Ranking heart surgeons has pitfalls

Editor—Dyer reports that heart surgeons are to be rated according to success in bypass surgery.¹ Cardiac surgery is a team sport, and each player can influence the score. The dilemma I face as a surgeon is that the result is mine, although the poor performance may not always be.

Furthermore, the potential problems with ranking cardiac surgical performance have been well described previously.

The cardiac surgery reporting system was mandated for all cardiac surgeons in New York State by its department of health in 1989. It was the first doctor specific mortality report published. As a result of successful application under freedom of information legislation by Newsday, both institutional and individual outcomes have appeared in the popular press from 1991.

Burack et al reported in 1999 that 40% of surgeons admitted to gaming with risk factors, and that 62% admitted to refusing to operate on high risk patients as a consequence of the review (those patients who stand to gain the most from a successful procedure).²

Shahian et al also emphasise these difficulties in their comprehensive review of “report cards,” and they comment on the flawed statistical methods used.³

Polonieki keenly observed that half of all doctors are below average and that poor statistics alone can make a surgeon's performance appear to be an outlier.⁴

Consequently, publication of individual surgeon's outcomes is not without detrimental effects. Those who mandate and apply such comparisons should be aware of these consequences.