A Legacy of Surgical Outcomes – April 22 2014 Chat

Thomas K. Varghese Jr. MDBlog post by Thomas K. Varghese Jr. MD, MS, FACS

Ernest Codman MD (1869-1940) was the prototypical genius surgeon. Graduate of Harvard Medical School in 1895, internship at Massachusetts General Hospital, and eventually a member of the surgical staff at Mass General and of the Harvard faculty. His impact was in many fields – shoulder surgery, bone sarcoma, general surgery, anesthesiology, radiology, and evidence-based medicine. In 1910 he helped start the American College of Surgeons, and he also helped form the Committee for Hospital Standardization, the forefather of the Joint Commission for Accreditation of Hospital Organizations (JCAHO).

He had it all.

And then one day he stood up during a surgical meeting he had chaired of the Suffolk (Mass.) District Surgical Society to unveil a cartoon he had drawn. He was ostracized, lost referrals, his income plummeted, and had little recognition for the remainder of his life.


In 1905, he proposed the “end result idea” – that doctors should follow up with all patients to assess the results of their treatment, and that their outcomes should actively be made public. His “End Results Cards” had basic demographic data of his patients, their diagnosis, their treatment, and outcomes for each case. Each patient was then followed up for at least one year to help observe long-term outcomes.

Every hospital should follow every patient it treats long enough to determine whether the treatment has been successful, and then to inquire ‘if not, why not’ with a view to preventing similar failures in the future.

This worked fine as long as he was concerned only about his outcomes. But then he wanted to institute a plan to assess competence of his fellow surgeons. This wasn’t received well (putting it mildly). He resigned from Harvard in 1911to start his own hospital. In 1920 he established the first bone tumor registry in the US. In 3 pamphlets bearing the name – A Study in Hospital Efficiency – he detailed the outcomes of 337 patients discharged between 1911 and 1916, and transparently disclosed the results of 123 errors. He constantly extolled his fellow peers to publish their outcomes. And then he unveiled the cartoon depicting an ostrich with its head in the sand, kicking up golden eggs. He explained that the ostrich typified surgeons and hospital administrators who had their heads in the sand, never studying their own results, but were content as long as they produced the “golden eggs”. And things were never the same.


Cartoon drawn by Dr. Ernest Codman 1915; source: http://shoulderarthritis.blogspot.com/2012/11/impact-of-implant-developers-on.html

Dr. Codman wasn’t the first to advocate for a surveillance and feedback system. In 1803, Sir Thomas Percival, a British physician best known for developing a code of medical ethics, promoted the idea of using a register to track outcomes.

By the adoption of the register, physicians and surgeons would obtain clearer insight into the comparative success of their hospital and private practice; and would be incited to a diligent investigation of the causes of such difference.

Over the decades, there have been incredible advances in the field of surgery with regards surgical technique, but also with respect to tracking outcomes. Databases have emerged such as the Society of Thoracic Surgeons Database, VA Surgical Quality Improvement Program, and the ACS National Surgical Quality Improvement Program (NSQIP). We’ve seen the incorporation of surgical safety checklists in the Operating Room, with plenty of debate about its impact. And the quest continues for the holy grail of the ideal surveillance and feedback platformto improve patient care outcomes.

Many of you reading this may think that this issue doesn’t concern you, and that surgery is not in your horizon. Some facts:

  • The global volume of major surgery is in excess of 200 million cases per year, translatingto about one operation for every 25 human beings. To put that in perspective, the yearly global volume of surgery exceeds by nearly double the yearly volume of childbirth.
  • In the US, the average American has 9 procedures in an 85 year lifespan – 1/3 in-patient procedures, 1/3 outpatient, and 1/3 procedures performed outside of the operating room.

As one of my mentors, Dr. David Flum at the University of Washington is fond of saying:

Everyone is pre-op; many of you just don’t realize it quite yet

So now that you know a surgeon is likely in your future, let’s learn more about this fascinating group of people (I should know, I’m one of them).

Surgeons are creatures of habit. Extensive years of training, meticulous attention to detail, supreme confidence in their abilities, and quick to embrace routines. Great surgeons need to have it all – Board certification, leadership skills, technical prowess, a never say die attitude, and constant seeking of ways to deliver the best care each and every time. Sadly, empathy historically hasn’t been one of our best attributes. Was it due to a needed confidence, bordering on hubris, that was essential to delivering the best outcomes? We may never know, but surgeons shouldn’t feel they alone are responsible. In fact, it takes a competent team, expert healthcare system, and yes, an engaged patient to have the best outcomes. The most outstanding technical surgeon is doomed to failure in the absence of a great team.

Change is happening all around.

The concept for Strong for Surgery came from the realization that most surgical quality improvement (QI) initiatives begin at the time a patient is admitted to the hospital. While these initiatives are important, a patient’s risk of negative outcomes from surgerymay be both predetermined and modifiable before entering the operating room.

Wouldn’t it be better to shift the spotlight for delivery of evidence-based interventions to the arena where you first interact with patients – the clinic visit?

Why not get the best change agent who can help deliver the best outcomes engaged in the process – the patient?

Optimizing a patient’s health before they enter the hospital to have a surgical procedure is one of the best opportunities to ensure the best outcomes. Strong for Surgery focuses on the pre-hospital setting and works to impact information sharing and decision-making related to preventable adverse events.

Strong 4 Surgery Logo with RmarkLaunched in 2012, Strong for Surgery is a Public Health Campaign that works by both raising awareness and changing practice. The awareness campaign helps educate healthcare teams and patients on the importance of optimizing health prior to surgery. Changing practice to implement and disseminate evidence-based interventions is a framework for delivering quality care consistently – every patient, every time. The program utilizes interactive tools to help optimize health, including checklists in preoperative clinics.

The biggest myth about a checklist is that it is a passive document. A robust checklist is a dynamic document – one that allows for standardization, communication between team members, and education for both providers & patients.

Strong for Surgery of course does not work in a vacuum. It is effective only to the extent that it can seamlessly flow into existing QI efforts, and become part of robust surveillance and feedback platforms. As of April 2014, the program is active in 21 sites in the state of Washington, with 118 engaged surgeons – and growing. We’ve learned from our sites, that there is no “one size fits all” strategy. There are a variety of successful models reflective of the culture of your work environment.

Elements of public reporting are certain to happen across domains, and has already occurred in some fields such as Cardiac Surgery. Patients are much more savvy now. The internet has quashed the barriers of information.

Doesn’t it make sense for you to have input into what becomes reported?

Now more than ever, essential and accurate information is needed to assess outcomes – the right information, delivered at the right time, to the right people (patients and healthcare teams). As Dr. Michael Zinner, Chair of Surgery at Brigham and Women’s Hospital has stated:

The most cost-effective surgical care is optimal care delivered correctly the first time.

The time has come for the journey begun by Sir Thomas Percival and Ernest Codman to become a reality. Please join me for #HCLDR weekly tweetchat on Tuesday April 22, 2014 at 8:30pm Eastern (for your local time click here) as we discuss the following topics:

  • T1 – What outcomes data should be publically reported? Is there ever such a thing as too much information?
  • T2 – What barriers exist that prevent embracing the formation of a transparent surveillance and feedback program?
  • T3 – What are the best methods to engage patients in becoming an active participant in their care?
  • CT – What’s one thing you learned tonight that you can use to help a patient tomorrow?

To learn more information about the Strong for Surgery program, please visit our website: www.StrongforSurgery.org where you can review the literature and request the implementation guide. Email us, like us on Facebook or follow us on Twitter [@TomVargheseJr ; @Strong4Surgery ]. We’re always looking for new collaborative partnerships and opportunities to learn from all of you.

Biographical sketch – Thomas K. Varghese Jr. MD, MS, FACS

Dr. Thomas Varghese is the medical director of the Strong for Surgery program, a novel patient-centered approach in Washington State to improving the health of patients in the pre-surgical clinic. He is the Director of Thoracic Surgery at Harborview Medical Center, as well as provides care at Northwest Hospital. Tom is an Associate Professor in the Division of Cardiothoracic Surgery at the University of Washington, and an Associate Program Director of the Cardiothoracic Surgery residency. Tom serves on the National Comprehensive Cancer Network (NCCN) Esophageal and Gastric Cancer panel, and holds leadership positions in the Society of Thoracic Surgeons and Joint Council of Thoracic Surgery Education.

Dr. Varghese’s clinical interests are in benign and malignant disease of the lungs, esophagus, chest wall and mediastinum; thoracic trauma; and minimally invasive applications for general thoracic surgery. He is dedicated to the education of healthcare providers, patients, medical students, residents and fellows and is a core faculty member of the Institute of Simulation and Interprofessional Studies (ISIS). Dr. Varghese’s research interests include methods to promote the uptake of research findings into healthcare (implementation science); educational interventions for patient-centered care; and surgical outcomes and quality of care research using population-based data, cost & utility analyses and patient-derived outcomes.


Mallon WJ. “E. Amory Codman – the father of evidence-based medicine.” AAOS Now  2014; Volume 8, Number 4. http://www.aaos.org/news/bulletin/janfeb07/research1.aspD.

Neuhauser. “Heroes and martyrs of quality and safety.” Qual Saf Health Care 2002; 11:104-105. http://qualitysafety.bmj.com/content/11/1/104.full

Donabedian A. “The end results of health care: Ernest Codman’s contribution to quality assessment and beyond.” Milbank Quarterly, 1989; 67(2): 233-256 http://www.ncbi.nlm.nih.gov/pubmed/2698445

Haynes AB, Weiser TG, Berry WR, et al. “A surgical safety checklist to reduce morbidity and mortality in a global population.” N Engl J Med 2009; 360(5): 491-499. http://www.ncbi.nlm.nih.gov/pubmed/19144931

Weeiser TG, Regenbogen SE, Thompson KD, et al. “An estimation of the global volume of surgery: a modelling strategy based on available data.” Lancet 2008; 372(9633): 139-144. http://www.ncbi.nlm.nih.gov/pubmed/18582931

“Avoiding Checklist Fatigue: Interview with Dr. Thomas Varghese .” Institute for Healthcare Improvement 2013 http://www.ihi.org/communities/blogs/_layouts/ihi/community/blog/itemview.aspx?List=0f316db6-7f8a-430f-a63a-ed7602d1366a&ID=21

Landro, L “Need Surgery? You might have to get healthier first” The Wall Street Journal 2012 http://online.wsj.com/news/articles/SB10001424052970203630604578072661685478032

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