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Know your surgeons data- Why is it hard to say who is “The Best”? Dr Malik explains…

Professor Sir Bruce Keogh, previously Medical Director of the NHS, and a cardiac surgeon by trade, said all surgeons should have their operation statistics published. He felt that doing so would make the surgeon more  careful. The risk taken would not be just for the patient, but would now also hang over the surgeon.

This seems obviously a great idea.

But hang on a minute…

Like all issue, it is more complicated than it seems.

  1. Did it mean that some surgeons were previously “gung-ho”- I have not come across those- most are very balanced on their approach to risk.
  2. Will it mean surgeons will practice more safely- perhaps- if they were “gung-ho” in the 1st place, but perhaps it will make them risk averse. That is, they will refuse to take on the higher risk cases-as that will reflect badly on their Stats. This is the same as the school not entering your child in for an exam because they wont get a grade 7,8 or 9, and that will reflect badly on their school performance table.

So, the outcomes have to be risk-adjusted

  • If the expected death rate is 5% from the surgery and the surgeons ouctome are 5%, then she/he is performing as expected.
  • If in fact their outcomes are 3%, they are better than expected (or the risk scoring system is out of date- as all surgery is improving as time goes by- remember a Victorian era surgeon would chop a leg off without anaesthetic or antibiotic!).
  • If they are performing worse- say 7% death rate:
    • it could be that the risk scoring system is not taking some other factor into accout that is vitally important (eg frailty of the patient- which is easy to judge in front of you when seeing the patient walk in, but hard to quantify).
    • Or the surgeon as not done as many cases to even things up, and a play of chance has made the stats look bad.
    • Or of course, there is a genuine problem that needs to be looked into- This is rare

So. Do you want a surgeon with very low mortality for their procedures- YES

But. Do you want a surgeon used to dealing with high risk cases-YES because they will find the easier cases very simple and get great results. BUT this surgeon will a mortality rate that will of course be higher than for the average surgeon.

 

Conclusion

It is hard to know who is “the best”. A personal recommendation by someone in the know is probably better than searching for statistics that are harder to interpret. On average surgeons, including interventionalists like me, get appointed as Consultants (in USA speak, “Attending Physicians”) at about 35-40, and reach their peak of experience 45-55- when they have been around long enough to know all of the issues, experienced all of the complications, and thus know how to deal with them. Their data is also more stable- as they have done so many cases that their average mortality is a true representation of what they do.

UK surgeons are now moving AWAY from individual surgeon data, but presenting data for their unit. If the whole unit data is looking bad, then individual surgeons data should be examined. This makes more sense to me.

We consult at One Welbeck Heart Health- and are proud of it, says Dr Iqbal Malik

Dr Malik, Professor Peters and Professor Mayet now consult at One Welbeck Heart Health, minutes away from Harly Street, and 60 seconds walk from Bond Street Station.

What we do there

Look at this animation of our facilities

We consult there. In additon we can do:

  • ECG
  • Echocardiography
  • ABPM
  • Holter
  • Bloods
  • CTCA
  • MRI

Take a Virtual Tour

This video shows you what the facility looks like

I hope you will agree when you visit that it is a special place to visit. We hope to give you a seamless experience with Consultation, Bloods, and Investigations all under one roof.

PFO closure can now be done at One Welbeck Heart Health by Dr Malik

The time  line for PFO closure in the UK. Dr Malik gives an update:

2017:

The strongest class of evidence (3 Randomised Trials) has been there since 2017. It reduces the risk of recurrent stroke if there is no obvious alternative cause found.  There has been no debate about the fact that for the right patient, PFO closure reduces risk of recurrent stroke.

2019:

The NHS finally approved PFO Closure!  I am glad I can now offer it to these young patients without the arguments about funding that have raged over the last 5 years.

NHS England recently published an article (read it here) where they announced:

“Hole in the heart – or Patent Foramen Ovale (PFO) – is a common condition which can trigger strokes. This potentially lifesaving procedure helps remove the risk by closing the hole … this expected to benefit up to 1,500 patients a year. The decision to routinely fund PFO closure comes after the procedure was assessed under NHS England’s Commissioning through Evaluation programme which builds evidence about effectiveness.”

2020 April:

COVID-19 has really slowed up access to PFO closure in the NHS and private sectors. This is as all elective procedures were stopped for safety reasons.  However, we have linked to The Wellington Hospital to do Imperial College Healthcare NHS cases-it has been taken over to do NHS procedures.

2020 July:

I have done day-case PFO closure for 15 years in the NHS. I performed the first  PFO closure at One Welbeck Heart Health. This facility is COVID-free, and offers a personalised service for my patients. It has already been used for AF ablation, Cardioversion and Pacemaker procedures.

 

-Organisation is via Annalysse, our senior physiologist,

-Admission is to a private room on our operations floor, looked after by Tracey, our specialist nurse.

-The theatre team set things up, and the anaesthetist, imaging team and I then do the procedure.  That’s only takes about 20 minutes.

-Recovery is back in the same room the patient was admitted to initially. Tracey looks after them and makes sure they have woken up, had a cup of tea and a snack, and more importantly, get up and about.

-And then you go home!

 

I am proud to be the Medical Director of OWHH. It really is offering a world class service despite the COVID-19 pandemic.

Dr Malik co-chairs Emerging Structural Technology (EST) Symposium

Structural Heart Disease (valves, holes, leaks) is a growth area, and treatment is undertaken by paediatric interventional cardiologists, as well as adult structural interventional cardiologists. The skill set needed is different from coronary angioplasty-the mainstay of work for the adult interventional cardiologist. Cases more variable than the average adult patient with just coronary disease. Education, and learning from your colleagues is vital.


This new meeting brought together Professor Shakeel Qureshi (Evelina Hospital, London), Dr Ziyad Hijazi (Rush University, USA and Sidra University, Qatar) and Dr Iqbal Malik (Hammersmith Hospital and Imperial College, London) to chair sessions on:

A lively audience of high volume operators contributed to a highly educational meeting over three days, sharing experience, discussing complications, and reviewing emerging technologies. The small and  interactive nature of the meeting added value beyond that found in attending large scale venues such as the main European and American Cardiology Society Programs that occur annually.

Dr Malik hopes that this meeting will become a recurrent and “must-do”event in the cardiology calender.

Prof Peters Pioneers GMC’s Revalidation Process

In the Governments new Revalidation Program, Professor Peters is in the very first batch of doctors in UK to be successfully revalidated.  Revalidation is the process by which licensed doctors are required to demonstrate on a regular basis that they are up to date and fit to practise. Revalidation aims to give extra confidence to patients that their doctor is being regularly checked by their employer and the GMC. This is a new milestone enabling continuation to practice as a doctor.