Last week the issue of the performance of surgeons came under scrutiny. The health secretary, Jeremy Hunt, threatened to ‘name and shame’ any surgeons who refused to publish their performance data, including mortality rates, in league tables. http://www.bbc.co.uk/news/health-22899448 Surgeons have raised many objections to the plans including potential stigmatisation of those seen as under-performing (an issue that is itself problematic say some authorities), the potential for misleading figures and, no doubt, a dent to professional pride.
The measurement of performance – at least in terms of quantitative measurement and aggregation – together with the publication of results are a modern phenomenon in the medical profession. It is interesting to consider the issue of performance, and of public perceptions of medical practitioners in the past.
In the early modern period, for example, reputation was most certainly a central factor in people’s choice of medical practitioner. They wanted at least some reassurance that the man about to lance their boil or cut for the stone was not some cack-handed amateur who would leave them bleeding to death on the kitchen table. But reputation worked at a deeper level than this. In rural communities, for example, people effectively became healers by reputation; once a cure had been attributed to them, word of the power of the healer would spread and a position cemented. This was generally the way that so-called ‘cunning folk’ and ‘irregular’ healers gained prominence.
It is interesting to consider early-modern perceptions of ‘performance’ though. If we were to apply a modern measure to seventeenth-century practitioners, what sorts of figures would emerge? For many reasons we have no means of accurately measuring the ‘figures’ for early modern doctors. Beyond parish registers there were no official figures for causes of death outside London (if we include the Bills of Mortality) and nothing like today’s patient records from which to infer case histories. Some physicians did keep case books, and these can often reveal interesting stories, but not enough to aggregate.
What does seem likely though is that, at least by modern measures, 17th-century doctors were probably highly inefficient. Mortality rates, at least for surgeons, were undoubtedly far greater than today. Major surgery (such as opening the chest cavity) was seldom done due to the overwhelming risk of losing the patient. Before anaesthetic, any surgical intervention was risky whether due to hypovolemic shock caused when the body loses too much blood, the physical trauma caused by the pain and wound infliction or, perhaps even more so, the risk of secondary infection after surgery due to unwashed hands and instruments, and dirty conditions. Even relatively minor procedures such as bloodletting carried the risk of introducing infection, and a certain amount of deaths must surely have been attributable to blood poisoning or infection caused in this way.
All of this begs the question of why, if it was so risky, did people elect to visit surgeons at all? Why did some surgeons, especially into the eighteenth century, gain prominence and even fame if they stood a fair chance of killing their patients? Surely people would not have given such people the time of day if it were proved that they responsible for the deaths of far more people than they saved?
The answer is that people simply had a different expectation of what medicine and surgery could do for them. This was a world of sickness in which the patient, while by no means powerless, relied on an array of defences to support them in their fight to return to health. These included domestic medicine, family and friends, books – if they were literate, and also medical practitioners. Rather than one consultation with one general practitioner, as today, people commonly consulted many healers until they found one they were happy with. They might combine treatments and seek the opinions of several, whilst still falling back on their own tried and trusted remedies.
But did they expect practitioners to heal them? They certainly hoped that they would, but also understood that they might not. Let’s imagine for a moment that an early-modern person learned that the mortality rate amongst the patients of their prospective surgeon were in excess of 70% A surgeon with those sorts of rates in today’s league tables might well not last long on the register. But a seventeenth-century person might well view things a bit differently. Whilst acknowledging the potential danger, they could well view this as a risk worth taking – as a last-ditch effort to make them well again.
This explains why people went to doctors at all, and brings us back to reputation. If a practitioner had healed at least some people then they were potentially worth visiting. The fact that many people died under their ‘care’ was not necessarily viewed as their fault; it was an artefact of living in what everyone acknowledged were dangerous times for the sick. Therefore, doctors who had had at even some success were a potential lifeline. More than this, they could be held up as figures of approbation, despite what might be seen as a good record of not curing! What they did, however, was offered some degree of hope where otherwise there might be none. In that case, half a loaf was better than none.
Performance, even today, relies on much more than bare statistics. The reputation of practitioners is still important; we would all ideally want to see the ‘best’ specialist or the most eminent surgeon. It is worth considering how statistics can only tell part of the story though, and the ways in which our perceptions of reputation have shifted over time.