High-risk surgery: the courage to fail.

Not so long ago, cardiothoracic surgeons were often called to see patients late in the natural history of their disease and asked to consider higher-risk operations. Most surgeons of an earlier era, when routine cases often carried a greater than 5% mortality, were willing to do this. The growth of intense institutional and public scrutiny of 30-day mortality has brought this era to an end. This is despite cardiac and thoracic surgery becoming much safer due to many factors. Diagnosis is now more accurate; anaesthesia and perioperative care have improved greatly. Techniques of anastomosis in the commonest operation, coronary artery bypass, have hardly changed in the last 30 years but other components such as myocardial protection and intraoperative imaging with echocardiography have improved markedly. In thoracic surgery, intensive preoperative optimisation of borderline patients, accelerated recovery pathways, standardisation and minimally invasive techniques are improving outcomes. In a setting of spotlight, sensationalism and social media some surgeons are less willing to take on higher-risk patients. The modern era of transparency, team-working and increasing involvement of well-informed patients are bringing about a major change of attitude and approach. The traditional model of individual mastery gained by many years of individual honing of surgical techniques together with sometime ‘assumed authority’ and autonomy has given way to a new style which encompasses integrity, compassion, altruism, continuous improvement, team-working and partnership with the patient. Of course, there is overlap between these two styles of professionalism but there has been a significant change in emphasis. Simultaneously, the environment has moved towards one of zero tolerance of poorer outcomes even when not due to mistakes. We have moved from paternalism to partnership. In the words of a former head of the General Medical Council (GMC), Sir Donald Irvine, ‘there has been a growth of awareness that medicine cannot be practised solely on the doctor’s ground’. Patients want to hear clear ‘jargon-free’ language, to be heard and to be central.