Radio National Transcripts:
The Health
Report
        Monday, May 12, 1997
 
A Severe Case of Surgical Misconduct

Norman Swan: Hello, and welcome to the program. Today, a story you won't forget, which some are saying is one of the worst medical scandals this century. Two heart surgeons whose results in children were allegedly so bad that tens, if not scores of children, have died or been maimed needlessly. We hear from the whistleblower who, true to fashion, was persecuted himself by the authorities, who actually promoted the surgeon concerned.

You'll also hear from New York about how they publish the performance of cardiac surgeons and hospitals, with the effect that death rates have plummeted.

Plus, as promised, more on cockroaches and asthma.

The combination of cockroach allergy and exposure to cockroach debris makes asthma attacks worse in inner city children - well, in the United States, at least. This finding has emerged from a study published in the current New England Journal of Medicine.

The incidence of asthma is inexorably rising, and no-one's sure why. In some countries like the United States, the rise is especially notable in inner cities, which is why a large study of children in inner city areas was started five years ago.

The researchers went in to family homes and analysed dust samples for different allergy-causing substances like cat fur, a tiny insect called the house dust mite, and cockroach gubbins.

They also tested the children for allergies and, for a year, monitored their asthma, if they had it.

Dr David Rosenstreich of Albert Einstein College of Medicine in New York, led the project.

David Rosenstreich: The only single major factor was that if a child was allergic to cockroaches and there was a lot of cockroach allergen, a lot of cockroach exposure in their bedroom, then the asthma was much more severe. So there were three times as many hospitalisations in that group and twice as many visits and there were many more days of wheezing and more schooldays missed; and basically all the measures we used to follow asthma were worse in that group.

Norman Swan: One reason this raised eyebrows was that the house dust mite didn't show up to be more important. For example, in many parts of Australia, it's the mite which seems to be a major factor.

David Rosenstreich: In this population we studied, neither dust mites or cats seemed to play a major role. Now that is only partly surprising. Previously studies have shown that cat allergen exposure in inner city homes is relatively low, because they don't have a lot of pet cats. What was surprising was that there weren't very many homes that had high levels of dust mite allergen. We're not really sure why that is, except that most of the homes were analysed during the winter when mite levels tend to be low and they're in cities that are not associated with very high levels of dust mite, because they tend to be a little drier.

Norman Swan: And the cockroaches didn't seem to be a marker for something else in the environment, such as tobacco smoke.

The children in this study were mostly poor, which also contradicted some previous research which has suggested that poverty is a protective factor against asthma.

That's called the 'clean living' theory, which argues that exposure to certain childhood infections may train the immune system not to be allergic. Dr Rosenstreich thinks the cockroach story is only part of what's going on, but believes that lifestyle changes do lie behind the asthma epidemic.

His is the television theory of asthma.

David Rosenstreich: You start with too many cockroaches in a home, in a closed environment, it is bad for children's' health. It's been postulated that people - especially in the United States - just spend more time inside. So there's much more exposure. It's television, video games, and then because of safety issues, children tend to be kept inside.

Norman Swan: So what about a good spring clean and having the pest control people in to clear out the roaches? David Rosenstreich again.

David Rosenstreich: There's no direct evidence that cockroach removal would be effective, and there studies being initiated at this time to see if that in fact is the case.

The bottom line is that the cockroaches are just one other environmental factor that causes asthma, and the message appears to be that asthma's coming from environmental problems and that if we can help correct some of these, perhaps we could do something about the problem of asthma.

Norman Swan: Dr David Rosenstreich is in the Division of Allergy and Immunology at Albert Einstein College of Medicine in New York.

References:

Rosenstreich, D.L. et al. The role of cockroach allergy and exposure to cockroach allergen in causing morbidity among inner-city children with asthma. New England Journal of Medicine 1997;336:1356-1363.

Platts-Mills, T.A.E. & Carter, M.E. Asthma and indoor exposure to allergens. New England Journal of Medicine 1997;336:1382-1384.

Norman Swan: Last week in the Medical Journal of Australia there was yet more discussion about the quality of care we receive in Australian hospitals.

But if you think we've got problems, you've got to listen to this story from Britain. It's a controversy of huge proportions involving allegedly sub-standard heart surgery on babies which has resulted in significant numbers of unnecessary deaths and injuries.

It occurred at one of the UK's most respected hospitals, Bristol Royal Infirmary.

Doctors from the Bristol Royal Infirmary are now before the General Medical Council, Britain's medical disciplinary body, to answer charges of medical misconduct.

For six years the hospital knew that babies were dying or being injured who shouldn't have been - yet did nothing about it.

One of the two surgeons who were performing these operations with unacceptably high death rates, Dr James Wisheart was in fact also Medical Director of the Hospital Trust - Trust is the name given to hospital groups in the National Health Service who sell their services to local GPs.

The person who blew the whistle, and who, as you'll hear was demonised as a result, was an anaesthetist who specialised in cardiothoracic operations.

His name is Dr Steve Bolsin, and he eventually took refuge in Australia, at the Geelong Hospital in fact. I got him into the studio because I really wanted to know what happened.

Steve Bolsin: Well I think what's probably emerging is one of the largest medical scandals in the United Kingdom this century. And it started when I was appointed as a consultant cardiac anaesthetist to the Bristol Royal Infirmary in 1988. And I'd been working in centres in the United Kingdom which were centres of excellence - the Brompton Hospital and other London teaching hospitals - and I noticed that the practice in Bristol was not as good as the practice had been in my previous centres.

Norman Swan: Was this open heart surgery you're talking about here?

Steve Bolsin: Yes, we're talking about paediatric open heart surgery. And I kept records of the cases that I'd done, and how the patients survived or didn't survive. And I began to note that there were discrepancies between the results that we were getting in Bristol and what were acceptable results for this type of operation in other centres in the United Kingdom.

Norman Swan: Can you give me some specifics?

Steve Bolsin: Well I think any complex paediatric open heart surgery, but I think we noticed particularly that with the arterial switch operation, and also with Tetralogy of Fallot and other complex operations, there were problems, to the extent that I actually wrote to the Chief Executive of the Trust, who was medically qualified, Dr John Roylance.

Norman Swan: Now to explain, what you've just there are operations on babies, essentially new-born babies, or at least in the first year of life, who have really complex congenital heart abnormalities where the left side of the heart might be coming off, the right side of the heart might be switched around, or there may be holes in the heart and arteries that are overlapping and things just really quite intricate surgery needing to be performed.

Steve Bolsin: Yes.

Norman Swan: How much worse were the figures?

Steve Bolsin: My concerns were that we had two or three times the mortality rates for other centres in the country. In fact it then transpires that for some of the operations by some of the consultants involved, mortalities were much, much worse, probably ten times as bad. The paediatric cardiac surgeons that were involved were producing results that were not in any way supportable by anybody who had any knowledge of the system. The problem that occurred in Bristol was that there was a systematic denial of the problem, and the senior paediatric cardiac surgeon, Mr Wisheart, was able to cover up the concerns that were being legitimately expressed from several quarters, not just from my own quarter, by becoming the Medical Director of the Trust and actually sitting on the Board of the Trust, and therefore suppressing any adverse comments that he didn't want people to know about.

Norman Swan: Now that's a serious allegation to make. Can you substantiate that, or has it been substantiated in other areas?

Steve Bolsin: Well I think it was announced last week. Firstly Dr John Roylance, who is the Chief Executive of the Trust, and Mr James Wisheart, who was the Director of Cardiac Surgery and the Senior Paediatric Cardiac Surgeon, and also his colleague, Mr Dhasmana, who was the other paediatric cardiac surgeon involved, have all been charged by the GMC with serious professional misconduct.

Norman Swan: Now you've said you complained to the hospital authorities; what sort of response did you get?

Steve Bolsin: The response that I got was a very unofficial one. I certainly got no written response from the hospital, but I was hauled up in from of the Chairman of the Hospital Medical Committee, and also the Chief of Cardiac Surgery who was Mr James Wisheart, and told that this was not really the way to behave, and if I valued my position in Bristol, then I wouldn't be doing this kind of thing again. Which essentially as a young consultant - I'd been in the post probably less than two years - this is a very serious threat to my livelihood, and I think as a result of that I took stock and I then decided on other avenues.

Norman Swan: Which were?

Steve Bolsin: The President of the Royal College of Surgeons who is Sir Terence English, and I contacted him and provided him with my own figures. And I know that he subsequently told the Department of Health that Bristol should be de-designated as a super regional centre.

Norman Swan: And did the Department of Health act on that information from the College of Surgeons?

Steve Bolsin: The reason that there is probably also going to be a public inquiry is partly because the Department of Health doesn't appear to have taken any notice of serious concerns that were expressed to it.

Norman Swan: How long did he continue operating after you first blew the whistle?

Steve Bolsin: He gave up surgery in 1996 which was six years after I had first raised concerns.

Norman Swan: Now something must have rung a bell; did you notice when you were actually in theatre anaesthetising a baby, that there was something different from what you'd been experiencing at, say, The Brompton Chest Hospital in London?

Steve Bolsin: Yes, I think there were two components that were particularly important - one was the length of time taken to complete the operations; to undertake complex open heart surgery you have to cut off the blood supply to the heart, and we were doing this for periods of anything up to four hours. And for the heart to then beat in an effective manner afterwards is very difficult. Normally the time that the blood would be cut off to the heart would be of the order of an hour at the most. And again, we were taking about four times as long, and it was not surprising that these children were getting very serious heart failure after that kind of operation.

Norman Swan: Surely you weren't alone? I mean Bristol has a very good reputation in the United Kingdom for its medical service in paediatrics. And the paediatric cardiologists in Bristol would know what the national average was, they would have known that they weren't getting the service from Bristol, that their colleagues just down the road in London would have been getting. Weren't they doing anything about it?

Steve Bolsin: I think it was generally accepted by a lot of medical practitioners in Bristol that there were problems with paediatric cardiac surgery, but I don't think the paediatric cardiologists were particularly prepared to rock the boat. I think there was very much a group activity of seeing criticism as an external threat that had to be resisted. And there was very little movement towards providing a solution. I was seen as the problem, rather than the death rate being seen as the problem. In fact patients were continuing to be operated on, and in fact even when the neo-natal arterial switch and the arterial switch program were under very serious review, the hospital continued to allow the operations to proceed, and I was present at a meeting at which all the cardiac anaesthetists and cardiac surgeons and paediatric cardiologists agreed that an operation should go ahead, when I said that I thought that the risks to the patient were too great. Now I also know that the Department of Health at the same time, was expressing serious concerns to the Chief Executive of the Trust, and they were all resisted - the operation went on the next day and the patient died that same day.

Norman Swan: And what were the recriminations from that?

Steve Bolsin: The recriminations were that this was a problem with Steve Bolsin, and if Steve Bolsin persisted in making these complaints, then he would be sacked by the Trust. And I was hauled in front of my Director of Anaesthesia with other senior anaesthetists present and told that the Trust was more likely to get rid of one troublesome cardiac anaesthetist than it was to get rid of two eminent cardiac surgeons.

Norman Swan: So was it the College of Surgeons who eventually came to your rescue?

Steve Bolsin: No. The people who came to my rescue were essentially the Geelong Hospital, and I applied for a post in Australia because I was not prepared to work under the constraints of a system which did not recognise such malpractice as I had seen, and was not prepared to do anything about it. I had very little support, apart from the Professor of Cardiac Surgery in Bristol was enormously supportive, but just as powerless as I was to achieve change.

Norman Swan: What was the problem - he just wasn't trained?

Steve Bolsin: I suspect that there was an element of training that was required.

Norman Swan: Now people listening to us will say 'Well it's the other side of the world, and it couldn't happen here' - or could it?

Steve Bolsin: I think it's much less likely to happen here. I think that one of the advantages of the quality assurance system in medicine as it stands in Australia is that all the information is privileged, and therefore cannot be subpoenaed by courts to be used in evidence or in litigation against hospitals. And I think that does make the process more open and much more likely to achieve change before the kind of thing that happened in Bristol. At the same time, there is now also an appreciation that we have to be looking at the outcomes of what we are providing with regard to the previous illness of the patient. What we're talking about is essentially risk adjusted outcomes.

Norman Swan: Meaning that if you happen to be say at the Royal Melbourne and looking after - or at the Royal Children's Hospital in Melbourne, looking after say a much sicker group of people than might be at Bendigo Base Hospital, that that should be adjusted so that you can measure apples with apples, so to speak.

Steve Bolsin: Exactly.

Norman Swan: But it's still difficult for a hospital, when you've got significant variation that might be related to an individual doctor, who might have been your colleague for 20 years, to go and do something about it.

Steve Bolsin: I think that there are a lot of difficult things that we have to do in medicine. I think there is the difficulty of counselling the parents of a child that has just died who you think may have died unnecessarily, and I would say that it should be easier to deal with our colleagues than to have to deal with the carnage that can ensue.

Norman Swan: Now how close are we in Australia to, do you believe, a risk adjusted outcome measure?

Steve Bolsin: Well I think there's a lot of progress towards it. The recent Australian Medical Journal has got risk adjusted outcomes from cardiac surgery being produced in Western Australia at the Charles Gardiner Hospital, and the Victorian State Health Board is dealing very actively with some proposals that I've made for risk adjusted outcomes for cardiac surgery for Victoria State. I've already had expressions of interest from hospitals in Queensland and Western Australia.

Norman Swan: What did that experience do to you personally; what was it like at the time?

Steve Bolsin: It was a very prolonged experience. It was essentially over something like six years, and I think these events creep up on you and you don't realise how much changed you are at the time, compared to what you were before you went into them. I think I was probably chronically depressed for a large part of the time, and I think it's only when the weight of responsibility is removed that you actually realise what was hanging over you at the time.

Norman Swan: It is said of whistle blowers that they sometimes take on a Jesus or martyr-like complex, that you become so obsessed with such issues that you become a pain in the neck, basically, and difficult to deal with because you are so caught up in this process. Did that happen to you?

Steve Bolsin: I don't think so. I think that my concern was always for the next child that was at risk of excess mortality and morbidity.

Norman Swan: It's interesting that you use those cold words for basically babies that are dying or suffering injury unnecessarily.

Steve Bolsin: I think that you have to when you're dealing with these issues in medical terms, you have to deal with cold, hard facts and cold, hard terms. I believe myself that I've probably saved the lives of in excess of 50 children, and I've probably saved a similar number from a fate of permanent brain damage.

Norman Swan: By doing what?

Steve Bolsin: By preventing the surgeons that were operating, from continuing operating. The fact that these two surgeons have for the last year and a half not operated on children, is saving lives.

Norman Swan: Now did that emotional overlay not have an impact on people? Even the paediatricians who were actually looking after these, who knew the families, who knew the children or knew the babies?

Steve Bolsin: I don't think so. I think they would perceive that the problem was not one of bad surgery, but of a troublesome anaesthetist, and that's still a very deeply held view in Bristol, sadly.

Norman Swan: Even now?

Steve Bolsin: Even now. Even though three of their number have been charged with serious professional misconduct, there is still a perception that the bad element in the process was the anaesthetist who complained.

Norman Swan: Good lord.

Steve Bolsin: It's an amazing story, Norman, which you just cannot understand in a very brief interview. There is a very deep and marked perception that I am a very, very bad person for having complained about the medical establishment in Bristol. Having said that, there are at least 50 relatives of adult cases that are currently contacting solicitors in order to try and sue the Trust and I think there are probably in excess of 50 parents of children who've died or who are seriously brain damaged who are also suing the Trust. So that the consequences of inaction have been much, much worse than the consequences of action would have been, had any action been taken at an earlier stage.

Norman Swan: Dr Steve Bolsin, who's now Director of Anaesthesia and Chief of Critical Care Services at Geelong Hospital. A remarkable story.

But relying on whistle blowers to protect the public's health is no way to run a health care system. And in any case it's unusual to have such extreme examples of dangerous practice. The common experience is of variations in quality of care which can still be large, yet are harder to explain.

It's vital to be able to detect these variations, find out why they occur and fix the problems. And this is what New York State has been trying to do for nearly ten years, in the case of coronary artery bypass surgery. That's where an artery or vein is grafted onto the heart to bypass the original coronary artery which has become blocked.

New York State obtained the co-operation of cardiac surgeons and hospitals to monitor how well their patients fared.

Dr Mark Chassin, who's now at Mount Sinai Medical Centre in New York, helped to run this audit of bypass surgery. It wasn't a pleasant experience at times, because early on, the surgeons' worst nightmares came true when their individual performances became public knowledge.

Mark Chassin: Yes indeed. But the intent was to publish data by hospital, and make those available to the public, but not by surgeon. But when one of the newspapers called Newsday, found out - a particular reporter did - that the Health Department was giving the information on risk adjusted operative mortality by surgeon back to hospitals, to help them with their improvement efforts, he sued the Department to get that data made public and he won.

Norman Swan: And you fought that?

Mark Chassin: We fought that, because we didn't think that the data on surgeon mortality would be as reliable, because there were smaller sample sizes, they would statistically fluctuate a lot, and we thought that the public was not ready for the difficult interpretation that you have to put around those estimates. So we fought it, but we lost.

Norman Swan: Were they raw data, or were they adjusted for how sick the people might have been when they came into -- you know, a particular surgeon might be particularly skilled at very sick people, and therefore the results might not look so good if a less skilled surgeon who treats only well people.

Mark Chassin: They were published with risk adjustment that really is quite excellent at adjusting for these differences between patients. Immediately as that happened, the Cardiac Advisory Committed voted unanimously to advise hospitals not to collect data on surgeon identity and pass it on to the Health Department. Well we thought that was a mistake as well, because one of the things that we found early on is surgeons with very low volumes of cardiac surgery had very high risk adjusted mortality compared with high volume surgeons. We didn't want to lose the ability to continue to investigate this.

Norman Swan: To the lay ear, the surgeon is all important.

Mark Chassin: Yes.

Norman Swan: He or she might be operating at a lousy hospital where they don't encourage people to wash their hands, and it seems like - although fairly extreme - a reasonable process that Newsday wanted to go through.

Mark Chassin: Well yes, but in this particular procedure there are more factors involved than just the surgeon's skill. There is a team that must be expert in operating the cardiac bypass pump, the post surgical intensive care that has to be delivered, and what we've consistently found is that both surgeon skill and hospital experience is important as independent factors producing good outcomes.

Norman Swan: So let's run through the factors in detail. Let's look at surgeons themselves. How many operations does a surgeon need to be doing, bypass operations, a year to feel confident that they're achieving best practice in terms of outcome?

Mark Chassin: Well I can tell you what our data have shown. Before we had this improvement process in place, surgeons who did fewer than 50 of these per year had more than twice the mortality on a risk adjusted basis than surgeons that did more than 150 a year.

Norman Swan: Were there any other surgeon related factors that were important? Such as training, for example?

Mark Chassin: It's very hard to find other easily measurable characteristics like where you went to Medical School, how old you are, where you got your training; hospitals have found that surgeons who do this procedure but who were perhaps trained not in adult cardiac surgery, but in vascular surgery or paediatric surgery, have relatively poor outcomes. Even if they do a relatively decent volume, and those surgeons have been gradually retired, one of the early attempts that hospitals made was to make use of these data, particularly the data showing this dramatic difference between very low volume surgeons and high volume surgeons to restrict privileges of those surgeons who did very few cases. And that clearly had an effect in removing about 27 surgeons who had a combined mortality of - going to guess now - at about 12% compared with the State average, which was about 3%. So they really took out a group of surgeons with very, very high mortality. And that happened early on.

Norman Swan: What were the important hospital factors?

Mark Chassin: Well again, it differs a lot, but we know that hospitals that do a large volume of this surgery do it very well, on average. But what we found as we looked at individual hospitals, is a variety of factors. One place, for example, which was a moderate volume hospital, we found that they had a statistically elevated mortality for their entire population, but what we found when we looked at it in more detail is that they were doing fine with their elective cases, but for emergency bypass patients, they were doing really badly.

Norman Swan: These were people who came in with a heart attack, or what seemed like an incipient heart attack, and were rushed to surgery there and then to open up the blockage.

Mark Chassin: Either some of them were having heart attacks, some of them were having unstable angina, but precipitous episodes that needed immediate attention. And they had a 27% mortality compared with a 6% Statewide mortality. They found after an intensive review that they were going into surgery too quickly with these patients, not taking enough time to stabilise them. They fixed all of those processes with a multi-disciplinary approach, and the very next year their mortality for that group dropped to zero.

Norman Swan: You might be wondering how Mark Chassin and his colleagues got the audit back on track. Well, they began to publish surgeon data only on those with reasonable numbers, hoping to eliminate some of the statistical problems.

But what's been the reaction of the market? Are the consumers using the information to march towards the best outcome hospitals?

Mark Chassin: Well we've got some pretty good data to suggest that consumers are not using them.

Norman Swan: That's amazing.

Mark Chassin: Well maybe it's amazing. I think we certainly have reason to believe that only a small number of consumers really want this kind of detailed information. And we know that anecdotally there are stories of consumers that have used it to at least question their physicians, if not actually seek out physicians at hospitals with good mortality rates. But that overall, if you look at hospitals that were either identified as best or worst on mortality, that the percentage of bypasses done in the State at those hospitals doesn't change.

But I think that that's OK. I'm actually rather pleased that health plans or consumers have not used this as a sort of shell game to try to move patients around, because I think the principal impact of this whole program has been to focus hospitals' attention on improving their results, and indeed the publicity that hospitals have gotten like this hospital I mentioned that had the worst results of the State two years running, but then improved them and got positive publicity, has been very beneficial, and hospitals have recognised that.

Norman Swan: Professor Mark Chassin is Head of Health Policy at Mount Sinai School of Medicine, and is Senior Vice President for Clinical Quality at the Mount Sinai Hospital and Health System.

References:

Hannan, H.L. et al. Improving the outcomes of coronary artery bypass surgery in New York State. Journal of the American Medical Association 1994;271:761-766.

Chassin, M. et al. New England Journal of Medicine 1996;334-398

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