Piece on cardiac surgery in Times Literary Supplement

In the current TLS I have a review of two books on cardiac surgery. One is Stephen Westaby’s  memoir of his career, the other is Thomas Morris’ historical perspective.


The full text is not freely available online, so here is the bit the TLS have made available to tease you all:

It is tempting to place Stephen Westaby’s Fragile Lives, a memoir of his career as a heart surgeon, in the category the journalist Rosamund Urwin recently called “scalpel lit”; following Atul Gawande’s Complications (2002) and Henry Marsh’s Do No Harm (2014) and Admissions (2017), here is another dispatch from a world arcane even for the majority of doctors. To some degree, Westaby’s book follows the Marsh template. In cardiac surgery as in neurosurgery, life and death are finely poised, and even minor technical mishaps by the surgeon, or brief delays in getting equipment to theatre, can have catastrophic consequences.

Like Marsh, Westaby, a consultant at the John Radcliffe hospital in Oxford, is jaundiced about the bureaucracy of health care and the mandatory “training” imposed on even the most experienced practitioners – “writing my personal development plan at the age of sixty-eight”. Now that death rates are published by the NHS,…

Makes you want to read the whole thing, does it not?

As it happens, Henry Marsh’s Admissions is reviewed in the same issue by George Berridge.

Stephen Westaby, “community focus”, and medical education

Not so long ago, surgery and (internal) medicine were the pinnacles of medical school, the final subjects before graduation. Surgery in particular possessed a dark, elitist glamour, its notoriously long hours and intensity attracting rather than repelling many. Of course, being attracted by a perceived mystique is different from having a sustainable career (and life)

In recent years, medical curricula have been reshaped by many factors, including the realisation that most doctors will practice not as surgeons but as general practitioners, and that the bulk of healthcare need is perhaps more mundane than what goes on in the operating theatre. While there is justice to this “community orientation” of medical education, there is also a certain sense of taking the surgeons and physicians down a peg or twenty. Perhaps there is also a certain anti-intellectualism at work – focusing on the behavioural acts that a doctor performs, rather than the academic disciplines (which include clinical disciplines)

Recently I have been reading Simon Westaby’s memoir of his surgical career, Fragile Lives: A Heart Surgeon’s Stories of Life and Death on the Operating Table. Indeed, the above paragraphs are taken from a first draft of my review (both paragraphs cut for reasons of space and general narrative flow of the review). Westaby’s book is a good read (there, that’s the review bit out of the way) and full of exciting surgical action, described deftly but dramatically. It is also something of an elegy for a certain time of medical and surgical training – an era of overwork and monomaniacal dedication, but also one of intellectual and moral curiosity and rigour, often absent from a modern practice subservient to bureaucratic imperatives. I have already blogged about Westaby’s thoughts (and research) on the impact of league tables on surgical practice. I do wonder whether, for all its manifold faults, “traditional” medical education created a breed of doctor with an espirit de corps to whom a resistance to bureaucratic imperatives came easier?



Unintended consquences and league tables

I have just finished Simon Westaby’s memoir Fragile Lives: A Heart Surgeon’s Stories of Life and Death on the Operating Table . This is for a review which will follow in due course. The main focus of the book is on the stories of the patients and the surgeries themselves, some passages have a (literal) heart-stopping intensity.

One recurrent theme, towards the end of the book especially, is the deleterious effect of blame culture and league tables on surgical practice. Prof Westaby, it turns out, wrote a recent paper on surgeon’s perception of this:

National Survey of UK Consultant Surgeons’ Opinions on Surgeon-Specific Mortality Data in Cardiothoracic Surgery


Background—In the United Kingdom, cardiothoracic surgeons have led the outcome reporting revolution seen over the last 20 years. The objective of this survey was to assess cardiothoracic surgeons’ opinions on the topic, with the aim of guiding future debate and policy making for all subspecialties.

Methods and Results—A questionnaire was developed using interviews with experts in the field. In January 2015, the survey was sent out to all consultant cardiothoracic surgeons in the United Kingdom (n=361). Logistic regression, bivariate correlation, and the χ2 test were used to assess whether there was a relationship between answers and demographic variables. Free-text responses were analyzed using the grounded theory approach. The response rate was 73% (n=264). The majority of respondents (58.1% oppose, 34.1% favor, and 7.8% neither) oppose the public release of surgeon-specific mortality data and associate it with several adverse consequences. These include risk-averse behavior, gaming of data, and misinterpretation of data by the public. Despite this, the majority overwhelmingly supports publication of team-based measures of outcome. The free-text responses suggest that this is because most believe that quality of care is multifactorial and not represented by an individual’s mortality rate.

Conclusions—There is evident opposition to surgeon-specific mortality data among UK cardiothoracic surgeons who associate this with several unintended consequences. Policy makers should refine their strategy behind publication of surgeon-specific mortality data and possibly consider shift toward team-based results for which there will be the required support. Stakeholder feedback and inclusive strategy should be completed before introducing major initiatives to avoid unforeseen consequences and disagreements

This was reported in the Daily Telegraph as follows:

Patients are dying because heart surgeons are too worried about their mortality ratings to operate on critically ill people, a major study has found.

One surgeon claimed he had a watched a three-year-old child die waiting for a valve replacement because a doctor was “too chicken” to operate because of the potential risk to his reputation.

Another warned that surgeons had “become experts in running away from difficult cases”.

 Patients have been able to see league tables showing how well doctors perform on an NHS website since 2014, while information about individual heart surgeons has been available for a decade.

But nine in 10 heart surgeons claim that publishing individual data has led to blame culture where the sickest patients are denied treatment for fear it will lead to an investigation if they die in theatre.

Research carried out by doctors including Stephen Westaby, of the John Radcliffe Hospital in Oxford, and Professor Lord Darzi, chair of surgery at Imperial College and a government adviser, found nearly 60 per cent of surgeons said they were opposed to the current system.

Some 87 per cent of the 264 heart surgeons who replied to a survey said that publication of surgeon specific mortality data had caused a “risk averse” culture in the NHS.

Report author Dr Westaby said: “We have been trying to establish what has been happening among colleagues for some time now. It’s so damning you can hardly believe [it].

“Doctors won’t see a patient if they think it will be a risk to their reputation.

“And it’s often the guys that are doing the sickest patients who end up with the worst scores, because their patients are more likely to die.”

One wrote: “Decisions have become about protecting me, not about what is best for the patient. This is a terrible form of medicine to practice. There is no dignity at the end of life, with surgeons delaying inevitable adverse outcomes in the hope of a miracle or transferring patients to other units so that they don’t count in the figures.”

Another said: “When previously surgeons would have been willing to give it a go on a patient who was certain to die, as there as nothing to lose, now they will be concerned that there is quite a lot to lose.”

Review submitted in Feb 2007 of “Mastering the Techniques of Glaucoma Diagnosis and Management.” for Eurotimes

OK, undoubtedly the writing I have been paid the most for over the years – the writing that has been the closest I have been to earning some kind of living via the pen – were the book reviews I wrote for Eurotimes, the publication of the European Society of Cataract and Refractive Surgeons, from 2004 until 2010. With a payment by the word, and a brief essentially to write a piece about a book that would include a physical description of the size, cover design and proportions of the book, this was an assignment that ultimately became too much “for the  money” rather than any great emotional investment on my part. Perhaps that was all to the good. Generally I would hold forth for some paragraphs about some wider issue inspired by the book, and this is fairly typical of my efforts.

I was upfront with the magazine about my lack of specialist knowledge of ophthalmology (although it has always been an interest and even quite far into psychiatric training I thought of changing specialties…. occasionally I think of it still) but that didn’t matter – the ability to write serviceable prose on a reliable schedule was the important thing. I tried to make these pieces interesting. I am not sure I always succeeded. Payment by the word may have engendered a certain long windedness.

Mastering the Techniques of Glaucoma Diagnosis and Management. Editors: Ashok

Garg et al. Jaypee Brothers, New Delhi, 2006. richly illustrated with colour

photographs, diagrams and tables. 556 pp.

Over the last number of months, this column has increasingly been dominated by the

publications of Jaypee Brothers of New Delhi. This production, from the cover in, is

their most lavish production yet. “Mastering the Techniques of Glaucoma Diagnosis

& Management” – which boasts a tiny picture of an eye in the “o” of “Glaucoma” on

the cover – is a production resulting from the efforts of 97 international contributors

from 15 countries. It required ten editors, with as nearly a spread of nationalities

involved. Perhaps unsurprisingly, the text on the back cover about this platoon of

editors requires quite a small typeface cover to accommodate all their life stories and


India is often used a case study in the effects of globalisation, and while from a

European point of view stories about outsourcing are often used as a stick to beat

globalisation, this books global range and scope illustrate the positive side of the

process. The internet has made the idea of a book published in India with contributors

from 15 different countries and editors from 7 countries all collaborating not merely

feasible, but a commonplace, and the globalisation of computer technology has made

the technical quality of the book achievable in a wide range of settings.

As glaucoma is now catching up with cataract as a worldwide cause of blindness, this

book is timely. Our awareness of the pathophysiology and natural history of glaucoma

has greatly increased. With an ageing population worldwide, chronic progressive

conditions like glaucoma will affect both patients themselves and practitioners more

and more as time goes by. New therapies offer the promise of a more efficient, more

cost-effective and therefore more available approach to glaucoma therapy.

The book is divided into four sections. First one on preliminary considerations and

diagnostic procedures in glaucoma. Secondly the management of glaucoma itself –

medical, surgical and laser – is discussed. This section, unsurprisingly, takes up the

largest section of the book, at over three hundred pages. There follows a short section

on complications of therapy, and finally a section on minimally invasive glaucoma

surgery, which focuses on recent technological and technical advances and possible

future developments.

The book is extremely practical. The final section in particular on innovative

techniques is, by its very nature perhaps, quite didactic and instructive. Experienced

surgeons will find this section of particular interest and will be able to compare their

technique with that of the authors due to the high quality of the instructions given.

In the early section on diagnostic and pre-operative assessment too, we see this

eminently practical approach. Checklists and instructions for very practical tasks are

given, while the more discursive text describes the evidence base and technical and

theoretical reasons for the actions recommended. We find the same approach

throughout the longest section on the technical issues around management of

glaucoma itself.

I have commented before on the high quality of books coming out of India in general,

and in particular on the high quality of books being published by Jaypee Brothers.

This book is not only of as high quality, it is aesthetically more pleasing. The typeface

and general design seem cleaner and more pleasing to the eye – and the various

sections are colour-coded for ease of access. The book is pleasant to handle. It is a

large, reference book, rather than one one could easily carry around the wards or into

theatre. It has a very attractive, soothing even, blue colour scheme on the cover.

The quality of the illustrations – and in particular the reproductions of colour

photographs – is also much to be commended. It is pleasant to come across a book

about ophthalmology so, in its way, attractive to look at. And again, this enhances the

practicality of the book.

As is the fashion nowadays, and as is the tradition with these large Jaypee Brothers

books, there is a DVD provided with the book. It is important to actually see

procedures being performed rather than just written about, and the selection of video

clips from the practices of some of the contributors is a valuable addition to the book.

Sometimes DVDs and CD-ROMs that come packaged with textbooks have a rather

gimmicky feel to them, replicating elements of the book rather than being used for

their own unique qualities, but this DVD is focused on providing visual backup for

the text rather than this pointless duplication.

This book is boggingly comprehensive and will satisfy both the trainee and the

specialist. There is perhaps overmuch detail for all but the most enthusiastic medical

student or non ophthalmologic doctor. With the rise of glaucoma noted above, it is

important that books for these groups are also produced, to raise awareness of the

condition and to give a simpler overview of treatment modalities. However, this

certainly is a useful overview of the state of the art with glaucoma management, with

a strong practical bent.