repercussion. How do we justify not using the insights available to us, particularly when our patients, colleagues and future doctors are increasingly better informed every day?
While I am unashamedly biased towards SurgicalPerformance.com, I am also a dedicated user of the system. This is because what I have learned from using it has transformed my practice on multiple levels. While not perfect yet (there’s still time!), reflection has made me a much better surgeon than I could have otherwise been.