The anonymous article below was sent to us by a doctor outlining the concerns he had about the competence of a surgeon he once worked with when he was a junior doctor. We asked four other doctors what the junior should have done, what they would have done had they been approached by the junior, and what the implications are for the regulation of medicine.
Perioperative mortality (death within 28 days of an operation) has became a key surgical phrase in the past decade, particularly after the publication of the first report of the confidential inquiry into perioperative deaths. This document detailed a variety of surgical and anaesthetic disasters, and, although it pointed out that many perioperative deaths were and remain unavoidable, there were contributory factors such as inadequate hospital facilities, poor supervision of junior doctors, and inappropriate surgery in severely ill patients.
This and subsequent reports, together with regular intradepartmental and interdepartmental audits, have raised the awareness of perioperative mortality. All operative deaths should now be discussed to discover if care could have been improved or death avoided. I have been fortunate to be a surgical trainee in these more enlightened times. Usually, the audits I have attended have had an average of one death every six months from routine general surgery lists (somewhat more from emergency surgery), and even fewer during my five years in specialist training. With one exception: during a six month period on one firm, five patients on routine lists died from a variety of reasons. All of these patients were led to believe that their conditions would be substantially improved if not cured by the surgery, and yet within a matter of days they were dead. I felt at the time that certain questions were overlooked, if not ignored. My polite queries to the consultant staff were brushed aside, and the surgeon allowed to continue (with more unquestioned deaths) until his eventual retirement.
Memories of the patients, and their families, have stayed with me, and I now wish the problems to be exposed to wider scrutiny. Am I being paranoid or too sensitive? Or am I raising legitimate problems associated with a certain brand of surgeon that was supposed to have been swept away with the advent of the modern NHS—surgeons who believe they cannot be questioned and that their techniques and beliefs are always right?
Each of the cases raised different questions, although all but one of the patients had cancer. One patient died of unexpected medical complications after routine surgery (could the preoperative work up have been improved?); another died of metastatic cancer which the operation could never have cured (it should not have been performed); and the other three deaths were totally unexpected. In one of these cases a necropsy was not requested, so we learnt nothing and realistically should not have issued a death certificate; in another case no cancer was found in the removed organ (should the operation have been performed?); and the last patient died from a presumed iatrogenic complication.
The surgeon may have been unlucky, though I feel that the deaths must be seen in the wider context. They all occurred within 16 weeks of each other, and within my six month rotation nine other major operations were performed, of which five involved major and potentially avoidable complications. Both the junior medical and nursing staff were concerned about obtaining the consent of patients for major surgery as there seemed no guarantee that they would do well. And the problems continued after my spell on the unit.
Criticism of the surgeon at the time was difficult. He was rarely on the unit and planned and assessed his major cases personally, rarely involving either his consultant colleagues or the junior staff. Disagreeing over patient management was not an option as I needed a report at the end of my stint that would be filed in my training record. I ensured that the cases were aired at the monthly audit meetings, but the surgeon concerned rarely attended these and the meetings were treated with little interest by the other consultants (formal meetings have subsequently been dropped, contrary to royal college guidelines). All I have done is keep a diary of the events, file the worry on my six month assessment form and discuss the problems with colleagues and friends.
See Editor’s choice BMJ 1998;316:1736-40