How frequently do surgeons and anesthesiologists lie to each other?

More often than you might think.

Results of a survey published in the journal Patient Safety in Surgery found that 27% of anesthesiologists and 7% of surgeons admitted that they “misreported” information to each other at least once a month in the perioperative setting.

Surveys were mailed to 2260 anesthesiologists and surgeons. The response rate was only 11%, which the authors ascribed to the sensitive nature of the questions asked.

The demographics of the respondents in each group were similar regarding age, sex, years of practice, hospital type, and self-described involvement with religion.

The most commonly misreported events by anesthesiologists were actions that affected vital signs, and the misrepresentation of vital signs and amounts of fluid administered. Surgeons most commonly admitted to incorrectly estimating the expected length of a case and misstating the nature of intraoperative adverse events, degree of surgical risk, and how urgent a case was.

The ultimate resident evaluation

It comes as no shock to me, and probably many other current and former program directors, that a recent study showed faculty overall performance evaluations of residents do not correlate with their scores on the yearly American Board of Surgery in Training Examination.

According to the JAMA Surgery paper, faculty evaluations encompassed technical skill and the six core competencies—medical knowledge, patient care, interpersonal and communication skills, professionalism, practice-based learning and improvement, and system-based practice.

The paper analyzed data for 150 residents at different levels of training over 4 years and also found that even faculty evaluations of the category medical knowledge couldn’t predict who would get a good or a bad score on the test.

It’s great to know that at the authors’ institution, the average annual evaluation scores ranged from just over 75 to 100 with means and medians both slightly above 92—like Garrison Keillor’s mythical Lake Wobegon, “where all the women are strong, all the men are good looking, and all the children are above average.”

Can you define "professionalism"?

A while ago, I wrote about a medical student whose school tried to dismiss him just prior to graduation for unprofessional behavior.

A judge ruled that the school could not do so because it had tolerated some similar behavior earlier in his medical school career and had not considered it important enough to mention in his letters of recommendation.

In that post, I said, "'Professionalism' is difficult to define, especially when trying to do so in a courtroom."

In the comments section, a medical student wrote that he had been given a two-week suspension for unprofessional behavior for silencing his phone during an exam.

Another commenter told of several students who were caught colluding on a take-home final exam in statistics. Their punishment was that they had to agree to do their residencies at the medical school. [Digression: What does that say about the school?]

The Accreditation Council for Graduate Medical Education defines professionalism, one of its six core competencies, as follows:

"Professionalism—Demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles."

I'm always a bit confused when the definition of a term contains the term itself, and this is no exception.

Three internal medicine foundations combined to publish a somewhat clearer definition that is two pages long, but does not mention specific behaviors like cheating on a test, falsifying a medical record, or being arrested for driving under the influence of alcohol.

The American Board of Internal Medicine Foundation produced this "Word Cloud," which is supposed to help one better understand what professionalism is. But all it did was remind me why I hate word clouds.



It is said to depict "words physicians most associate with medical professionalism."

If you are having trouble reading some of them, I can help. Here are a few: "empathize, compassion, respect, responsibility, ethics, integrity, caring, honor."

Those sound pretty good, but here are some more: "tougher, smoker, diet, sick, job, prevent, financial, good insurance, disease, death." What do those words have to do with medical professionalism?

Since we have trouble defining professionalism, we can hardly blame the judge in the case I wrote about before for ruling in the student's favor.

He said, "Although courts should give almost complete deference to university judgments regarding academic issues, the same deference does not follow university character judgments, especially on character judgments only distantly related to medical education."

I disagree with the last part of his statement. I think character judgments are strongly related to medical education, but how are medical schools and residency programs supposed to teach professionalism and assess whether their trainees possess it, if it is so ill-defined?

Facebook and unprofessional behavior among surgical residents

Have you ever wondered about the behavior of surgical residents on Facebook? I have. A study from the Journal of Surgical Education posted online in June 2014 looked at the issue.

The paper, "An Assessment of Unprofessional Behavior among Surgical Residents on Facebook: A Warning of the Dangers of Social Media," identified 996 surgical residents from 57 surgical residency programs in the Midwest and found that 319 (32%) had Facebook profiles.

Most (73.7%) displayed no unprofessional content, but 45 (14.1%) exhibited possibly unprofessional material. Clearly unprofessional behaviors were noted in 39 (12.2%) resident profiles. The paper said, "binge drinking, sexually suggestive photos, and Health Insurance Portability and Accountability Act (HIPAA) violations were the most commonly found variables."

There were no differences in the rates of unprofessional behavior between male and female residents or by postgraduate year.

I have blogged previously about the ill-defined nature of professionalism, and the papers' authors acknowledged that it can be subjective. Some of the behaviors they felt were potentially unprofessional such as photos of residents holding an alcoholic drink, holding a gun while hunting, or making political or religious comments are debatable.

They referenced another paper that found similar rates of unprofessional behavior (16%) on Facebook among applicants to an orthopedic surgery residency program.

A 2005 New England Journal of Medicine case-control study found that practicing physicians disciplined by state medical boards were significantly more likely to have had documentation of unprofessional behavior in medical school as well as lower Medical College Admission Test scores and poorer grades in the first two years of medical school.

Unprofessional behaviors listed in the New England Journal paper were irresponsibility, diminished capacity for self-improvement, immaturity, poor initiative, impaired relationships with students, residents, nurses, or faculty, impaired relationships with patients and families, and unprofessional behavior associated with anxiety, insecurity, or nervousness.

Some of those \ seem a bit vague. Are diminished capacity for self-improvement and poor initiative really unprofessional behaviors?

Facebook unprofessional behavior and the unprofessional behavior documented in the NEJM paper which pre-dated the widespread use of Facebook may not be comparable.

But I suppose one could say that some of the Facebook behaviors could be categorized as immature or irresponsible.

Until stories about residents being rejected for jobs after training start emerging, there probably won't be a change in the way they use Facebook or other social media.

Or maybe society will change.

In 1987, politician Gary Hart had to withdraw as a candidate for the Democratic Party's presidential nomination because he had an extramarital affair, and just a few years later, the president himself had a dalliance with an intern in the White House and survived.

Who thought marijuana use would ever be legalized?

Healing the hospital hierarchy: A different view

The other day, Theresa Brown, an oncology nurse who has somehow finagled a quasi-regular column in the New York Times, wrote about, you guessed it, another unpleasant encounter with a mean doctor.

Her patient was about to undergo a stem-cell transplant when he developed what she called "textbook symptoms of a heart attack." A cardiogram had been done and while awaiting the arrival of a cardiologist (apparently a myocardial infarction can only be ruled out by a cardiologist at her hospital), the patient's doctor, a big bad oncologist, arrived on morning rounds.

He took a quick look at the EKG and said “This does not concern me.” In the hallway, Nurse Brown challenged him in front of his team of doctors and he had the temerity to ask her why in an intimidating way. 

After another 600 or so words about collaboration, blah, blah, teamwork, blah, blah, we come to find that the cardiologist confirmed the oncologist's impression that the EKG did not show a heart attack and the patient went for the procedure.

OK, I'm not saying that doctors don't intimidate nurses. And I'm not saying that it's all right to do so. I realize that some physicians can be annoying, overbearing and even disruptive. I just blogged about this myself today on another site. But was this really the best anecdote that Nurse Brown could come up with about how she rose to the defense of a poor patient?

When I was in practice, I had no problem with nurses questioning my actions if the question was based on a legitimate concern and (this is important) the nurse knew what she was talking about.

Unfortunately, the latter feature was often not present in the discussion. This is because as Nurse Brown points out, "Doctors and nurses are trained differently." 

She also says, "Some nurses reject the whole idea of doctor’s orders; they think the term makes nursing sound subservient." Excuse me? What would be the alternative? Nurses deciding what should be done? Anarchy?

Maybe it would have been better if she had said to the oncologist, "Can I have a word with you in private?" 

How do you think a nurse would feel if I confronted him in front of all of his colleagues at the nurses' station? 

Nurse Brown laments that there are no protocols to resolve disagreements between doctors and nurses. I disagree. Since the overwhelming majority of orders are not of a life-or-death nature, one can simply go up the chain of command. When this has happened to me, I have spoken to the nurse's supervisor to help sort things out. It works in reverse too. The nurse can talk to her boss who can talk to the doctor's chief of service. It's called "communication," one of the very things Nurse Brown says is lacking.

One of the reasons so many doctors are depressed and burnt out is the seemingly endless supply of articles like Nurse Brown's blaming us for everything that is wrong with medical care in the United States.

 

Unprofessional behavior by medical hospitalists

By their own admission, medical hospitalists are guilty of many types of unprofessional behavior says a recent paper published ahead of print in the Journal of Hospital Medicine. A group of researchers from the University of Chicago surveyed medical hospitalists from three major Chicago area teaching institutions. The respondents themselves rated each listed behavior on a professionalism scale. There were 77 responses from pool of 101 hospitalists who were sent the questionnaires. The study asked respondents to state whether they had either engaged in and/or observed unprofessional conduct.

The key findings were as follows:

• Most of the respondents had engaged in at least one unprofessional behavior.
• The most common unprofessional behavior was [I hope you are sitting down.] having non-medical/personal conversations, such as discussing plans for the evening, in hospital corridors. [Gasp!]
• Over 60% of these doctors admitted that they ordered a routine test as “urgent” as a way of obtaining results more quickly. [Can you believe it?]
• My favorite is that 40% confessed that they had made fun of or disparaged the emergency department team for missing findings. [Unreported but very likely true is that 60% of those questioned committed another unprofessional act, which was lying by claiming they had never made fun of or disparaged any ED MDs. The only physicians I know who do not routinely make fun of the ED staff are pathologists because they never deal directly with the ED. Before all you ED docs get your panties in a knot, I am certain all of you disparage all of us too.]
• Other alleged unprofessional behaviors were celebrating a blocked admission, going to working when ill and texting during conferences.

Another interesting finding was that for every one of the over 30 unprofessional behaviors listed in the questionnaire, hospitalists said they had observed many more such behaviors than they admitted to participating in.

Despite what many surgeons may have believed, this survey shows that medical hospitalists are really pretty normal. 

But I suspect there will be corrective actions for these doctors at the three hospitals. A curriculum will be developed and monitoring metrics will be established. Maybe listening devices will be placed in hallways. These scandalous behaviors must be stopped.

A final note—this study was supported by grants from two different sources.