The Naked Surgeon by Samer Nashef, book review: The truth about the operating table

This frank account by a leading surgeon has both good and bad news for patients

Peter Forbes
Saturday 13 June 2015 10:15
Wild West: surgery still lags behind airlines in its safety culture
Wild West: surgery still lags behind airlines in its safety culture

The doctor's tale was one that was kept mostly under wraps until recently but that has changed completely. With healthcare high on the news agenda, there is no shortage of books about modern medicine. Henry Marsh's Do No Harm, though, was something different, setting the gold standard for a humane account of life in a high-risk profession.

One can't help but think of Henry Marsh when reading Samer Nashef, a senior heart surgeon at Papworth Hospital, Cambridge, because they are in some ways polar opposites, despite being united in their frankness and expertise. Marsh is old school: a surgeon who doesn't like hospitals, hates bureaucracy and the wave of managerial motivational verbiage that cascades over the NHS, and is only ever happy when he is operating. Nashef is a prophet of the new world of patient empowerment: he is one of the originators of the EuroScore system of assessing the risk of heart operations and a passionate advocate of ranking doctors by their outcomes and making the data publicly available.

But, unlike some who sing a similar song, Nashef shows how outcomes data can be misleading. The great bugbear of auditing medical interventions is that the statistics are open to manipulation and even without that are poorly understood by the public and, as the fearless Gerd Gigerenzer pointed out in Risk Savvy, even many doctors, Nashef does a fine job of guiding the reader though the surgical and statistical intricacies and he writes clearly, with plentiful moments of humour. He also lays has own career open to scrutiny in the boldest fashion, recounting an early episode in which, as a trainee, he made his first outcomes assessment in the heart unit. Unwisely, he tried to share this data with the department, the result being that he was blacklisted in that area and had to seek work elsewhere.

His frankness extends to spilling the beans on the tribal lore of surgeons (their ancient tussle with the anaesthetists, for example) and his detailed accounts of clinical procedures are so lucid you almost feel you could try your hand at them. Doctors are supposed to have a bedside manner: Nashef has the authorial counterpart, a knack of even making you care, for instance, about the mechanical properties of the suture material Prolene (this isn't a mere technicality but a life-and-death matter about which Nashef cares deeply). The revolution that Nashef helped to create is still incomplete. He gives examples of procedures of proven benefit that have been implemented patchily and he points out that the intense concern for outcomes now standard in heart surgery has yet to be applied to most other forms of surgery.

This reader, at least, feels reassured that if, as Nashev says, surgery is still the Wild West when compared with the rigorous safety culture of the airlines, it has improved immeasurably in the past 20 years (correction: it has improved measurably). What worries me (and clearly worries him too) is the fact that he has to spell out, to a mostly statistically illiterate audience, that if you have a league table someone has to come bottom. And if you have any metric whatever, one half of the sample will be below average. That does not imply "no good". That is what an average means.

Peter Forbes' latest book, 'Nanoscience: Giants of the Infinitesimal' (with Tom Grimsey), is published by Papadakis

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