Surgery News- July 2008

J U LY 2 0 0 8 • SURGERY NEWS NEWS providers with behavioral problems must either enter a formal intervention program or lose their privileges. Dr. Graeme L. Hammond proposed that all surgeons be required to have a yearly physical examination with history taken in an effort to identify medically related behavioral problems. Surgeons experiencing depression, alcoholism, and diabetes, for example, may suddenly “start making mistakes and can’t quite put their finger on the problem,” said Dr. Ham- 460 Closed Claims Reviewed Liability • from page 1 municating sufficiently with patients; not pursuing an abnormal sign, symptom, test, or simple postoperative problem; not adequately assessing primary surgical problems before surgery; not enlisting consultant support in a timely way; and not obtaining cross-coverage. Other common behavioral deficiencies were operating outside one’s proper scope of practice, not assessing comorbidities before surgery, and not checking test results. Behavioral deficiencies were significantly less frequent in closed claims involving older and emergency patients. Patients over age 59 were involved in 35% of cases with no behavioral violations but only 25% of cases with behavioral deficiencies. Similarly, patients receiving emergency care comprised 37% of cases involving no behavioral violations and only 18% with behavioral shortcomings. Behavioral deficiencies were common in cases involving delayed treatment, failure to treat, or wrong treatment. Diagnosis-related adverse events, involved in 250 cases, were a feature of 61% of claims involving surgeon behavioral deficiencies but only 31% of claims without such deficiencies. Technical misadventures marked 229 of the 460 claims. Panelists judged 78% of complications in technical misadventure cases with behavioral deficiency as preventable, compared with only 45% of complications in technical misadventure cases lacking behavioral violations. In cases with no technical misadventure and no behavioral violations, no complications were judged preventable, he said. His report prompted some frank soul searching among his fellow surgeons. “He has shown who the enemy is—and it is us,” declared Dr. James A. O’Neill Jr., an ACS Fellow who is professor and chair emeritus of surgical sciences at Vanderbilt University, Nashville, Tenn. Dr. Alden H. Harken observed that patients understand that to err is human, and they accept it. “What they don’t accept is the misbehavior or the behavioral stumble. We surgeons are pretty good with the basic knowledge and the clinical skills. Where we stumble is in the interpersonal skills and the professionalism. “Surgeons have to be self-confident. The problem is when that self-confidence becomes errors,” said Dr. Harken, an ACS Fellow who is professor and chairman of surgery at the University of California, San Francisco, East Bay Campus, Oakland. Dr. O’Neill said a Vanderbilt closedclaims study showed that behavioral deficiencies are a major problem in lawsuits involving all specialties, not just general surgeons. Because physicians and surgeons with behavioral problems have an increased number of liability claims, Vanderbilt has established a process whereby mond, an ACS Fellow and professor of surgery at Yale University, New Haven, Conn. Dr. Griffen said he and his coinvestigators in this study, which was part of a larger ACS-sponsored medical liability study, believe that educating surgeons in the behavioral sciences may result in safer care. “Hopefully, with research and development we can establish evidence-based behavioral practices that will enable [us] to provide safer outcomes,” he said. ■ DATA WATCH Average Claims Payments on Medical Malpractice, 2005 WA MT OR ID WY NV UT CA AZ NM TX CO NE KS OK IA IL MO TN AR MS HI AK Puerto Rico Guam LA FL AL GA ELSEVIER GLOBAL MEDICAL NEWS ND MN SD WI MI PA IN KY SC OH WV MD ME VT NH NY NJ MA RI CT DE D.C. VA NC Source: Kaiser Family Foundation Less than $230,000 $230,000 to $289,999 $290,000 to $360,000 More than $360,000 Untreated Depression Tied to High Physician Suicide Rates BY JANE ANDERSON Else vier Global Medical Ne ws day in the States, roughly one by suicide. Studies Each doctor dies United confirmed over the past 4 decades have that physicians—especially women physicians—die by suicide more frequently than people in other professions or those in the general population. “Physicians have the means and the knowledge and access to ways to kill themselves,” said Dr. Paula Clayton, a psychiatrist and medical director for the American Foundation for Suicide Prevention, in an interview. But the data on physicians dying by suicide are difficult to come by, and “we certainly don’t have any data that [say] any particular specialty has any higher rates of suicide,” Dr. Clayton said. Although no information is available on the risk of suicide in surgeons, researchers know that physician suicides are equally divided between men and women, whereas in the general population, four times as many men kill themselves as do women, according to Dr. Clayton. Awareness of the problem remains low, and professional and cultural barriers deter or prevent physicians who are depressed from seeking treatment for their illness, Dr. Clayton said. For example, most physicians do not have a regular source of health care; only 35% of doctors have a personal physician, and even fewer interns and residents have a doctor themselves. Dr. W. Gerald Austen, an ACS Fellow and surgeon-in-chief emeritus at Massachusetts General Hospital, has first-hand experience with physician suicide. Twenty-eight years ago, when he was surgeonin-chief, one of his younger staff committed suicide. And about 11 years ago, a surgical resident committed suicide. “It wasn’t as if the institution and the department weren’t aware that they had some problems,” he said in an interview. “Both of these individuals were under psychiatric care. They were believed by both their doctors and their contemporaries and colleagues to be doing rather well.” In each case, the surgery department reviewed the situation with the psychiatry department, Dr. Austen said, and “we certainly did everything we could in terms of their family in both cases.” But he said the department didn’t find any procedures to change internally as a result of the deaths. It’s possible that increasing awareness of physician depression could help get physicians the help they need before it’s too late, Dr. Austen said. “Friends who work with people in medicine need to be aware that, if they see something that concerns them, they need to transmit the message to the powers that be.” But it’s difficult to know the difference between someone who is simply unhappy, and someone who is clinically depressed and potentially at risk for suicide, he added. “[Physicians believe] their job is to help other people with problems. If they have a problem themselves, they would prefer to not have people know about it,” said Dr. Austen. “There’s this proudness about their ability to cope,” Dr. Clayton said. “They are reluctant to seek help because they fear the stigma will harm them—people won’t refer them patients, the hospital might revoke their privileges, and licensing could become a problem.” State medical licensing boards ask for information on whether the person applying for licensure has been treated for a mental illness, and that information can affect licensing, she said. “I worked with a physician who took lithium,” she said. “The state board made him get blood drawn periodically to prove he continued to take it. That’s punitive—they don’t do that for other illnesses.” However, some progress has been made in reducing the stigma: A total of 19 states now focus specifically on whether an applicant is impaired because of psychiatric illness, she said. Dr. Clayton’s group recently funded the production of three films on physician suicide as part of an ongoing outreach campaign that seeks to educate physicians about depression. The goal is to help them better recognize the symptoms in themselves and their patients while also cultivating a more thorough understanding of mood disorders in the community at large. One of the films was designed as an educational video for use at medical schools. Because many of the mood disorders that can lead to suicide might become evident first during medical school, where professional and institutional barriers already exist, the goal of that program is to encourage medical students to seek help for depression. Good treatments exist, Dr. Clayton said. ■ See current and archived issues of online at www.facs.org. And don’t miss the exclusive online-only articles available on the Web site. This month, read about new measures for evaluating physician and hospital quality and safety, and new clinical findings that will affect the treatment of heart and lung transplant patients, as well as burn-related infections. More news is just a click away! http://www.facs.org

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Surgery News- July 2008 Contents The 20/20 Vision: Health Reform Trauma: Airway Anchor News From the College: Jacobson Winner General Surgery: Worth the Trouble

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