Do fewer patients die when the surgeon is away or on strike?
July 31st 2018, 14:21
I can imagine that the typical surgeon, when he was a young boy (or girl, of course), was the sort who would keep fiddling around with things until his exasperated mother exclaimed: "For goodness sake, Bernard (Bernadette), it'll never get better if you keep touching it."
This fiddling around doesn't do anyone any good, least of all the patient. This universal truth struck me recently when I was reading a study that discovered that heart attack patients are more likely to survive if the hospital's leading cardiologists are away at a conference. It's like the urban myth that when doctors go on strike, fewer people die.
Why should this be, when doctors—and heart specialists in particular—are life-saving heroes? That's the problem: because they see themselves as that, they like to perform ever trickier and more invasive procedures. But, as lead researcher Anupam Jena from Harvard Medical School points out, "Many medical interventions deliver no mortality benefit." In other words, the patient is more likely to die.1
The junior cardiologist left holding down the fort isn't quite so gung-ho and is prepared to do less, probably very relieved and happy to do less, in fact. The result? The patient survives.
Jena and his colleagues restricted their research to a specific few days when the annual Transcatheter Cardiovascular Therapeutics conference was taking place. The conference attracts the best and brightest cardiologists from around the world, and Jena wanted to know how the patients were faring back at the hospital while these cardiologists were away.
Jena has form. He did something similar a few years back when he checked on the survival rates of heart attack patients when the top cardiologists were attending the annual American Heart Association events from 2002 to 2011. Same result—more survived.
Not only do the top cardiologists go to the big conferences, they also write most of the academic papers—especially about their breakthroughs, new procedures and so on. So they like to fiddle around, sometimes to the detriment of the patient.
This fiddling around also happens to be behind the great urban myth about fewer patients dying during a doctors' strike. On the face of it, it's true. The myth started in 1983 in Israel when 8,000 of Jerusalem's 11,000 doctors refused to treat hospital patients for three months. There were 83 deaths recorded during the strike, and 89 deaths in each of the three months before and after the strike when the doctors were working.
But a similar pattern had been seen seven years earlier in Los Angeles when half the surgeons reduced their care to emergency cases only for five weeks—and the hospital mortality rate dropped by 18 percent.
Researchers from Emory University carried out a review of the impact on mortality rates of five doctors' strikes that happened between 1976 and 2003. In each of the five instances, the mortality rates in hospitals either went down or stayed the same—but none went up, as would be expected. By the end of the strikes, the average mortality rates were lower than anything recorded in the previous five years. The rates were reversed when the doctors went back to work; in Los Angeles, for example, there were 90 more deaths in the first two weeks after surgery resumed.2
In each of the five strikes, doctors still provided emergency cover for life-threatening problems; it was the elective procedures that were canceled. Elective surgery is the scheduled, non-emergency operations that range from anything from a facelift to cataract removal, angioplasty for widening arteries or a hip replacement.
In a fascinating review of elective procedures published back in 1974, two researchers from Cornell University estimated that 20 percent of recommended surgeries were unnecessary—in other words, the patient didn't benefit—which translated into 2.4 million pointless procedures a year that result in around 12,000 deaths. And remember, this review was carried out at a time when people actually did think twice before having surgery; today, those figures could be conservatively multiplied by a factor of 10. 3
So there you have it: all that fiddling around does nobody any good, just as Bernard's mom told him.