Advertisement

 

 

Where Does a Surgeon’s Responsibility End?

Author Information (click to view)

Skeptical Scalpel

Skeptical Scalpel is a retired surgeon and was a surgical department chairman 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 three years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog averages over 1300 page views per day, and he has over 8000 followers on Twitter.

+


Skeptical Scalpel (click to view)

Skeptical Scalpel

Skeptical Scalpel is a retired surgeon and was a surgical department chairman 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 three years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog averages over 1300 page views per day, and he has over 8000 followers on Twitter.

Advertisement
In the 21st Century, when medicine is such a team sport, should one person assume responsibility for everything that happens to a patient?
Share on FacebookTweet about this on TwitterShare on LinkedIn

A couple of months ago, a post called “Everything’s my fault: How a surgeon says I’m sorry” appeared on KevinMD. It was by a plastic surgeon who feels that no matter what goes wrong with a patient, surgeons should never blame anyone else.

She gave some examples such as the lab losing a specimen, a chest x-ray that was ordered and not done, a patient eating something when he was not to be fed, and a surgeon having to cancel a case because the patient’s blood pressure was elevated. She felt that all of these incidents should be owned by the patient’s surgeon.

I’ve been thinking about this since I read that piece. While I agree that if I order a chest x-ray and find out later it wasn’t done, I would accept the responsibility to have made sure it was done. I have always believed that you should not order a test if you aren’t going to do something with the result.

But if the lab loses a specimen or a patient who was not supposed to eat does so, how is that my fault?

Yes, it is very noble to stand up at a morbidity and mortality conference and say “Everything is my responsibility.” It’s also good roundsmanship because it cuts off further criticism. No one can heap further abuse upon the doctor if she has already admitted fault and accepted responsibility.

But accepting the blame implies that you are going to do something to prevent the error from occurring again.

How does a surgeon prevent a food service worker from putting a tray of food in front of a patient who is NPO? Believe it or not, I used to tell every patient I operated on, “Don’t eat anything after midnight, even if someone brings you food.” Do you think that always worked? The answer is, “No.”

The example of a case being canceled because of an elevated BP is a good example of why a surgeon saying everything is his fault is misguided. At an M&M conference described in the post on KevinMD, this exchange was said to have occurred:

“It’s your responsibility to know the blood pressure in advance,” a senior surgeon called out from the back of the room.

“Of course,” the young surgeon said, with complete sincerity. “Everything is my responsibility.”

And just how did the young surgeon plan to prevent a patient’s BP from going up prior to surgery? It is common for patients to become anxious before an operation, occasionally leading to hypertension. Should he stay at the patient’s bedside overnight? Should he put every pre-op patient in an ICU? How does one stop that sort of event from happening?

Here are some possible scenarios. You tell me if the surgeon should say, “It was my fault. I’m sorry.” If you think it is the surgeon’s fault, tell me how a surgeon can prevent its recurrence.

A nurse gives a surgeon’s patient a medication meant for another patient.

After a CT scan, a patient falls off the gantry in the radiology department.

While drawing routine lab work, a phlebotomist injures a patient’s brachial artery.

Without warning or a previous history of mental illness, a patient jumps out a window.

I’m sorry. Maybe this is my fault, but I just don’t see why in the 21st Century, when medicine is such a team sport, one person should assume responsibility for everything that happens to a patient.

Skeptical Scalpel is a retired surgeon and was a surgical department chairman 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 three years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog averages over 1300 page views per day, and he has over 8000 followers on Twitter.

16 Comments

  1. How about a “critical care” physician seeing a 52yof 6 weeks post-op, with hypostension, tachycardia, lethargy but responsive to questions – telling the pt she only proem is that she is over-medicated. No further assessment. No referral to ED. Pt died 12 hours later due tp PE. Still haven’t heard from MD.

    Reply
    • I am so sorry that this happened. What else can I say? If it was as you describe, you have every right to an apology and to be angry.

      Reply
  2. Great article Skeptical Scalpel! In the examples you mentioned, it is not the surgeon’s fault that those things happened and the surgeon doesn’t need to apologize for them to the patient. However, as probably the senior member of the healthcare team, the surgeon can take it upon himself/herself to establish protocols to try to make sure avoidable mistakes don’t occur as frequently.

    Dr. Guitron, I thought some of your statements were a little extreme. The one about the relationship of the surgeon and his/her patient being one of the strongest bonds in society today. Wow! I hope my relationship with some of my family members or spouse is a lot stronger. What if I take care of my body and am lucky and never need to have surgery, will I be missing out on something? Who does the patient ultimately trust for their wellbeing? People see their primary care physician or nurse practitioner more often than a surgeon, unless of course they have body dismorphic disorder and find a plastic surgeon to constantly carve up their bodies.

    Reply
    • I wish that establishing protocols was all it took. As long as there are humans involved, protocols can be defeated. I think a lot of errors labeled as “system errors” are really human errors.

      Reply
  3. not trying to be facetious here but just to add a different perspective on this- a lot of patients i see here in india- come to me after consulting their family astrologer regarding the best day/time to get admitted and even the best times(astrologically for their birth star/sign) to have surgery and insist on being operated on at the time- regardless of the impracticability/inconvenience to the doctors…so if anything is goofed up- we have one more person to add to the list to blame- the astrologer (jus kidding)

    Reply
    • Thanks for enlightening us on a topic I had not even considered. I can only hope that the idea of consulting the family astrologer for advice about the time of surgery does not migrate to the United States.

      Reply
  4. Interesting article. Highlights changes occurring in practice in the UK. We used to have what is known as a firm system whereby the clinical team consisted of the boss , a consultant surgeon, and various junior doctors at different stages of their training. the members of the team only changed when junior doctors moved in their rotation, every 6 to 12 months. The boss was the boss – everything he said went.
    Because of the dramatic changes to working hours of junior doctors who now mainly work shifts, the firm system is now practically dead. Care is delivered by teams of doctors, nurse and surgical practitioners using protocols for care and for handover. Those of my generation and older mourn the passing of the Firm. Continuity of care has suffered sometimes and the word of the boss is now not as feared or respected as it once was. In those days the Surgeon was repsonsible for everything. On the other hand there are many important benefits that result from collaborative team working and the new system, when it works well produces outcomes that could have never been acheived by the old system. Examination of human factors and designing systems for patient safety are only possible with team working. Some may mourn the loss of indivdual accountability but public flogging of an individual never really helped the patient.

    Reply
    • Thanks for the comments. I think it is the same here. But as stated in the post I linked to that set me off, some people still believe that the surgeon is responsible for everything that happens to a patient. You can’t have it both ways. If we are merely part of a team, then the other members of the team must be accountable for their actions.

      Reply
  5. While I don’t believe surgeons should be blamed for everything, I do believe they need to more responsible overall, and then not need to apologize.

    I have been that patient whose X-rays were taken and not looked at prior to a surgery that I probably didn’t need had they looked at it. I have had the surgeon take out “too much” skin so that I am now disfigured, again if they had looked at the X-ray and given me tests I had asked for…bone density; MRI; etc. I was assured, with insistence that I was only stage 1 when I was already stage 4. I was not even informed of this…my family was told and I was not.

    And still. N

    Reply
    • Sorry…and still no apology.

      Reply
      • I’ll apologize for that surgeon. If your account of the events is true, it should not have happened. A doctor should not order a test if he’s not going to look at the result or if it will not affect the way a problem is treated. Some tests to confirm findings are ok.

        Reply
  6. Very interesting topic that certainly brings on passionate discussions from both sides of the spectrum. We should start by accepting that there’s nothing written in stone and that there will be variations as to how each surgeon decides to approach the multiple different situation in the good and the bad.

    While we could assess the details of specific situations individually, in my mind many of those multiple discussions can be distilled to what to me is the central premise: who does the patient come see and ultimately entrust his/her health and well-being?

    Of course the answer is: his/her surgeon, with whom the patient establishes one of the strongest bonds there are in society. The patient starts by assessing the surgeon in the office right on the first encounter, and then, if there’s a positive impression, proceeds to progressively trust him/her. The surgery is explained, informed consent takes place and finally the day of the procedure arrives. The patient eagerly awaits to see the surgeon that morning; does he look well rested, is he in a bad mood, is it a “good day” to have surgery? If all goes as planned the patient is then rolled to the OR after the heartfelt goodbyes and has to let go ultimately putting all trust in the only individual behind all those masks he/she knows: the surgeon.

    Although I’m a relatively young surgeon I do subscribe to the time-honored sense of responsibility for the overall care of the patients. Of course, this can be quickly misinterpreted as antiquated and anti-team player (as I’ve been called when bringing this up on twitter).There is no question in my mind that now more than ever in the history of medicine, is success critically dependent on the properly working health care team. From the office health manager that discusses the preoperative orders with the patient to all the members of the team that are in charge of the many different aspects of the care of the patient such as: Was the patient secured to the table appropriately? Is blood available before a major case? Is the equipment and supplies (appropriate staplers, stents, etc.) in the room and available? There are so many factors that the surgeon would never be able to coordinate by himself. The team approach to medicine and surgery is at the core of a successful practice and I favor the calmed eye-to-eye conversation with every member of the team with ample communication as opposed to the old-school dictatorial and all-mighty boss. In my experience maintaining such a collegial, open relationship with the team results in great success where everyone takes full ownership of their particular tasks.

    However, what happens when a complications occurs? Should the team arrive at a consensus as to how to deal with it? Should there be a vote as to what choice maneuver to make? What would the patient expect? If I put myself in my patient’s situation my full expectation would be that my surgeon, with whom I’ve established such an important relationship, be the one dealing with unexpected events or complications to the best of his/her abilities! Of course, if the surgeon is surrounded by a team of committed individuals that will do whatever it takes to facilitate the management of such complication chances are things will work out for the better. But my point is, the surgeon represents the person in the room with the most experience and training, and is therefore the individual who bears the most responsibility. If the patient falls off the table, it is the surgeons responsibility because although we rely on our team to ensure appropriate restrain to the table, every surgeon has a different preference as to how to secure the patient to the table; one uses pads, other rolled sheets, one likes tape the other leather belt, there’s beanbags, etc. etc. etc.

    Lastly, and I apologize that this resulted in such long post, there are many areas that are murky when it comes to assigning responsibility such as specimens getting lost, x-rays not being done, food delivered when it wasn’t supposed to (either preop or right after completion of an esophagectomy!). I still feel the surgeon represents the hospital and even health system when that happens. Of course, PR, RM and other individuals step in the situation to help deal with the situation, but to the patient, the surgeon is the face of the entire health system he/she is in. This is one of the main reasons I also believe in a patient-centered practice, where patients participate as much as they can in their own care. Because often the patient himself may ask the nurse what the x-ray showed, or refuse to eat the food she knows she shouldn’t eat, etc. I hope all this makes sense and that the discussions about improving health care delivery continue with passion, to find solutions and common grounds. I welcome further discussion and comments @julianguitron.

    Reply
    • Thank you for he very thoughtful comments. I’m glad you were stimulated enough to speak up. I don’t think we are too far apart about this.

      Reply
    • In a private hospital when 3-4 specialist doctors/consultants look after the a critical patient and all are charging the patient, and then there are high salaried intensivist, a surgeon is only responsible for surgical decision making,execution of actual operation and PO care plus a bit of coordination between various specialties and explaining to relations only surgical aspect of the management.It is high time surgeons start relegating responsibility/ownership to other consultants of areas of patient management they are not trained/suited to manage.

      Reply
      • You have highlighted a reality of community hospital practice. The surgeon does not control much in a community hospital ICU.

        Reply
    • DR. GUITRON, MY CONCERNS ARE AFTER SURGERY AND REMOVAL OF STAPLES HOW LONG IS THE PHYSICIAN RESPONSIBLE FOR THE CARE OF THE PATIENT FROM THAT POINT. IS THERE A SET TIME FRAME, A YEAR?

      Reply

Submit a Comment

Your email address will not be published. Required fields are marked *

seventeen − eleven =

[ HIDE/SHOW ]