Are all surgeons arrogant?

The recent publicity surrounding the prosecution and conviction of breast cancer surgeon Ian Paterson risks seriously undermining trust in surgery and in surgeons, especially in relation to his reported arrogance and supposed ‘God complex’ (see the BMJ 2017 for further details and discussion). Sadly, he is not the first surgeon to be accused of these unfortunate characteristics – nor will he be the last. Surgeons do require a high level of confidence in their own ability; however, they need to communicate that confidence with humility, rather than arrogance. Surgery is an innately risky business; surgeons need to be in charge, make the tough calls and know what to do if things do not go according to plan. Patients do not want a timid, under-confident, surgeon.

That being said, a proficient surgeon does not have to be arrogant. Effective surgeons not only welcome second opinions, they are open to new ideas and new techniques, analyse their results and learn from their mistakes, as well as those of others. It appears that Ian Paterson failed in this respect, and instead allowed himself to become overconfident and complacent.

It seems plausible that Ian Paterson permitted himself to believe that his wrongful behaviour and non-evidence-based operations were somehow justified. The fact that Paterson kept himself apart from colleagues, seldom if ever discussing his cases or attending conferences, is revealing. What is rather surprising is that it took so long for his colleagues and his employers to realise that something was amiss.

As has often been pointed out, surgery is not a solitary act. The individual surgeon is no longer the lone ‘captain of the ship’. The notion of the heroic leader is outdated and inappropriate in a modern health service. Safe, effective surgery should now be team-based, with accountability being distributed across the team, rather than invested in an individual leader.

What are your views?

Comments (11) Add yours ↓
  1. Peter Rimington Urologist

    How is it possible for this to happen in our world of clinical governance? How did these cases escape the notice of multi-disciplinary meetings? How could the pathologists not recognise large numbers of mastectomy specimens with no cancers? How many were quietly dumb collaborators? What on earth or in heaven drives a surgeon to operate unnecessarily? Hells bells there’s more than enough serious work to keep us all busy with really needy patients. What is a “God complex”? I still get nervous before the start of every major case and remain aware during each procedure that this person is depending on me, my colleague from anaesthetics and my theatre team to deliver the better than best outcome. Is that not God like enough?
    There are sociopaths out there in teaching, airline pilots, preaching, nursing, banking….you name it. You can’t say they don’t exist. It’s just that in all of medicine, we are trusted with the health of our patients. And the well being of everyone. Who knew, and said nothing? Who should have known, but made no effort. This is not just the surgeon. This is a huge system failure.

    May 2, 2017 Reply
  2. Louise de Winter Chief Executive, The Urology Foundation

    Totally agree with Peter Rimington above; this is a huge system failure but individuals make up a system and it comes down to individuals being aware and taking action. How does one ensure that one doesn’t become one of the wheels in the system that didn’t notice or act when necessary? Was Ian Paterson always an overly confident, arrogant individual with a ‘God complex’, or did he become one through practice and habit? Why were his colleagues not more proactive in ensuring his practice was checked or reviewed? What made them so complacent or inert? Were they individually thinking that the problem was someone else’s responsibility?
    It takes guts to raise a complaint or blow the whistle but the profession owes it to themselves and their patients to act when there are doubts or misgivings. Having the confidence to do that takes a degree of self-knowledge or awareness which can be taught through courses such as The Urology Foundation’s ‘Taking the Lead’ course which raises these types of issues and challenges delegates as to how they would or should react.
    Leadership isn’t just about having the big title or job description, it’s about having the confidence to do the right thing, even if one might be a junior pointing out some flaws in a senior. Similarly, it’s not a weakness if someone in a leadership role shows themselves to be willing to listen to others more junior than them and to take their thoughts and comments on board. It’s actually about being big enough to be humble, to recognise one’s weaknesses and take steps to improve. That way, hopefully through leadership courses such as TUF’s and similar, we can mitigate against future Ian Patersons.

    May 3, 2017 Reply
  3. Simon Brewster Consultant Urologist

    I agree with all the above comments. I was standing looking at the newspaper stand in our local supermarket last Saturday with our divisional manager, observing 9 out of 10 newspaper headlines screaming about this rogue surgeon. How awful for the patients and how damaging to the reputation and trust by patients in our profession I thought. We looked at each other and agreed these people are rare and that this simply couldn’t happen today in our hospital. Or could it..?

    The MDT would pick up cases of insignificant cancer being treated inappropriately with radical surgery, but probably not cases who do not have cancer, unless specifically requested. The newspapers reported that concerns about Paterson’s conduct (by for example a couple of GPs) were ignored but as yet we don’t know by whom. Then his NHS hospital was dealing with multiple patient complaints and compensations were being paid. It sounds as though he continued to plough his own furrow in both sectors and got nasty with anyone who challenged his conduct, so colleagues kept out of his way.

    The TUF leadership course described above by Louise sounds very useful in empowering us to take on difficult issues, raise questions at the right level and then deal effectively with them to protect our patients and the reputation of our profession.

    May 4, 2017 Reply
  4. Culley C Carson Professor of Urology

    I completely agree with the above comments. While most surgeons take their patients and families needs and problems to heart and ruminate about surgeries to be performed, often losing sleep over complex cases and significant patient morbidity, there are narcissistic surgeons who put all of us in a poor light. As was mentioned, we as surgeons and medical providers MUST police our colleagues. If we see an outlier, we must report and follow up on our concerns. One of the advantages of academic medicine is the oversight of M&M conferences, residents asking questions and colleagues questioning our practices at conferences.

    Surgeons must take on this oversight as part of our professionalism and duties to our patients and medicine in general

    May 4, 2017 Reply
  5. Christian Brown Consultant Urologist

    It’s likely that Patterson may become in the surgical world the new Shipman. These are names that we hear and just can’t imagine in our governance strong NHS and private systems how it could have happened.

    Are we good at identifying poor performance, poor decision making and unconventional practice? We all know clinicians that we would like to treat us, our family or friends and perhaps some that we wouldn’t!

    What do we do about it? MDT, appraisal, national mandatory audits and working in a team helps but the ‘rogue’ doctors remove themselves from this.

    The only way to prevent this type of practice is better team working, performance review (appraisal does not cover this in medicine as it does in other professions), and mandatory training and let’s be honest people speaking up if they don’t think something is quite right – this clearly didn’t happen here as Peter Rimmington quite rightly point out.

    As always it’s a balance between doing the right thing, innovation and making sure the patient is put first rather than the surgeon.

    May 5, 2017 Reply
  6. Roger Kirby Professor of Urology

    Interestingly, the BMJ has today published a damning editorial on the Ian Patterson case, which has already cost the Heart of England NHS Foundation Trust almost £18 million (BMJ 2017;357:j2138) (http://dx.doi.org/10.1136/bmj.j2138). It denounces the “enduring professional “club” in medicine, which so often acts to protect doctors rather than patients” and calls for an inquiry. What do others think? What is the best way to avoid similar scandalous and damaging surgical scenarios?

    May 5, 2017 Reply
  7. Duncan Summerton Consultant Urologist

    It is truly sad to see cases such as this and the obvious system(s) failure which allowed the situation to get so out of hand and affect so many patients before being acted upon.
    The colleagues who we would wish to treat our families are not only those with the neccessary knowledge and expertise but those who also possess integrity, compassion, and a degree of humility. Theu would not be those with the unwavering conviction that they must always be right and unchallenged – surgery and treating surgical patients is so much more than just operating, and is indeed becoming more of a team-based approach.
    I suppose one of the reasons that this has hit the headlines so forcefully underlines that it is still a rare event but we must do, and be seen to do, all that we can to mitigate against this type of behaviour and to reassure our patients that it will be as rare as we can possibly make it.

    May 6, 2017 Reply
  8. Mike Kirby Professor

    I guess the key is in the definition:
    The act or habit of arrogating, or making undue claims in an overbearing manner; that species of pride which consists in exorbitant claims of rank, dignity, estimation, or power, or which exalts the worth or importance of the person to an undue degree; proud contempt of others; lordliness; haughtiness; self-assumption; presumption
    Which clearly has no place in medical practice, where we see it we must speak up!
    Surely the pathologist must have raised an eyebrow??

    May 8, 2017 Reply
  9. Peter McDonald Consultant Gastroenterological Surgeon

    Like so many of the commentators above I feel an overwhelming sadness that Paterson’s case will tarnish all surgeons. Men and women who do a hard job as best they can for the right and proper motivation of wanting to change lives for the better. If we have too many Patersons and the professions’ status falls significantly I doubt that we will retain and recruit future surgeons easily.
    I have often said that surgeons should be ‘paranoid optimists’ not unapproachable arrogant beings. Always looking around expecting disaster but confident enough to cut through the next bit of fascia and repair the problem. They should always be willing to ask advice from those around – the patient, the trainee, the nurse etc. They should behave as benign headmasters – in charge mostly but always ready to compromise and to listen. It is a hard task indeed and now will be made more difficult as the enquiry that will follow Paterson’s activities will show.

    May 9, 2017 Reply
  10. Krishna Urologist

    What is happened is very sad and shameful to medical profession.Medical professionalism signifies a set of values,behaviour and relationships that underpins the trust the public has in doctors. The case in illustration has failed in all the required parameters of professionalism. It has posed more questions than providing any answers. Is it the arrogance or the ignorance? We all know arrogance never helps in any walk of life. It creates many enemies and in the needs of time even friends are unable to help arrogant person.An arrogance is a sum total of ignorance,insecurity and inferiority complex. Experienced,skilled and knowledgeable persons are always humble and broad minded.We have so many opportunities to reduce all the problems by discussing patients in MDTS or discussing with ones colleagues. There is so much work ,there is no need of manufacturing false situations which are damaging to the patients and our profession.
    It is not possible to undo the damage done to so many patients and the sufferings of the relatives. We need to learn lessions and prevent professionals doing wrongs.Be bold to expose evil things happening around. Otherwise the Evil becomes powerful if good people are timid.

    May 14, 2017 Reply
  11. Roger Kirby Professor of Urology

    Following Ian Paterson’s abhorrent actions, the President and Vice-Presidents of the Royal College of Surgeons (RCS) have issued an open letter on Wednesday 17 May reassuring the public that rogue doctors should now be caught by modern rules governing medical practice. However, they warn there is no room for complacency and the RCS today calls for a review by the next Government of how safety standards and transparency can improve, particularly in the private sector.

    In the letter, they welcome the Secretary of State for Health’s suggestion that an inquiry be conducted by the next Government to understand how Ian Paterson was able to practise for so long. They say the review “should build on the findings of Sir Ian Kennedy’s report as well as the independent review of the governance arrangements at Spire Parkway and Little Aston hospitals and assess what action has been taken following those reviews.” The RCS Council will also review the Paterson case and judgment, in particular to understand why doctors were unable to spot or unwilling to challenge Ian Paterson’s malpractice.

    The surgeons also call for ‘An equal focus on patient safety in both the private and public sectors’, warning in particular that there is poorer public availability of patient safety and clinical data from private hospitals. They say:

    A review should be carried out by the next Government into how safety standards and data transparency can improve in the private sector and not just the NHS.
    The private sector should be expected to report similar patient safety data as the NHS. This should include data on unexpected deaths, never events, and serious injuries.
    The private sector should be better at taking part in clinical audits – this could become a condition of all NHS and private organisations’ registration with the Care Quality Commission.
    Cosmetic surgery, which happens almost entirely in the private sector, needs to be better regulated. The RCS is calling for legislation to enable the General Medical Council to annotate the medical register with details of which surgeons are qualified to undertake cosmetic surgery.

    May 18, 2017 Reply

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