Last week on Twitter I asked this question:

The 130 (2.5%) of 5,213 respondents who said they would allow a CEO to make a skin incision highlight the unscientific nature of Twitter polls. Restricting the voting to surgeons only is not possible. Many people asked me why I asked the question because surely no surgeon would ever have allowed it. Here is why.

Greg Neal, former CEO of a Bristol, Tennessee hospital, was asked to resign after having been involved in a surgical procedure. He is not a licensed physician. A local newspaper published his statement about what happened. In part, it said: “Recently, at the invitation of a surgeon, I entered an operating room to observe a surgical case and to support our surgical team, as many health system and hospital CEOs do throughout the nation. As the case began, the surgeon asked if I would like to make the initial incision for this surgical procedure. I regret I did so.”

The incident was reported to the hospital’s compliance program. Neal apologized to the patient, the family, employees, and management of the hospital.

A subsequent article by a television station said the attorney general of the district in which this took place has asked the Tennessee Board of Medical Examiners to investigate the event for a possible “criminal violation of Title 63, Chapter 6 of the Tennessee Code.” The TV station also named the surgeon, Nathan Smith, and said he had been fired by the hospital.

Many questions arise.

What did Neal hope to learn by observing an operation? I can think of no reason for a hospital administrator to even be a spectator in the operating room. Contrary to what he said in his statement, it is not common for hospital CEOs to go to the operating room to observe a surgical case. The infection risk alone would not be worth it.

Since the patient apparently was not aware of the CEO’s presence, a HIPAA violation may have occurred. Back in the old days, it was common to have device salesman, pre-med students, and others to watch cases without the patients’ knowledge. Now many hospitals are requiring informed consent for anyone outside of the normal operating room complement to be present. Those hospitals that don’t require such consents probably should.

What was the CEO thinking when he accepted the surgeon’s offer to make the skin incision? Was he thrill-seeking? Perhaps an investigation will determine whether this was done on the spur of the moment or was it planned in advance?

Why would a surgeon allow a hospital administrator to make an incision on an unknowing patient? This was clearly unethical and probably illegal. In my 40+ years as a surgeon, I never heard of anything like this.

The scrub technician and circulating nurse must have assisted the CEO in donning a sterile gown and gloves. Did the CEO know anything about sterile technique? Why didn’t the OR personnel including the anesthesiologist question what was going on? I can’t think of a single operating room nurse I ever worked with who would have allowed this to happen. Was this the first time the CEO had ever been in an operating room?  Was everyone intimidated by the presence of the CEO? Was the culture of the hospital not supportive of staff complaints about physician or administrator behavior? We know someone eventually called the hospital’s anonymous tip line, but why didn’t they feel empowered to say something in the moment?

Could the CEO be successfully sued for medical battery? A liability insurance website defines medical battery as “an intentional and wrongful physical contact with another person without that person’s consent that includes some injury or offensive touching.” Because the patient suffered no physical damage, I’m not sure a plaintiff’s attorney would take the case.

Whether the surgeon will be sanctioned by the Tennessee Board of Medical Examiners remains to be seen.

Skeptical Scalpel is a retired surgeon and was a surgical department chair and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times.For the last 9 years, he has been blogging at and tweeting as @SkepticScalpel. His blog has had more than 3,700,000 page views, and he has over 21,000 followers on Twitter.