Proctoring, supervising, and coaching

Any surgeon who acts as a proctor for another surgeon or supervises residents or mid-level providers should be aware of the potential legal pitfalls.

An informative discussion of proctoring and supervision called "Is There a Proctor in the House?" appeared in 2012 on a website called Law Journal Newsletters.

Proctoring has always been an issue. For many years, surgeons have been assigned to proctor newly appointed staff in order to confirm that they were properly trained. Proctoring has been extended to those learning new techniques in minimally invasive and robotic surgery.

The usual scenario is that a proctor is assigned by a hospital's department chair or credentials committee with the expectation that the proctor will observe and report on the new individual's skills.

According to the article, "a surgical proctor who acts only as an observer should not have any medical malpractice liability if a procedure is performed below the standard of care." This holds true as long as the proctor has no physician-patient relationship and does not participate in any medical decision-making or scrub in on the procedure.

Should all surgeons have video assessments of their skills?

Last month, a superb study by the Michigan Bariatric Surgery Collaborative showed that the more skilled surgeons were, the better were their outcomes.

Surgeons submitted a video of their choice depicting their performance of a laparoscopic gastric bypass. Since it was self-selected, it was presumably their best work. At least 10 of their peers, blinded as to the name of the surgeon, rated skills on the video which had been edited to include only the key portions of the case.

Surgeons in the lowest quartile of ratings for surgical skill had significantly more postoperative complications, readmissions, reoperations, and deaths.

A New York Times article about the paper features a couple of short video clips—one from a not-so-skilled and one from a very skilled surgeon. The differences are obvious and dramatic.

According to the discussion section of the paper, the Michigan bariatric surgeons are now watching each other operate and will soon be receiving anonymous feedback about their technique from their peers.

It is not clear whether this will improve the skills of the lower-rated surgeons or have any effect on outcomes.

Many people rightfully praised the research. Some suggested that all surgeons should be scrutinized in this same fashion.

I agree that the study was well-done and shows that technically better surgeons have better outcomes.

But there are some problems with generalizing this to all surgeons.

The American Board of Surgery recently noted that there are almost 30,000 board-certified general surgeons in the US. This raises a number of logistical issues.

Let's say we focus on the most common major surgical procedure—laparoscopic cholecystectomy, 10 surgeon-raters would have to view at least 15 to 20 minutes of video for each of the 30,000 board-certified general surgeons. How long would that take? Who would collect and edit all the videos? Who would make sure that the ratings were consistent? Who would collate and distribute the results? How would follow-up be done? Who would pay for all of this?

And that is just for the board-certified general surgeons. What about the general surgeons who are not board-certified and all the other surgical specialists? Maybe gastroenterologists should have their endoscopy procedures scrutinized. Maybe primary care docs should have selected office visits recorded too.

This is similar to the enthusiasm which surrounded the concept of using retired surgeons to coach other surgeons. The idea was based on the experience of one surgeon, who had access to an expert coach and wrote about it. I blogged about the logistical difficulties that would preclude coaching from becoming widespread. To my knowledge in the two years since I wrote that post, coaching has not caught on as a performance improvement measure.

It's too bad, because in an ideal world, video evaluation of operative procedures and coaching would be great. Unfortunately, we don't live in an ideal world.

Penn State Scandal: It Gets Worse

Yesterday I blogged about the many things wrong with Penn State and the way the child molestation scandal was handled. Little did I know that it would get much worse.

The Penn State Board of Trustees finally appeared to do the right thing by firing coach Joe Paterno. But according to an article in USA Today, they did it in the best interests of the school. Here’s a quote from the vice-president of the board [italics mine]: "The current situation we are in at the moment is not in the university's best interest. We believe a change is necessary to allow us to continue going forward without further damage to the university. Great difficulties have engulfed our university.” Damage to the university? Great difficulties engulfed the university? What about the children?

Speaking of children, what is going on with the students at Penn State? I realize we aren’t talking about high intellect over at Happy Valley, but the moral compass and sense of priorties seem to be missing. Someone is wasting a lot of money on tuition. Check out these quotes from some of the rioters on campus via the New York Times.

“I think the point people are trying to make is the media is responsible for JoePa going down,” said a freshman, Mike Clark. Yes, the media did it. I guess if this hadn’t been exposed by the media, everything would be just fine at PSU.

“We got rowdy, and we got maced,” Jeff Heim, 19, said rubbing his red, teary eyes. “But make no mistake, the board started this riot by firing our coach. They tarnished a legend.” Oh, the board tarnished a legend. I see.

“It’s not fair,” Mr. [Justin] Muir said hurling a white ribbon. “The board is an embarrassment to our school and a disservice to the student population.” No, the students are an embarrassment to their school.

“Of course we’re going to riot,” he [Paul Howard] said. “What do they expect when they tell us at 10 o’clock that they fired our football coach?” Of course. There’s a big game this Saturday against Nebraska. How could they fire Joe now?

“This definitely looks bad for our school,” he [Greg Becker] said sprinting away from a cloud of pepper spray. At least this guy is on to something. It does look bad for the school.

The article said, “Mixed in the crowd were a few dissenting opinions.” But it seems the vast majority of the rioters were protesting the firing of their football coach.

Meanwhile, what about the children who were the victims? Where's the outrage for them?

The Surgical Coach

By now, most medical people have read or heard about Dr. Atul Gawande’s latest New Yorker piece. After taking a tennis lesson which improved his game, he decided to see if acquiring a “surgical coach” would improve his “surgical game." He wanted to continue to reduce his—[self-described] already lower than the national average but level for a few years—complication rate. He enlisted a retired surgeon, who was a mentor during his residency training, as a “coach,” and his complication rate is falling again.

I was asked to comment by Dan Diamond, Managing Editor of The Advisory Board’s Daily Briefing. He quoted me in his commentary on Gawande’s concept: 

But not all think that Gawande's article heralds a viable model.

The blogger known as Skeptical Scalpel—a longtime surgeon and former surgical department chair who writes under a pseudonym—told the Briefing that he's, well, skeptical about the ideas that Gawande raises.

"I would accept a coach but doubt I could find one," according to Skeptical Scalpel, particularly a coach as talented, experienced, and available as Osteen. He adds that surgeons often are challenged by issues outside of the operating room, such as in areas like diagnosis, communication, and bedside manner. Skeptical Scalpel also wonders whether the coach would be liable if the patient experienced complications and elected to sue.

Medicine's cultural barriers may present the most significant barrier. As Gawande acknowledges, many surgeons are happy to prescribe a coach for others—but few would acknowledge the benefits of finding a coach of their own. Skeptical Scalpel told the Briefing that a successful surgeon needs a healthy ego; "most of us feel we are the best surgeon we know. If you didn’t feel that way, you probably can’t do some of the things we do."

I’d like to further explore my issues with Gawande’s surgical coach.

Where would the average surgeon find a suitable coach? There aren’t many retired surgeons who would have the necessary skills, the time or the motivation to do it. Gawande practices in a major teaching hospital in Boston. Very few surgeons would have access to people like the coach he chose.

The coach is apparently only involved with what goes on in the OR. Many complications arise due to patient co-morbidities, timing of the operation, postoperative care, supervision of residents and many other factors. Should the coach make floor rounds or see patients in the surgeon’s office too?

The liability question is real. You can bet that if a patient has a serious complication or dies in the OR, everyone in the room, including the coach, will be sued. And the coach, a retired surgeon, is not likely to have malpractice insurance. 

The patient has a right to know who is in the operating room. How does one explain the presence of a coach to the patient? At the end of his article, Gawande shares a vignette depicting his rather awkward attempt to introduce his coach to a patient on the operating room table:

“He’s a colleague,” I said. “I asked him along to observe and see if he saw things I could improve.”

The patient gave me a look that was somewhere between puzzlement and alarm.

“He’s like a coach,” I finally said.

She did not seem reassured. 

That is not surprising since only the most enlightened patient would see the value of a coach in that situation. I think a more typical reaction would be to think, “Maybe the coach should operate on me instead of the trainee.”

From an ivory tower in Boston, the idea of a surgical coach is a lovely one. Too bad it has little to do with the average surgeon in the United States.