Operative risk and surgeon decision-making

Should it surprise you that surgeons might have differences of opinion about whether or not a patient should have an operation?

It doesn't surprise me, but apparently a lot of people were taken aback by an Annals of Surgery paper published online last week stating just that.

The authors gave 767 surgeons four brief complex clinical scenarios and asked whether they would operate on each patient. The vignettes were purposely designed to not have "correct" answers.

In response to the question would you recommend an operation, the surgeons could choose one of the following responses: very likely, unlikely, neutral, likely, or very likely.

If you were in the emergency department with mesenteric ischemia, would you want a surgeon who responded "neutral"?

Why the authors selected five possible choices is puzzling. In real life when you are faced with a difficult decision in the middle of the night, you don't have five options. You have only two—operation or no operation.

A medical riddle: Where do incident reports go?

Incident reports are frequently submitted by hospital personnel. Did you ever wonder what happens to them? I have.

Over the years, I estimate that I’ve heard of hundreds of such reports being filed, but rarely have I heard of a problem being solved or for that matter, any action being taken at all.

In fact, I don’t even know where they went or who dealt with them. When I was a department chairman, I sat on quality assurance and risk management committees. Yet we never discussed individual incident reports.

The original intent of incident reports was to identify patient harms and increase patient safety.

According to a 2009 post by patient safety expert Dr. Bob Wachter, hospital incident reports are a spinoff from the Aviation Safety Reporting System which had successfully used them for identifying potential safety issues such as near misses.

At Dr. Wachter's hospital, San Francisco General, about 20,000 incident reports were filed every year. That is about half of what the Aviation Safety Reporting System receives per year, and San Francisco General Is only one of about 6000 hospitals in the United States.

Dr. Wachter feels that analyzing incident reports is not worth it. He estimates that each incident report creates about 80 minutes of work times 20,000 reports, which equals about 26,600 hours of wasted time. He also estimated that about one fourth of US hospitals do nothing with incident reports. That saves time but renders the reports useless.

He says an even bigger problem is that incident reports in his hospital fail to capture most events that harm patients.

That has also been my experience. I think most incident reports were filed by people wanting to "cover their asses" and most of the reported incidents were minor. A reference in Wachter's article states that most incident reports are submitted by nurses with only about 2% by doctors.

Incident reports can backfire too. From a 2002 Medscape article: "In some states, under certain conditions, the incident report is considered confidential and cannot be used against the nurse practitioner in a lawsuit. However, if copies are made or the chart reflects that an incident report was completed, the incident report can then be subpoenaed by the patient and used against the defendants in court."

And from the Louisiana State University School of Law: "The nonjudgmental nature of an incident report is very important because in most cases the incident report will be discoverable in litigation. An accusatory remark in an incident report may gain unintended weight in a legal proceeding."

Since incident reports generate a massive amount of wasted time, fail to identify most events that harm patients, are frequently ignored, and can possibly have a negative effect on lawsuits, why are they still being filled out by the thousands?

OR tech: "How do I deal with an abusive surgeon?"

Have you ever come across problems with rage and temperament issues in the OR. I have been an operating room tech for many years and have been in a variety of surgical settings.

A certain surgeon brings in a lot of money to the hospital, but he is terrible. I have been called things no one has ever called me. He throws instruments on my table and mayo stand, screams, and implies that I and my colleagues have no idea what we are doing. I have reported him to my manager and the OR director, but nothing ever comes of it.

Other surgeons have witnessed his behavior and have said something, but nothing was ever done. I understand the OR is a beast of its own, but the culture has to change with these newer guys coming out of residency. The mindset of the surgeon being our 'customer,' which is being rolled out to us now, is not reason for us to put up with abuse. What have you encountered on a peer-to-peer level on how to handle such demeaning behavior? I trained and worked at a level 1 trauma center with emotions that constantly ran high, and still it was less stressful than this particular surgeon. Thank you for your advice. 

A recent paper in the American Journal of Surgery addressed this topic. The authors interviewed 19 OR personnel including nurses, medical students, surgical residents, anesthesiologists, and 2 scrub technicians. Dr. Amalia Cochran, the paper's lead author, told me the reason there weren't more scrub techs was that they were reluctant to participate.

Should every man over the age of 65 be on a statin?

If you believe the latest arteriosclerotic cardiovascular risk calculator, the answer is yes.



A previous version seemed to recommend statins for everyone over a certain age. I decided to plug in the optimal values, conveniently stated in a footnote beneath the data entry fields, for a 65-year-old man. Here is what the data entry looks like.



As you can see below, the risk calculator recommends "moderate to high-intensity statin therapy."



Below the recommendation, it says, "Adults 40 to 75 years of age with LDL-C 70 to 189 mg/dL with no diabetes and estimated 10-year ASCVD risk ≥7.5% should be treated with moderate to high-intensity statin therapy." This is a apparently high-level (A1) evidence-based recommendation.

What am I not understanding here?

I would very much appreciate it if some cardiologists would comment and explain to me how such a sweeping recommendation came to be.

Is this accepted as gospel? Do all cardiologists recommend statins in the above situation?