Are Surgeons More Likely To Kill You On Their Birthday?

The paper is the work of two physicians trained in internal medicine and a health economist, so they are free of bias as well as any practical knowledge about how surgeons operate, literally and figuratively. They made use of Medicare's dataset of beneficiaries and considered the 30-day outcome for surgery performed on a surgeon's birthday. They found 2064 operations (0.2%) of 980,000 procedures performed by 45,000 surgeons that were performed on their birthdays. With lots of variables to choose from, they compared the results of those 2064 to all the surgery on the other days, 978,000 give or take a few. They limited themselves to 17 procedures, four cardiovascular ones, and 13 of the most common non-cardiovascular procedures among Medicare beneficiaries. The endpoint, how many of these patients, undergoing emergency surgery, died within 30 days of surgery. [1]

They found

"The overall unadjusted 30-day mortality of patients on the surgeon's birthday was 7.0%  (145/2064), and that on other days was 5.6% (54,824/978,812)."

 

To be fair, they tested many variations and adjustments to make sure that they were comparing apples to apples and found a 1.6% increase in mortality for those patients, even with adjustments. For the mathematically inclined, you could say that emergency surgery on your surgeon's birthday was associated with a 29% greater risk of dying or 30 excessive deaths. You should also know that this was over three years, so we are talking about ten excess deaths per year.

Much of the article's red-meat is alluded to in the text but found in the supplements that accompany the article. Let me share some of my favorite findings:

• For those undergoing elective surgery on a surgeon's birthday, there was no increased risk. As one commentator noted, we saved our bad results only for emergency patients.
• Emergency patients were those undergoing surgery within three days of admission. That blurs the lines a bit and includes both emergency patients and those that are urgent and can use a bit of time to "tune them up." Of course, if you need time to tune them up, there may be underlying problems not coded in discharge summaries – the source of all of this data.
• Landmark birthdays, at age 40, 50, and 60, were no more lethal than those other birthdays.
• Surgical care rendered on birthdays had no greater rate of complications than those procedures performed on unbirthdays.
• But the smoking gun that puts the whole study in perspective is that for each of these 17 operations, there was no statistically significant difference in outcome based upon surgeon birthday when considered individually – the numbers were too small to show anything. You had to aggregate them to identify those ten excess deaths per year. That makes me wonder, are these findings signal or noise?

My favorite part, though, was the connect the dots section, labeled discussion. What could have caused this to happen, other than finding a pattern in random data after careful statistical magic? The answer is the distracted surgeon. Included in their list of possible distractions,

• Additional birthday phone calls during surgery
• Additional birthday wishes from the operating room staff
• Time pressure – after all, you have got to finish the case before the big birthday party. Parenthetically, the researchers did consider whether this increased mortality occurred on birthdays involving more or less than the 1.25 average cases the surgeon performed daily. But few surgeons do one case a day; most have a block of 4 hours and get as much as possible done.
• But my absolute favorite was this line, "surgeons might allow surgical trainees to do more on the surgeon's birthday in order to get home early for a celebration or other birthday related reasons." Here let me quote from an older text, The House of God, "Show me a best medical student who only triples my work, and I will kiss his feet." This rule applies equally as well to all resident surgical trainees.

These last two possible distractions get at an even bigger problem with the paper, none of the authors know anything about surgical care's practical realities. The heartbreaking problem is that this peer-reviewed paper will now wander in the medical literature and undoubtedly gather citations enforcing the concept of the distracted surgeon, too enamored with their upcoming birthday celebration to pay attention to caring for the life in front of them. It is demeaning. That it would be picked up by the media and further publicized is demoralizing. 

[1] Deaths, as a result of surgery, has multiple definitions. They can refer to deaths while hospitalized within the 30-day interval or during the hospitalization irrespective of its length. It can refer to deaths only in the hospital or those at home.

Source: Patient mortality after surgery on the surgeon’s birthday: observational study BMJ DOI:10.1136/bmj.m4381