The Doctor’s Surgery Theodore Dalrymple

No one wants an operation but, if one becomes necessary or unavoidable, everyone wants his or her surgeon to be the best.

Very little thought is necessary to realise that this is an impossible wish. Even the best surgeon can perform only so many operations; besides which, he may live many miles away. We may have to make do with the second, third or nth best; in short, the one who is available.

In any case, it is not always easy to say who the best surgeon is. Everyone in a hospital (by which I mean the staff) knows who the bad surgeons are, but medical omertà does not permit revelation of their names to mere patients. And everyone, in the same sense, knows who the good ones are – but not necessarily the best. The best for what, exactly?

It is not as easy as you might suppose to compare surgeons by results, because any such comparison would have to control for all manner of variables that might affect the results. If a surgeon is prepared to operate on patients who are half-dead already in the hope of saving one of them, his results will be worse than those of a surgeon who would let them all die.

It is much more important for the vast majority of us, statistically speaking, that the general standard of surgery be high than that we find the best surgeon, even if we could do so. Whether the general standard of surgery has risen or fallen is a moot question. It is not necessarily because the surgeons are better that results overall have proved.

We all know what surgeons are supposed to be like: James Robertson Justice playing Sir Lancelot Spratt. Those types did once exist: the supremely confident, larger-than-life but irascible men who threw their weight and their instruments about. It was not only in England that these types existed: my wife, who trained in Paris, well remembers a surgeon who peppered the operating theatre with surgical instruments like shrapnel.

Surgeons have calmed down since those days. Still, surgery remains a high-stress occupation, and it is hardly surprising that surgeons’ tempers still sometimes fray.

A recent paper in the Journal of the American Medical Association examined the interesting question of whether surgeons who had been the subject of complaints by other staff had worse results than the comparatively sweettempered who had not. The measure of poor outcome was the proportion of complications within a month of surgery.

The researchers found that patients of surgeons who had been the subject of complaint had more surgical complications than patients of those who hadn’t been. Of 13,653 patients operated on, 11.6 per cent experienced a complication. Patients whose surgeons had been the subject of no complaints had a complication rate of 10.7 per cent, while those who had been the subject of complaints had a complication rate of 14.1 per cent. As is always the case in such papers, the authors took correlation to mean causation.

There was something rather odd about the results, however. Patients whose surgeons had had between one and three complaints had a complication rate of 14.3 per cent, while those who had had four or more complaints had a complication rate of 11.9 per cent.

My advice to patients, therefore, is: when you’re choosing a surgeon, choose one who has had no complaints against him or her; failing that, one who has had more than four complaints. Avoid those with between one and three complaints.