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Improving surgical care: looking beyond individual competence

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In 1998 the General Medical Council (GMC)—the body responsible for registering doctors and for setting standards of professional behaviour in the UK—found three senior doctors from Bristol guilty of professional misconduct. The story, a complex one, centred on the work of two cardiac surgeons whose operative mortality for difficult operations for children with congenital heart disease (transposition of the great arteries and complete atrioventricular septal defects) was higher than expected.1 There was public outcry. The surgeons were jostled outside the GMC's building by angry crowds shouting “murdering bastards” and carrying cardboard coffins.2

These events—now known simply as “Bristol”—are the subject of a public inquiry looking in depth at the circumstances of the unnecessary deaths (the inquiry can be followed on the Bristol web site http//:www.bristol-inquiry.org.uk). The focus of the GMC was the surgeons' professional conduct. The inquiry, probing into aspects of patient care beyond individual competence, has found that “institutional and organisational problems also played an important part in determining outcome, particularly in higher risk cases”.3 These issues are likely to have an impact on British medical practice far beyond the detail of complex paediatric cardiac surgery.

Cardiac surgery is only possible with organisational support. In addition to technical competence, successful heart surgery requires appropriate case selection, accurate preoperative diagnosis, detailed preparation for surgery, skilled …

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