Surgeons must take the lead to balance patient, societal needs

Clare Marx, CBE, DL, MB, BS, FRCS
Clare Marx, CBE, DL, MB, BS, FRCS

On Wednesday, Clare Marx, CBE, DL, MB, BS, FRCS, will deliver the Distinguished Lecture of the International Society of Surgery, Right for the Patient, Right for the Citizen: Professionally Led Changes in Health Care.

“The whole of the world is increasingly alarmed by the amount of money that is spent on health care,” said Dr. Marx, associate medical director and emeritus consultant in trauma and an orthopaedic surgeon, Ipswich Hospital, Suffolk, U.K. “Sometimes one has to make a judgment about what is right for the patient but is also right for the citizens who pay the taxes that fund care. If we are not to have these judgments imposed upon us, we have to make sure that we as health care professionals lead the changes that are designed to give the best value for the money.”

As the immediate Past-President of the Royal College of Surgeons of England, Dr. Marx has often explored the balance of making medical decisions in a health care system with limited resources.

“One of the real problems is that doctors like to do what we think is best,” Dr. Marx said. “The question is, how are we going to make limited resources stretch farther and make the best difference in our patients?”

Every country and health system has its own methods of setting health care priorities and allocating medical resources, she continued. In Great Britain, the National Institute for Clinical Excellence (NICE) makes some of the cost-effectiveness decisions.

“If you have glaucoma, at what threshold should you progress from medical treatment to surgery? NICE has set out guidelines for the level at which you should consider glaucoma surgery, the balance between indications and contraindications, the best bang for your buck,” Dr. Marx explained.

Similar questions arise in Dr. Marx’s own field of orthopaedic surgery. Surgeons can implant a hip replacement device that costs £800 ($1,000) and functions as a perfectly adequate joint. Another device might cost £5,000 ($6,700) and also provide a perfectly adequate replacement joint.

“From the citizen’s point of view, I am spending £800 because I want my resources to go farther,” she said. “From the patient’s point of view, yes, you can put in something for £800, but you’re only 45, so maybe we can spend £1,500 [$2,000] for a replacement that might last longer. That’s the dilemma of the health care professional, making judgments that are financially based because we are in a system that does not have limitless resources.”

Surgeons can sit on the sidelines 
and watch as others make those financially based decisions and have 
the repercussions imposed on them. 
Or surgeons can take the lead in gathering and understanding the necessary data to facilitate the standardization of surgical procedures to ensure clinical factors are prominent in the decision process.

“We are having to learn about this really quickly in the U.K.,” Dr. Marx said. “Some of our experiences may be of use, given that surgeons in other parts of the world could be faced with these same kinds of discussions.”

The Distinguished Lecture of the International Society of Surgery was established in 1990 and endowed by the U.S. Chapter of the International Society of Surgery to recognize the society’s worthwhile activities by honoring distinguished international surgeons.