Monday, August 18, 2014

Are surgeons responsible for everything that happens to their patients?

Several months ago, a post called "Everything's my fault: How a surgeon says I'm sorry" appeared on KevinMD. It was written by a plastic surgeon who feels that no matter 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 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 she stay at the patient's bedside overnight? Should she put every preop 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 don't see why in the 21st Century, when medicine is a supposed team sport, one person should assume responsibility for everything that happens to a patient.


artiger said...

In the views of many, we are responsible for everything. I will say that it is very conscientious of this surgeon to feel the way she does, especially in this day of fractured and fragmented care. I don't know how many times I've heard subspecialists tell patients "that's not my problem to deal with, you'll have to call your other physician for that" for even the simplest of issues.

That being said, I'm with you. If it involves the patient not being ready for surgery, it's on us. Lost specimens after they have left the office or OR and orders that are not followed are as beyond our control as the weather.

Everyone wants medicine to be a team sport, but no one wants the liability to be shared.

Anonymous said...

I was also trained to assume responsibility for everything (in the pre-80 hour work week dark ages). But the day I went from being "the surgeon" to "a valuable member of the health care team" is the day I stopped accepting blanket responsibility for every single thing.

Anonymous said...

I am the oddball patient. I take responsibility for my screw ups, I expect the surgeon to take responsibility for his/hers. At some point, we'll both screw up. I've had docs fix it - and praised them up the admin chain for their respect, honesty, and the fact that I can trust them. I've had docs not fix it. A fundamentalists Christian is probably not the sort of patient you want when you make a mistake and lie. Not only do they tell you made a mistake and want an apology, but then they sermonize on the lie.



Anonymous said...

"Then I drew the patient’s blood myself, hand-delivered the test tube to the lab, and waited for the results to get printed before I ventured back to the wards."

What a waste of time, time the author could have spent treating sick patients or doing something meaningfull that requieres an MD.
This post is not only about throwing empty apologies for stuff you have no power over (unless you want to stop operating and start rolling your patients to the radiology department) - making sure they continue, it´s also about not trusting the support staff.

With that attitude you "disempower" the nurses and techs working with you. I mean taking the responsibility for the actions of other grown adults...

Artiger - I agree that modern healthcare is to fractured but we also need to realise that modern healthcare is way more complicated than it used to be. I have worked at a hospital where people don´t call their colleagues for help and let´s just say that i´ve seen some ugly stuff resulting from that.

/Swedish Doctor

Anonymous said...

I am grateful for this guest post, because it highlights the lunacy that is surgical exceptionalism. By that I mean the philosophy that surgeons or surgery are "different" and somehow requires extra-human dedication and commitment to succeed. This false nobility really does nothing other than feed the ego of the surgeon himself/herself. And I say this as a surgeon-in-training with nothing but the utmost respect for discipline itself and its legendary history.

But, I mean, really?? "It's my fault if the patient eats when they're not supposed to"? In what kind of circlejerk echo bubble chamber is such a ludicrous statement not blatantly laughed at from the getgo?

I have a news flash for you surgeons- you are not special. Your discipline is not special. You operate on a person, maybe you hold one life in your hands (if even). A pilot holds hundreds. Air traffic control holds thousands. You get what I mean. Surgeons are not special, they are not machines, they are not hard-working gifts from god who must assume responsibility for all failures in the hospital otherwise they will fail in their career. Surgeons are humans. Work hard, take appropriate responsibility for what you should, learn how to delegate, work well with teams.

And, for the love of god (or Surgeon?), do not write absurd self-aggrandizing posts that falsely illuminate your own discipline to do nothing else but serve your own ego.

- Captain Howdy

Skeptical Scalpel said...

Thank you all for commenting. I agree with you that we are not necessarily any more dedicated than other specialists.

I also agree that you can't ask us to take responsibility for everything that happens to a patient and also simply be one of the "team."

RobertL39 said...

For all you team players out there, remember that teams need captains. They should only take responsibility for what went wrong IF they can actually, not theoretically, take complete responsibility for fixing it. Maybe they might be able to help ameliorate some 'system errors' (S.S. I know you *love* that term). Human errors; not likely. Remember the Swiss cheese metaphor.

Skeptical Scalpel said...

Robert, thank you for commenting and remembering that most errors are human.

Anonymous said...

The problem Skep is that most surgeons don't remember they're human. Where we come from, people mess up and apologize and try to fix the problem. We dont blow it off or hire lawyers and risk managers or lie to get out of it.

Unless you want the Deacons/Elders and Pastors giving you a talk and loving on you.

Skeptical Scalpel said...

I think most surgeons do remember that they're human. We have to hire lawyers when we are sued. It would be suicide not to.

Dr Dross said...

It's laudable that surgeons are trying to maintain the probity once held in high regard by society. In today's climate, that probity no longer applies.

Medicine is a consumerist business now. We manage populations, we don't treat individuals. Cookbook and protocol are the words of the day.

Responsibility should be taken by the leader. The leader is someone who answers to nobody. That someone is the CEO of the hospital and its investors.

Any mistakes made in a hospital should be on the hospital corporation and the board. They are the leaders now. Let's have them take responsibility.

Skeptical Scalpel said...

Dr. Dross, well said. I agree completely. The new team leader is the hospital CEO.

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