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BMJ 2002;325:124 ( 20 July )

News

Surgeons must know their limitations, but so must governments

The children's heart surgery deaths at Bristol illustrate the danger of surgeons not knowing their limitations, says Professor Peter Bell, consultant vascular surgeon and vice president of the Royal College of Surgeons. He talks to Debashis Singh of his concerns that new regulations will inhibit surgeons

Professor Peter Bell is sitting behind his large desk on which he involuntarily taps his hand as he speaks about the nature of fate. Behind him is a myriad of photos of him at restmost of which show him playing in the garden with his grandchildren. The subject of fate arises when we discuss his career path, which on the surface would seem to belong to a ferociously ambitious being. "I've never had any ambition. It may sound strange, but it's true actually. You can ask my wife if you don't believe me. I've just done the job as best I can," he says in his native Yorkshire accent.

At the age of 34 he went to Leicester and was the first professor of surgery at the general hospital. He went on to establish a surgical department that grew from the humble beginnings of a semidetached house shared with the department of medicine to an internationally recognised department. "You had to be young to do the job because it was pretty daunting. I was doing a one-in-one rota for quite some time, but so was everyone else."

Born in India, where his father had been posted as an army officer, he came to England in 1948 when independence was achieved. "I always wanted to do medicine as long as I can remember, and I've always wanted to be a surgeon. My mother planted the idea in my mind a long time ago when I was about 3 or 4 years old. I suspect she must have been rebuffed by a surgeon or a doctor at one point and decided to have her own," he says chuckling to himself.

At medical school in Sheffield there were few indications of his future career. He and his friends were always in trouble for their pranks (including stealing alcohol from the laboratories for their punch). Six months before his finals, the young Professor Bell suddenly realised that he was the only one in his year who had not organised his own house job.

"The only person whose job was not filled was the professor of surgery, Andrew Kay. He gave his job to the person with the best marks in surgeryso I applied myself to that." After working hard he was awarded a distinction in surgery and was duly offered the job. "That's how I finished up in academic surgeryby fate if you like."

I wondered how the fate of surgery has been affected by the Bristol case. "Bristol is something that has happened all over the world. It is an example of somebody who doesn't recognise their limitations and act on them. It just so happens that it is more important in medicine than it is in making a car.

"I think the public and the government have gone a bit too far in trying to control thingsall that will happen is people will not do surgery. If you are going to get harassed at every turn and be watched under a microscope, and when you make a mistake you are going to be pilloriedwho needs that? Already there are very few paediatric cardiac surgeons training in this country as a response to what has happened at Bristol. They say, `I don't need to be exposed in the press every time a child dies.' Because someone is going to die. You can't have a 100% success. All that will happen is that people will not do difficult cases, who may have a 20% chance of survival if they are operated on. They will now have no chance of survival. You have got to ask yourself if 20% is better than 0% The response to Bristol has been somewhat exaggerated, and the effects of it will be worse than the cure. Far worse."

What did he think of league tables comparing surgeons' performances? He turns back to the car analogy: "In the past, people took more care over who serviced their car rather than who did their operation. I know patients are anxious to choose the best surgeon for their operation and that's perfectly reasonablebut not by means of a league table. To compare surgeons [in a league table] is totally artificial and means nothing. For example, if I wanted to be top of the league table all I would have to do is just do easy cases. You should compare not surgeons, but institutions. A surgeon does not work on their own but works as a member of a team, with the intensive treatment unit and anaesthetists. I think it is good to compare institutions and to look for institutionalised norms for certain operations and see if they give acceptable results."

As Professor Bell prepares for his retirement, he has been thinking long and hard about the future of surgery: "Surgery is dedicated to eradicating itself . . . surgery is a [sign of] failure, in a way. If you have got to open someone up and put something else in, [medicine] has failed. It is a last resort treatment. It has got to get less and less invasive as time goes by. [In future] you will have specialist, disease based groups such as cardiovascular or gastrointestinal teams, in which you will have people with multiple skills. Some will be more invasive, and some will be less invasive. There won't be just surgeons and physicians like there are now. They will work together more on a ward."

I wondered how he would like to be remembered. "Your memory is carried on by the people you have trained. That's the most important legacy you leave. You are forgotten in a generation anyway. All that history will show is that I was the first professor of surgery here and that it was built up from nothing to a reasonable level of activity nationally and internationally. I did the job as well as I could, and it worked out fine."

"Surgery is dedicated to eradicating itself"

(Credit: KEVIN FEBRUARY)

© BMJ 2002
 

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