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I was curious about this thrice-upvoted comment, which says: Surgeons are also known for refusing to operate in order to maintain their ratios. So I Googled it and it seems surgeons can refuse to operate, but it's not immediately obvious they do so to "maintain their ratios". I recall something along these lines in the movie Doctor Strange:

Billy: I have a 68-year-old female with an advanced brain stem glioma.
Doctor Strange: Yeah, you want me to screw up my perfect record? Definitely not.
Doctor Strange quote.

This makes me suspect it might be an urban legend. A bit more digging yields a published claim along these lines:

Usually, most experienced surgeons operate in the most challenging cases, thereby distorting their mortality statistics. For patients, these statistics represent mainly a surgeon’s skills and competence. Therefore, “gaming” occurs: Surgeons may refuse to operate on high-risk patients or may pass the difficult cases to colleagues to keep their own statistics clean196,197.
Johanna Ruohoalho, Complications and Their Registration in Otorhinolaryngology – Head and Neck Surgery, PhD Thesis, University of Helsinki, 2018 (pdf, p.56)

Unfortunately, I don't have free access to either of the references above (one is a book, and one is behind a paywall).

Question: Do surgeons refuse to operate "to keep their own statistics clean"?

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    This may be something that doesn't generalise. Some health systems may have incentives that drive this behaviour, but there are many systems and some may have no such incentives. So the answer might be "it happens in some systems but not in others".
    – matt_black
    Jan 6 at 9:46
  • 19
    It may be worth pointing out that Dr. Stephen Strange at the beginning of the movie is presented as an unlikeable character. It's possible that rejecting patients so he looks better is another facet of his narcissistic personality. Jan 6 at 15:49
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    This question is framed as if the practice in question is a bad thing. If your surgeon isn't confident that they'll be successful, don't you want them to decline and pass you to someone more experienced? They have an obligation to do no harm, so it seems natural that they'd pass on cases where they're more likely to harm than heal. This only really becomes a problem if nobody will do the surgery, but that's not really something you can track using per-surgeon statistics.
    – bta
    Jan 6 at 16:17
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    @bta: I would want them to decline for someone more experienced. I believe this question is more about experienced surgeons declining risky surgeries and then inexperienced surgeons taking them on. Jan 6 at 18:31
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    @mbrig What if the surgeon says "Without surgery, the patient will die. With surgery, they have a 50% chance to die or survive. I won't perform the surgery to keep my statistics clean", that's one thing. If the surgeon says "You are at high risk of complications, and giving you these (totally unneccessary) breast implants has a ten percent chance of killing you, I won't do it" that's a completely different and very reasonable and commendable thing to say.
    – gnasher729
    Jan 7 at 10:14

1 Answer 1

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Risk aversion in surgeons is widely believed to be true but the evidence suggests it isn't universal

The potential for surgeons to behave in risk averse ways occurs when surgeon level outcome data is published. This clearly creates an incentive to select patients whose risk of complications is low so that the published statistics for the surgeon look better.

But–especially when the evidence is handled carefully including proper risk-adjustment and careful presentation–it is less clear that the incentive to be risk-averse is clear and simple. If risk-adjustment can be done well and presented well so even the public can understand the results, there may be little real incentive to avoid risky patients.

The belief that open publication of outcome data is a problem is clearly widespread. This 2014 article in the BMJ is one of a series arguing against surgeon-level outcome data for related reasons (note the date for context later).

The UK experience of using surgeon-level data is a useful story. In the 1990s a whistleblower exposed a serious problem with heart surgery in children. The Bristol Heart scandal as it is known exposed serious deficiencies in surgical competence in one department that had been hidden for some time because there was no open publication of surgeon-level outcome data. One outcome of the eventual enquiry prompted the NHS to promote open publication of risk-adjusted surgical outcomes for all cardiac surgeons. The profession resisted this at the time (largely because of the supposed incentives for surgeons to "game" their numbers by risk-averse selection of patients but they were browbeaten into accepting the proposal by the NHS Medical Director, Bruce Keogh and public pressure from the Bristol scandal.

But the early results of the use of surgeon-level data did not create the expected effects. One BMJ report on the results in 2009 "Survival after heart surgery continues to improve after publication of mortality data" reports:

Outcomes for adult cardiac patients have improved substantially in the past five years, even though more elderly and high risk patients are now being treated. Mortality rates after coronary artery surgery have fallen by 21% and for isolated valves by a third, a study by the Society for Cardiothoracic Surgery of Great Britain and Ireland has found...

Ben Bridgewater, consultant cardiac surgeon at the University Hospital of South Manchester and author of the report, said, “One of the benefits we are now seeing from public reporting of outcomes is not just about bringing poor performers ‘into the pack’ but improving the performance of the pack as a whole. The very act of auditing services brings about improvements as centres learn from one another.”

And these results were so convincing that the Royal College of Surgeons though other specialties should also openly publish their data (my emphasis):

The results have prompted the Royal College of Surgeons of England to urge all surgical specialties to follow the lead as soon as possible and publish mortality data.

The college said that although critics expected that publishing mortality data would lead to risk averse behaviour from surgeons, with the most sick and elderly patients denied surgery for fear of worsening the statistics, in practice, the opposite has turned out to be true.

Note that this report was published 5 years before the 2014 article arguing the opposite. As one critic responding to the 2014 argument summarised well (my highlighting):

The article by Steve Westaby dealing with publication of surgical mortality data is at best a superficial examination of the issue and at worst misleading. The evidence has been irrefutable for many years that the collection and feedback of risk-adjusted mortality data will reduce mortality rates by between 40% and 24% in cardiac surgery and other specialties. The issue of ‘gaming’ cardiac surgery outcomes by avoiding high risk patients was proposed and investigated at the time of the initial publication of the results and no evidence was found to support the assertion. More recently it has been suggested that without the knowledge of their own mortality or complication rates and that of their colleagues it is not possible for surgeons to obtain full informed consent from their patients. Thus complication and mortality rates become a tool for continuous quality improvement, patient information and informed consent rather than a stick with which to beat the surgeon.

The UK data and discussion illustrates two key things. One is that many in the profession still believe that open data promotes risk-aversion. But the second is that this is refuted by the actual experience of publishing the data.

Whether this is universal in different health systems is unclear. The NHS has few if any direct financial incentives for its surgeons but the US system has strong financial incentives which might promote the pursuit of volume rather than quality. It is clear, though, from the UK data that the expected risk-aversion does not always occur when data is published and that publication can lead to systematic improvement over time.

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  • Worth noting also that the GMC hates doctors and even trivial complaints to them can tie a doctor up for years and hundreds of thousands of GBP in costs, so while there isnt a direct financial incentive for NHS doctors theres both an indirect one and a licensing one (the GMC is the UK licensing body, and its quick to revoke and slow to reinstate).
    – Moo
    Jan 6 at 20:59
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    This may or may not be apropos, but there was a study some time ago, in the US, that clearly showed that a great deal of the success/failure rates of a surgeon was actually due to the presence/absence of a stable surgical team that worked together frequently. Practice does indeed make perfect (or as close as you can come in an operating room). Hospitals that did frequent heart (whatever) transplants and had a stable team that did them week after week had much better results than those where the same operations were less frequent, or the team changed. So is rating only the surgeon ok?
    – davidbak
    Jan 7 at 2:22
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    Do you think a random patient has enough numeracy to understand the mortality data? I highly doubt that. The common-folk can barely wrap their heads around correlation vs causation.
    – Nelson
    Jan 7 at 3:36
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    @davidbak The issue of whether the team was more important than the surgeon was a big argument used by opponents of rating in the UK. "It's so unfair" they argued. But who is in charge of the team? Part of the reason this lost in the UK was that teams and hospitals had conspired to hide the incompetence of some surgeons in the Bristol scandal partly because the strong leaders had a huge influence on their teams. Transparency incentivises the leader to ensure they have a competent team.
    – matt_black
    Jan 7 at 9:25
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    @nelson Yes patients can understand the data, if it is presented to them in careful, well-designed ways. This was carefully done in the UK with clear, simple visuals and robust analysis not raw data. Some argued that only the professionals were equipped to interpret mortality data. But the Bristol scandal showed that the reaction of some professionals was to hide the data they understood rather than acting on it, which somewhat undermined their argument.
    – matt_black
    Jan 7 at 9:29

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