A. Douglas Heymann,
MD, FACS.
Over 50 years of experience.

Dr. Heymann

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Danger in Surgical Care, Too! (Part 1 of 3)

This series, in three parts, is prompted by the article, HOW THE HEALTH CARE SYSTEM CAN HARM YOU” BY RICHARD LALIBERTE, AARP Bulletin, September 2016, V57, #7, pp 18-25.

 

This article is featured in the AARP Bulletin received by many AARP members who are older than 50.

 

Stay with me!

 

The reference article provides valid and important advice.  I do not know the author but agree with his thesis.  I have been a Surgeon for 50 years starting with a Straight Surgical internship and I am still in active practice and have witnessed radical changes in the evolving American Health Care system.

 

I recommend that patients participate thoroughly in their surgical experience.  Whether operative or consultation, assure understanding of plans and the process by obtaining and listening to explanations, keeping your own records, doing research for the purpose of comprehension, and assuring cooperation and planning among consultants.  Freely ask for help, explanations, and clarifications.  Beware of explanations that do not make sense, are dogmatic, or not forthcoming.

 

Comprehensible Communication improved most of these issues.  (see Paragraph #4, second installment)

 

Explanation and communication, however, require plenty of physician time.  Employed physicians are given guideline-demanding work volume and therefore limit time for each of their many tasks and encounters.  Physician extenders and printouts fulfill the duty to inform and document.  Non-physicians, no matter how intelligent and diligent, do not have the same conceptualization of interrelated factors.  The written word that seems satisfactory can be misleading and omits important possibilities and considerations.  I have observed that patients who come after other medical encounters have received a bare minimum of information.

 

I am not a high volume surgeon and do not participate in insurance programs.  I spend plenty of time during consultations.  The super majority of surgeons are now captives of corporate health and hospital systems and victims of low reimbursement by insurance companies and high productivity demands by employers.  Unemployed physicians are impacted by diminishing insurance payments, increased paperwork including fighting insurance companies, compliance requirements by hospitals, and government and increasing overhead including electronic medical records, computer upkeep, malpractice insurance, salaries and rent.  The increased demands and obstructions by insurance companies, along with need to increase patient volume and adhere to time constraints, increases the number of employees and office space required to function.  This downward spiral catalyzes the trend to accept hospital employment, to hand off care for hospitalized patients to hospitals, or retire from practice.  Even greater demands by Corporate employers on hospital-employed physicians also diminishes encounter time and predisposes to delegation of care to various extenders and Residents at different levels of education at various stages of care.

 

I’ll review some aspects of this AARP article in a while, but I also just read a viewpoint article in the  Journal of the American Medical Association, Surgery, September 2016, V158#9, p 791-92.  By Steven Yuel, MS et al, Harvard Medical School entitled “Innovative Approaches for Modifying Surgical Culture.”   Some quotes for thought:-

 

“The practice of medicine….depends on the interactions between patients and clinicians within the confines of a larger health care system.”  “Surgical culture represents the broader relations at play.”

 

The “culture of surgery tends to be defined within 3 primary factors:  teamwork, communication and safety climate.” “These efforts (to improve quality) also demonstrated that meaningful engagement of hospital leadership is an indispensable component to ensuring success.”

 

“Another method of assessing culture is observation of the behavior of surgical team members.”

 

“Several studies have shown a positive association between hospital culture and surgical quality.”

 

Consider when reading these quotes that Leadership includes Chairman of Department and Hospital or Corporate Executives.  Professional leadership and also that most physicians who are employed and controlled and are subject to decisions by Management which are Financially driven.  Just think about it!

 

So let me review.  There were twelve items discussed in this thoughtful and valid AARP article with some comments.

 

1-“WRONG DIAGNOSIS”- quotes, “Diagnostic errors contribute to 10-17% of all episodes of preventable harm.”  ”Mistakes can spring from poor collaboration or misunderstandings among clinicians, patients, etc.”  The solution boils down to clear thinking, education, experience, attention to detail, consultation, communication, and reconciliation of different opinions and logical confirmation of diagnosis consistent with findings and symptoms.

 

2-“SLOPPY PRACTICE”- quote:  “is the treatment plan right in the first place?”

 

Is the diagnosis consistent with the clinical picture?  Is there a strategic plan?  Are risk factors for complications integrated in strategic planning?  What tactics minimize risk?  Are prophylactic SAFETY measures included in the plan?

 

Same solutions as in #1 plus an organized strategic plan considering the patient’s initial concern, comorbidities, and risks of the environment including a comprehensible sensible explanation and an attentive, informed, trained and integrated support system.

 

3-LAX HYGIENE - This focuses on preventing SEPSIS, a high risk presenting as a complication of diseases or treatment.  This includes not just handwashing, caregiver and patient hygiene, but preventing communication of diseases, separation of dirty from clean problems, antisepsis and compulsive sterile technique when doing surgery or caring for wounds.  The problems identified by Florence Nightingale and Lister still exist and are possibly compounded by antibiotic usage in medicine and other industries.

 

You can predict “good surgical technique,” which depends on an organized surgeon and supporting operating room staff, by attentively observing care.  This is an integral aspect of how surgeons are taught to do surgery.

 

How is the environment controlled?  Hospital management must follow government and insurance company’s limitations and demands and also apply RULES and DASHBOARDS for performance (many a priori and intuitive) to all patient care irrelevant of specific problems.  The availability of sinks, sterile equipment, specialty nursing, and intraoperative discipline is also now dependent on the Managerial organization with minimal input from surgeons.  Surgeons, now mostly employees, still know what is needed, but sometimes deal with what is deemed appropriate by Administrators…most of whom have no clinical experience or training.  Employed MDs hesitate to get “pushy” with their employer.  Traditional input from committees composed of rank-and- file MDs is minimal.  Senior Medical leadership is deluged with meetings, paperwork, regulations, compliance issues, mandates and Corporate profit & loss considerations.

 

PART 2 TO FOLLOW.

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    © 2020 by Dr. A. Douglas Heymann, MD, FACS.