Intended for healthcare professionals


Every system is designed to get the results it gets

BMJ 1997; 315 doi: (Published 11 October 1997) Cite this as: BMJ 1997;315:897

So taking only one element out of it may not improve anything

  1. Gerald T O'Connor, Professor of Medicine and of Community and Family Medicinea
  1. a Center for the Evaluative Clinical Sciences, Dartmouth Medical School, Hanover, NH 03755-3863, USA

    Patients and public assume that the surgeon is responsible for the quality of surgical care and that they are protected from substandard care by quality monitoring conducted by professional bodies. These bodies are often presented with evidence suggesting suboptimal clinical care and rule on its validity. Such is the case of a cardiothoracic surgeon from Bristol who has been cited for having unacceptably poor results which comes before Britain's regulatory body, the General Medical Council, next week (in a case expected to last four months). These cases occur with some frequency and often concern high visibility specialties with easy to count outcomes. Yet causal attribution is difficult since most clinicians provide care in complex settings over which individuals exert only limited control.

    In cardiac care the skills of the anesthesiologist, perfusionist, cardiac intensive care nurse, and others also affect the outcomes of care. Their individual competence is not sufficient: they must also work well together. It is the product of their individual work—not the sum—that the patient experiences. Removing one “outlier” surgeon from practice will, at most, influence the second decimal place of the national cardiac surgery mortality rate. It may be necessary for the public welfare that we do this, but the public should not be led to believe that such actions do much to improve the …

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