Time Out

The news this morning brings a report from Minnesota of a wrong-sided removal of a kidney. Horrible, we will all quickly agree. How did it happen, we ask? Wrong sided surgery reports continue to come to our attention despite the many checks and balances we have brought to our systems. Most famous of course is the "Time Out" just before incision (puncture, etc.) wherein all members of the team are to agree that the right patient at the right time is getting the right procedure performed upon the correct side. If the paperwork and the images and the relevant parties all agreed that the correct action was about to be undertaken, how could the wrong kidney be removed from this unfortunate patient? There are many reasons, we all know, and these have been well characterized.

In my humble opinion the major obstacle we still face in preventing any future tragedies of this kind is the persona of the surgeon. Ladies and Gentlemen: many of us persist as major SOBs in this age of emotional intelligence. We have yelled at enough people enough times so as to prevent the necessary "stop-the-line" mentality that all must embrace. In Pogo-esque fashion, we have met our enemy.

How many of us patrol our OR's to get a sense of the validity in our own institutions of our time-out processes?

Surgical GME

From 1990 to 2006 I was the Program Director of a General Surgery residency. It was a passion of mine, and a fulfilling one. Yet the changes that we saw in general surgery training in particular, but in our overall philosophy and processes of graduate medical education were staggering. Those changes continue to this day. The most advertised of those changes was of course that which carries the label of the 80 hour work week. As most know, the rule that there is a cap of 80 hours averaged over a rolling four week measurement is just one of several such regulations promulgated by the ACGME. Now there is a strong possibility that there will be a further reduction in the maximum number of hours worked per week, and there may not be any allowed averaging. At the behest of Congress there is an IOM Panel that is investigating the matter and will be reporting back to Congress via AHRQ. There are very strong signals that this Panel will "optimize" GME by limiting the work week to no more than sixty hours, akin to the shrinking training week in the European Union.

Now without showing how long in the tooth I am, let me make one observation. Here it is: for decades the center piece of surgical education has been the morbidity and mortality conference. Here at one and the same time we can smooth out the competencies of knowledge, patient care, professionalism, communication, practice based learning, and systems based practice. The most vivid and useful lessons of my training years derive from the often foreboding lessons learned at M&M. As I go to M&M in my present institution, I groan inwardly when I hear the presentations each week. "Well I wasn't there at the subsequent operation." "The patient dehisced when I was post-call and I didn't see it." "He became septic and Fred was on night float taking care of him." So much for continuity of care. Can the lessons of surgical pathophysiology truly be learned by trying to put parts of different puzzles together at different times? I wish I knew the answer to that question, for at the age of 55 I am almost certain to be looking up one day at a product of our new uncontrolled educational experiment. I hope that it is a success.

Competence versus Territoriality

In order to assure the public that they will obtain safe and effective care in a hospital, it is the Chair's responsibility to assure that the surgeon is competent to perform a procedure - i.e., the essence of procedural credentialing. One highly effective evolution of American medicine has been increasing specialization in various disciplines. Such narrowing of focus may become counterproductive, losing the forest for the trees - but that is the subject of another day.

The mantra of specialist can also be used to protect patient volume with economic motivation. Obviously any physician with such a motivation will usually be less than forthcoming, and it becomes rather difficult to challenge the Mom and Apple Pie cry of expertise through specialization.

The underpinning of that cry will frequently relate back to numerosity. Dr. David Leach, the recent head of the ACGME was often heard to relate the axiom "we are what we repeatedly do." Yet as a surgical educator I have seen trainees exhibit masterful conduct of an operation after seeing a mere few, and others on their hundredth attempt remain tentative. It ain't just the numbers.

Assuring competence is a difficult job - to have it complicated by various specialists (medical and surgical) crying quality concerns when protectionism is the underpinning certainly obscures the issue further.

Conflicts of Interest

One estimate of the average annual salary for an orthopedic surgeon is $459,000. This is is contrast to all workers in the United States at $25,149, a factor of 18.3 times as much for the surgeon. On the one hand, it would seem that this level of compensation should be sufficient. On the other, this is America where market forces reign and one should be able to make what one can make. Yet the average orthopedic surgeon sees that the average neurosurgeon makes $541,000 and this perhaps engenders some envy.

Now I have used orthopedic surgery and neurosurgery as a matter of convenience as they are at the high end of the pay scale but physicians and the money they make are a topic rich for conversation. We as surgeons know all the arguments: high income, but far less per unit work than before (and seemingly less each year), after training we are aged close to Medicare eligibility, enormous loans for medical school, discrepancies between primary care and specialists, etc., etc.

Set against these income levels, let us focus upon "consultation fees" that device manufacturers provide these doctors. Last year the five major companies that make hip and knee joints provided at least $227 million in such payments. Now set against a quarter of a billion dollars being paid for these "consults" by doctors, can we focus upon the topic of this post? These same surgeons who are getting supplementary payments of thousands (and in some instances quite a bit more) are coming to our hospitals asking that new expensive equipment and supplies be purchased. I am certain that the overwhelming majority of surgeons are asking for the betterment of their patients. Yet despite some publicly available lists, we are not always certain who is on what company's payroll, and if a company is paying a surgeon, should that surgeon be able to influence the hospital's purchase of equipment?

At a minimum, we need transparency in such interactions. In my opinion, we need more: anyone with a financial relationship with a company should not have any influence at all upon the institution's purchases.

Introduction

My name is Tom Whalen, and I am the Chair of the Surgery Department at Lehigh Valley Hospital and Allentown and Bethlehem, Pennsylvania. LVH is a large institution with significant teaching and research activities. It is a member of The Council of Teaching Hospitals
, one of about 400 such hospitals. Chairing a Surgery Department at such an institution is a full time job with daily challenges. I am creating this blog in an attempt to engender dialog among my fellow Chairs of Surgery. The problems that we face: credentialing, quality assurance and patient safety, surgeon behavior, on call specialists, competition among hospitals and other institutions, etc. are far from unique. The collective brain power we may bring together will certainly outweigh our individual efforts.

In the days and weeks to come I will try to highlight issues one at a time, and I hope that many will share their own experiences with us as a group.