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Council President Addresses RCSI Millin Meeting

“Surgical Leadership and Medical Professionalism”
Millin Meeting RCSI 14th November 2014
Professor A.E. Wood, M.B., B.Ch., F.R.C.S.I., D.C.H
Medical Council President

President, Members of Council, Fellows, Members, Trainees and Guests. Thank you for the invitation to speak to you on professionalism in surgery and surgeons.

Firstly, as is current practice, I should declare that since December 2013, I am currently teaching Anatomy in the very room Abraham Colles did over 200 hundred years ago and chairing the Medical Council. The hospitals I spent so much of my life in: The Royal Victoria Hospital Belfast, The Mater Misericordiae University Hospital and Our Lady’s Children’s Hospital, I now have no attachment to.

Surgery is not a pure science as many would like to believe. Indeed in my view it is an art supported by science, scientific hypothesis and in particular unbiased scientific analysis.

Successful outcomes cannot be absolutely predicted. Death and injury can and do occur through no fault whatsoever. There are two certainties in life: Death and taxes. Surgeons additionally can over a career spanning 3 decades expect to appear in the High Court; be complained to the Medical Council, attend the coroner’s court; have a national inquiry on their decision making and finally be publically censured by the Medical Council. This should not be a barrier to leadership. Indeed, I have experienced/endured all the above.

Much has changed over the last 30 plus years since I became a consultant surgeon. Medical litigation has gone through the roof, between 2006 and 2013, the total annual settlement figure has gone up 5 fold. Currently, the clinical State Claims Agency is paying out €80-90 million annually. My indemnity which cost £71 in 1982 had increased a thousand fold to €92 thousand by the time I stopped operating in 2013. Regulation has increased hugely as a consequence of successive international and national medical care scandals, in particular the Harold Shipman affair, the Neary Affair and the Hepatitis C Inquiry. The Bristol Inquiry into Paediatric Cardiac Surgery in Bristol Royal Infirmary during the 80s and 90s changed for ever the trust the public had in surgeons and surgery. Public trust in the medical profession was shaken. There appeared to be a wall of silence, a cloak which no doctor or surgeon would lift to unveil or lay bare the truthful facts about poor performance or patient harm.

Widespread changes in medical regulation occurred in Europe, the United Kingdom and here in Ireland giving greater responsibility and duty to the regulator to ascertain and verify the competence of the practising practitioner. Trust, honesty and competence are the basis for the proper patient surgeon relationship. The fundamental principle of Surgery is “Primum non Nocere”, first do no harm. There is another principle “Errare human est, perseverare autem Diabolicum”. To err is human, but to persevere is diabolical. How can a Surgeon maintain Competence, assess harm and learn from experience? The late Prof. Eoin O’Malley, President of this College in its 200th anniversary said in 1988: “Objective Clinical Appraisal by an unbiased observer is still the hallmark of medical progress”.

I have been fortunate over my career to introduce a number of National Programmes; Heart Transplantation, Homograft Valve Banking, Lung Transplantation and Artificial Heart Devices but it was in the field of Congenital Heart Surgery where most surgical innovation took place.

Transposition of the great arteries is the commonest cause of Cyanosis in the 1st year of Life . Without treatment 95% of Babies die; the majority in the first six weeks. Atrial redirection leaving the Right Ventricle as the Systemic Ventricle was the treatment norm in the 80s having been introduced in the 60s and early 70s. There were many concerns about it; Mortality by 15 months of age was up top 20%, higher if a VSD was present, frequent rhythm and baffle problems and lastly terminal right ventricle failure in the late 20s early 30s. Hardly an operation giving a normal life expectancy? Jatene successfully performed an Anatomic Arterial Correction in 1976. Magda Yacoubian took this up enthusiastically in the late 70s in London and some Centres around the world began to apply it in the early to mid-80s.

I began such a programme in 1985 with the support of Dr Brian Denham (Cardiology) and Dr Pat Doherty (Anaesthesia & Intensive Care). It is an extremely difficult operation especially on a new-born of 3kgs.. It involves transplanting the Great Arteries and relocating the Coronary Arteries, concomitantly closing the Atrial Septal Defect and Ventricular Septal Defect if present. Much was unknown especially about the development of neonatal ventricular function and the Coronary Artery Anatomy which was extremely varied and could and did have a direct influence on success or failure – Life or Death. How did I undertake/ manage Quality Assurance? Quality Improvement?

Well, I simply kept a Logbook, as I did with all the other programmes, detailing all the patients, anatomic and operative details including outcomes and death if it occurred and the findings at post-mortem, having examined the heart myself with the pathologist. All of this yielded vital information to refine the Surgery and improve outcome. Here you can see the number of operations by year and the outcome and the following slide shows the dramatic effect of introducing the “Le Compte Manouver” where the Pulmonary Artery is brought in front of the newly constructed Aorta. This change of technique reduced compression on the relocated Right Coronary artery reducing the risk of Fatal Myocardial Ischemia. The survival by 2000 was approaching 100%.

I am glad to report that that success has continued. This slide compares the recent outcomes for this operation by my Colleagues in Crumlin with all the Paediatric Centres in the UK. This can be viewed on the website of NICOR- The National Institute for Clinical Outcomes Research. I compliment them on having their work continually validated internationally- this is modern medical professionalism.

Why mention this at all? Well Bristol Royal Infirmary decided to start such a programme in the early 1990s. Great Ormond Street (90 miles) and Birmingham Children’s (60 miles) already had programmes up and running. The first 12 Babies died. A Multi-Disciplinary Team meeting was held to decide if the team should proceed with the 13th? All consultants except the anaesthetist, Dr Steve Bolsin agreed the operation should proceed. The consultant surgeons met with the parents and indicated the operation had an 85%+ chance of success. The baby died. The rest is history. Both surgeons and the CEO of the hospital, radiologist were struck off. Professor Sir Ian Kennedy led the inquiry into the debacle. It reported in 2002. There were fundamental failures in medical professionalism, failure to place the patient first and frank dishonesty. To quote Fintan O’Toole when he wrote recently about the Garda/GSOC Report: “Pietas super Veritatem”- Loyalty above Truth. Do such actions place the patient first?

Widespread changes followed, giving the Regulator more authority to assess competence; basically, the medical profession failed to self-regulate. Our society quickly appreciated the need to collect and publish surgical activity and outcomes, which it did in 2003 under the guidance of Bruce Keogh now Prof Sir Bruce Keogh, National Director of the NHS and Honorary Fellow of this College. Has this QA/QI had any effect on outcomes? Well Ben Bridgewater and colleagues did a review of CABG Surgery in the North-East of England and demonstrated a 50% improvement in Survival. As David Taggart a former President of the Society of Cardio-Thoracic Surgeons of Great Britain & Ireland said “There is nothing like clear comparable publically accessible information to promote change”.

The society has since gone on to produce a professional guide for all cardio-thoracic surgeons in these islands. The Royal College of Surgeons of London has recently followed suit, in which it states every Surgeon must participate in Audit, Outcome Activity and Analysis. Bruce Keogh put it succinctly: “Surgeons have a moral and professional duty to know what they are doing, how well they are doing it and to use that information to help improve (their care), otherwise they have no right doing it at all”.

Certainly, other regions of the world are undertaking this type of QA/QI. In Australia and New Zealand under the auspices of the Royal Australasian Society, Surgeons have been involved in and undertaking this type of review, publishing both national and regional reports. The participation rate has been very high, the only outlier is Obstetrics and Gynaecology. North American surgeons are particularly active in this field through their Professional Societies. Here at home as I’ve mentioned the congenital heart surgeons are doing it, but so also the Faculties of Pathology, Radiology, Gastroenterology and Neonatology are undertaking QA/QI programmes. This is commendable.

The Medical Council in its current term has placed patient safety at the centre of all its Strategic Goals. A majority of Council hold the view that every doctor should know what they do, how much they do, how well they do it and to use that information to improve patient care and service. After all, 100% of us are patients and 70% of us will have an operation before we die. The Council looks to you, the delegated college in surgical matters, its Fellows and Members to work together in taking a leadership role in establishing clinical performance measurement which will ensure the standards in surgery underpinning patient safety and safeguarding public trust in surgeons.

“Our Lives begin to end the day we start to remain silent about the things that matter”

Martin Luther King