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Published Online 12 June 2015

Surgical outcomes: a Victorian viewpoint: A project researching the RCS’ journal collection shows that concerns about outcomes publications are far from new.

Publication: The Bulletin of the Royal College of Surgeons of England
Volume 97, Number 4
Since their inception more than 150 years ago, The Lancet and The British Medical Journal (BMJ) have dominated doctors’ journal-reading habits and exerted a remarkable influence across medical practice. Currently ranked among the top five of general medical journals for impact, they were originally conceived as campaigning, reforming journals, tackling some of the biggest socio-medical issues of their day.
The 19th century witnessed both their emergence and struggle for ascendancy. The Lancet first appeared in 1823 and enjoyed the largest circulation of any medical periodical until it was overtaken in the 1870s by The BMJ. It is perhaps less well known that the Victorian period was also a remarkable time for the wider medical journal market. As medicine professionalised, there was an expansion in the variety of general and specialist titles (from The Medical Press and Circular to the British Gynaecological Journal), whereas new, divergent medical practices saw an increase in periodicals representing the medical fringe (such as the Monthly Homeopathic Review). Journals designed for both a lay and medical readership also emerged, including Climate: A Quarterly Journal Of Health And Travel. These are part of an extraordinary collection of titles, buried in the labyrinthine basement of the College, which are in the process of being excavated by academics as part of a new partnership between the RCS and the University of Oxford.
Funded by the Arts and Humanities Research Council, and headed by Professor Sally Shuttleworth (Professor of English Literature, St Anne’s College, Oxford), Constructing Scientific Communities: Citizen Science in the Nineteenth and Twenty-First Centuries is a project that also sees the University of Leicester, the Natural History Museum and the Royal Society team up with the College as part of a wider collaboration. Bringing together historical and literary research, it looks at the ways in which patterns of popular communication and engagement in 19th-century science can offer models for today. As part of one of the project’s strands – jointly supervised by Sam Alberti (Director of Museums and Archives at the RCS) and Professor Shuttleworth – postdoctoral researcher Sally Frampton and doctoral student Alison Moulds are exploring interactions between the medical profession and the public through the lens of 19th-century journals.
When researching these collections, it is not uncommon to come across stories that resonate strongly with contemporary medicine and surgery. More often than not, it is the non-clinical material – the correspondence columns and the gossipy editorials of the journals – that best illustrates the concerns and anxieties of medical professionals and the public during the 19th century.
Take the case of the Chelsea Hospital for Women, an institution that received major coverage from the medical press in 1894. That year, the attention of the local Medical Officer for Health, Louis Parkes, had been drawn to the hospital following an outbreak of scarlet fever among its nursing staff. However, what started as a routine public health inspection quickly became something more serious when his investigations revealed the hospital had a higher-than-average surgical mortality rate: 21 of the 36 deaths at the hospital that year had been as a result of surgery, some from exploratory procedures. The majority of these patients had succumbed to postoperative septicaemia. Parkes concluded that both the sanitary conditions of the hospital and the competence of the surgical staff were to blame, and he subsequently notified the Local Government Board and the Home Office, requesting an investigation into the hospital’s management.
Staff at the Chelsea Hospital bristled at the possibility of their surgeons being put under such public scrutiny and the correspondence columns of the medical journals soon facilitated heated debates on the matter. The treasurer of the hospital, Henry E Wright, quickly drew attention to the importance of interpreting these surgical statistics accurately. ‘It is manifestly unfair to take one year’s work, and upon that to credit us with a death rate of so many per cent for this or that operation,’ Wright argued in a letter to The BMJ in March 1894. Through their editorials, many medical journals expressed similar opinions.
But it was also the public nature of the controversy, and the fact that medical men were being forced to make themselves accountable to laypeople that troubled the hospital staff. Many medical journals expressed concern that the scandal would filter into the lay press. As the Provincial Medical Journal warned, ‘If this case is to form a precedent, we may easily have a crop of hospital scandals served up for public delectation in our evening papers’. These fears were not unfounded: the title ‘Human Vivisection’ ran atop one story about the hospital in the Huddersfield Daily Chronicle during July of that year, a headline that might rival the tabloid scare stories of today’s press. The scandal quickly snowballed as dissatisfied former patients began to publicly air their grievances to Parkes. That same month The Medical Press and Circular reported that ‘two persons have written to say that their wives have died consequent upon operations performed in the hospital’. Despite the concerns of the medical press, an inquiry led by a mixture of medical professionals and laymen reiterated Parkes’ findings, leading to the resignation of the hospital’s medical staff.
Although our hospitals and wider healthcare system have undergone considerable changes since the 1890s, it seems pertinent that a century later high mortality rates can still play an instrumental role in highlighting scandals in patient care. It is not difficult to detect parallels between the Chelsea Hospital incident and the ‘Bristol heart scandal’ of the 1990s – from the way in which poor outcomes triggered public inquiries, to the role both the lay and medical press played in debating the controversy. Yet there has been a significant shift from the presentation of sporadic morbidity and mortality rates to the more comprehensive roll-out of publishing individual consultants’ outcomes data. In summer 2013, the RCS presided over the publication of more than 3,500 surgeons’ results – a move hailed by then-President Professor Norman Williams as ‘an historic moment for surgery’.
Despite these achievements, challenges in the publication and presentation of the data remain. In 2013, paediatric heart surgery at the Leeds General Infirmary was briefly suspended after data suggested a higher death rate than average. However, a year-long review by NHS England declared the hospital’s unit safe, with no evidence of ‘excessive mortality’. There is a danger that outcomes data can trigger responses that are unwarranted. Unsurprisingly, perhaps, the lay press has shown a tendency to treat the publication of individual consultant surgeons’ outcomes as if they amount to league tables, attempting to identify outliers and draw conclusions about poor care. In this climate, some have expressed concerns about the way in which data is risk-adjusted and the extent to which it can be made meaningful to the general public.
An exploration of 19th-century medical journals and their responses to poor outcomes allows us to anticipate some of the directions of contemporary debates. But the episode also points to the broader questions at the heart of our project – how do professionals and non-professionals engage with one another on scientific and medical issues? And what part do journals and the press play in this? By looking at a wide range of scientific disciplines, from public health to natural history to meteorology, Constructing Scientific Communities recognises the historic precedence – and indeed circularity – of some of these debates and seeks to show how we might use them to move the conversation forward.
For further information go to: www.conscicom.org

References

1.2013 Journal Citation Report: Science Edition. Thomson Reuters: 2014.
2.Editorial. Provincial Medical Journal 1894: 201–202.
3.‘Chelsea Hospital for Women. ’. BMJ 1894: 550.
4.‘Human Vivisection. ’. Huddersfield Daily Chronicle. 24 July 1894. p4.
5.‘The Chelsea Hospital for Women. ’. The Medical Press and Circular 1894: 259.
6.Royal College of Surgeons of England. RCS hails landmark publication of individual surgeons’ outcomes data. https://www.rcseng.ac.uk/news/rcs-hails-landmark-publication-of-individual-surgeons2019-outcomes-data#. VO8AFF2zXIU [last accessed 2 March 2015].
7.NHS England. Leeds Children’s Heart Surgery Services Review. 11 March 2014. http://www.england.nhs.uk/ourwork/patientsafety/leeds-chil-hr/ [last accessed 2 March 2015].

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cover image The Bulletin of the Royal College of Surgeons of England
The Bulletin of the Royal College of Surgeons of England
Volume 97Number 4April 2015
Pages: 190 - 191

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Published in print: April 2015
Published online: 12 June 2015

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Sally Frampton
Postdoctoral Research Assistant
Alison Moulds
DPhil Student University of Oxford

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