August 13, 2015

Surgeon Scorecard - Good or Bad?

There has been a media frenzy regarding ProPublica's Surgeon Scorecard which rates how "good" a surgeon is based on calculated death and complication rates for surgeons performing one of eight elective procedures. Unfortunately, a surgeon paradox will develop where one may actually WANT the surgeon with the WORST score because a surgeon with the BEST score refuses to operate on a high-risk patient.

Why? Although great in concept, the Surgeon Scorecard introduces the law of unintended consequences. As beautifully explained by Dr. Saurabh Jha (read his article!), in order to avoid a bad grade, surgeons will start to:
  • Avoid operating on any very sick patients who need surgery, cherry picking only the healthiest to operate on.
  • Only surgeons who "don't care" about their score will continue to operate on any patient who medically needs it regardless of whether there will be an increased risk of complications.
  • Overall surgeon skill will decrease as surgeons as a group start to avoid operating on any patients who may be anatomically difficult in order to avoid a complication and a bad score.
  • Overall, surgeons who will have the worst grades will be those who work in highly rated institutions like Cleveland Clinic, Mayo Clinic, Johns Hopkins, etc. Why? Because surgeons there treat the most difficult and sickest patients who naturally will have a higher complication and death rate.
It is accepted that a surgeon grading system is here to stay, but something needs to be done to improve the grade to reflect that true quality of the surgeon rather than basing it solely on death and complication rates (even if adjusted for hospital quality).

I propose that operating room nurses, surgical technicians, and anesthesia personnel also be able to anonymously rate the surgeon. As any healthcare professional knows, these personnel know from working day in and day out with many different surgeons, who the best ones are from a technical and intellectual standpoint.

Although actual death and complication rates should be factored in, these "human evaluators" would provide perspective to the raw numbers and provide a more realistic grade of how good a surgeon is.

For example, here's a hypothetical example taken from the ENT world... A patient presents to a community-based ENT with a severe sinus infection. It's so bad that an abscess has formed next to the eye and the eye has swollen shut. The patient has been on oral antibiotics throughout this time period. The next step is aggressive sinus surgery to drain the abscess and clean the sinuses of all infection. HOWEVER, this patient also has very bad diabetes with out-of-control sugars which increases risk of poor wound healing, is on coumadin due to atrial fibrillation which significantly increases bleeding risk, cultures show MRSA growing but the patient is allergic to vancomycin, and to top-it-off, also just had a heart attack 4 weeks ago. This patient NEEDS surgery given the worsening sinus infection and abscess around the eye. However, because of all the medical problems the patient is suffering from, the ENT declines to operate given the risks (but also perhaps of the fear of getting a bad surgeon score) and refers the patient to an ENT at Johns Hopkins.

Fauquier blog
Fauquier ENT

Dr. Christopher Chang is a private practice otolaryngology, head & neck surgeon specializing in the treatment of problems related to the ear, nose, and throat. Located in Warrenton, VA about 45 minutes west of Washington DC, he also provides inhalant allergy testing/treatment, hearing tests, and dispenses hearing aids.

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