Just Try to Change a Surgeon

Though doctors' medical licenses generally indicate permission carte blanche from governing medical societies to practice both medicine and surgery; it is generally accepted that surgical procedures will be of a limited nature; it is given to the individual staffs to mandate which procedures and under what conditions an individual doctor may perform an operation. A surgeon may not just walk in to an operating room and perform an appendectomy, e.g.,without his credentials having been been closely scrutinized by a committee of his peers.

Hammering out these rules caused many hard feelings especially when turf battles were involved. A surgeon may say, "I've been taking out tonsils or appendicies before you were born. Why must I stop now?" The answer is easy: he need not stop. He must just prove his qualifications..

I remember one particular surgeon who was irate when the head OR nurse stopped him at the operating room door and refused him admission. Our staff president asked our pathologist along with a significant committee to review the surgeon's previous 10 appendectomies. Tho' each case was diagnosed by the admission surgeon to be an "acute appendicitis," in actuality only one showed evidence of infection.  It was further made clear that the surgeon did not understand the disease as he blatantly wrote in the chart, "Schedule for appendectomy in 2 weeks when I return from my vacation"; surely at least one of the appendicies would have ruptured during that 2 week period if the diagnosis were correct. The reviewing committee decided to require the admitting surgeon to obtain a consultation on every new case of suspected appendicitis. Result? He gracefully stopped treating patients with abdominal pain.

Problems concerning surgical privileges generated much hostility and were a bane of contention in the opening months of the Aliquippa hospital. To the credit of the Aliquippa surgeons and to those general practitioners who for many years had included minor surgery as their domain, Final decisions were, eventually assigned to, board certified surgeons. The very loose rules acceptable for years to the older staff at Beaver County's three hospitals were summarily overturned by Aliquippa's Staff and soon adopted almost overnight in the three other county hospitals. It was not only a significant advance in medical care but also the prevention of potential malpractice suits.

It took longer to eliminate "ghost " surgery. A "surgeon" would be gowned as he said "hello" to his patient at which point another surgeon unbekownst to the patient would walk in and perform the operation. The referring surgeon would collect a major portion of the fee.

“You’ll make no friends serving on the Quality Control Committee,” my brother, Jerry, cautioned me.  It was to be the first of its kind at the Aliquippa Hospital.  At Jerry’s hospital tempers raged during their first attempts at quality control; a couple of meetings ended as members stormed out.

My reaction?  “What!  A Harvard man shirking the responsibility of teaching colleagues and protecting patients?”  “It’s not arrogance,” I mused.  “Rather a solemn obligation to my profession.”  Whatever my noble or immodest motivations, I let myself be maneuvered even to the committee’s chairmanship.  Jerry wished me, “Happy hunting.”

In truth at our first meeting I successfully sidestepped one land mine after another, maintaining a full complement of friends.  It could just as easily have gone otherwise.
 
At first glance a layman or a physician-reviewer might not fault the first patient record to be reviewed.  On the patient’s history page Larry, the orthopedic surgeon, had written: “This forty-five year old male came to the E.R. with a fractured femur.”  End of history.  Then on the physical examination page: “There is marked swelling and deformation of the region of the upper right thigh.  Heart and lungs, normal.”  On the pages meant for progress reports Larry wrote: “Performed closed reduction of femoral fx under gen’l anesthesia.  Cast applied.”  And lastly, three days later: “Patient walking on crutches.  Home.”  The chart furthered included the minimum blood tests required for giving a general anesthetic.  Completely impersonal, not once did Larry indicate that the patient’s name was Carl.
 
“No problem here,” said a member of the committee.
   
“Not so fast,” said another member.  “It just so happens that I’ve been Carl’s family doctor off and on and I know for a fact that he’s quite a heavy drinker.  The history makes no record of this and I see the surgery took place four hours after admission to the E.R., time enough to obtain liver function tests.  None were done.”
     
The first physician, who thought the chart passable, minimized the criticism.  “Carl got through the surgery well enough.  What’s the problem?”
          “C’mon.  Though you’re right, we’re not here to whitewash our colleagues.  The surgery was successful but if the history of alcoholism had been elicited and if liver function tests had been performed, a different anesthetic might have been indicated.  And you know what else?  Mention is made in the nurse’s notes that Carl fractured his leg when he ‘fell down the stairs at home.’  No written comment by Larry.  Listen.  I know this guy’s son.  He’s a violent kid who’s always fighting with his Dad.”
       
“So, you’re saying that the chart is lacking in liver function tests and information as to how the fracture occurred,” I summarized.
   
“I’m saying that as much as I like Larry, apart from making the right diagnosis, he did the work of a carpenter.  I hate to make an example of him but I got out the hospital record of two years ago when I admitted Carl for pneumonia.  Look at what I wrote on the discharge summary: ‘1. Pneumococcal pneumonia.  2. Chronic alcoholism.  3. Aortic stenosis, possibly from rheumatic heart disease.’  Did Larry ask the record room for old records?  Of course, not.  ‘Heart and lungs, normal’, my arse.  Any second year medical student would have heard Carl’s heart murmur.”
     
I added fuel to the fire.  “I doubt that Larry had ever sat down with Carl to ask about work-related financial concerns – nor did he call for a social service consult.  Furthermore I would have given him a gold star if he had verbalized the known myth in patients’ minds that equates a fractured leg with impotency.  So, what are your recommendations?” I asked, looking at each member of the committee.
     
Larry’s critic spoke up.   “Well, I agree that the outcome was satisfactory.  But I think Larry fulfilled only half of his responsibilities.  No disciplinary action is indicated but I believe that the minutes of this review should be given to him.  He’ll be mad as hell.  Put him on the committee next year.”
     
With a unanimous vote we did approve a recommendation that charts of all previous hospitalizations be provided the attending physician as expeditiously as possible.
   
That’s not the end of the story.  After receiving our report, Larry asked to be invited to the next meeting of our committee.  More accurately, he asked for an immediate opportunity to face his critics.  We accommodated him.
   
“What do you guys want from me?  You all trust me with your orthopedic patients.  Dave, I operated on your cousin’s knee and Jim, you let me operate on your wife’s back.”
   
I called a halt.  “Hold it.  No one has challenged your surgical competence.”
   
“Well, at least, thanks for that.  Okay.  Let’s go point by point.  Carl’s alcoholism.  Listen, he eats three meals a day and is as strong as a bull.  The anesthesia was brief, no more than fifteen minutes.  I set the fracture and took an x-ray to see if all was in place and finish.  There wouldn’t have been any ill effects even if he had alcoholic cirrhosis.  You may not know it but the anesthesiologist hasn’t had a great deal of experience with the new less liver-toxic agent.  And if Carl wants to announce that’s he’s a member of AA, that’s his privilege.  Why should I write it in the chart for busybody eyes?  It’s nobody’s business.”
   
The orthopod certainly had a point about privileged information.  We all had struggled with this dilemma.  I remember wanting one particular patient’s history to be complete; I felt smug substituting “sexual identification problem” for “homosexual,” hardly much of a ruse these days.  In an effort to direct others involved in the patient’s care I had divulged privileged information.
     
As chairman of the committee I took the liberty of concluding at the point: “I find little or no fault with your reasoning.  If no one disagrees, let’s move on.”   One hand went up.
     
“Okay.  So I missed the heart murmur.  As I said, Carl is as strong as a bull.  If he could run up three flights of stairs, I couldn’t care less if he has a heart valve problem.  It’s true that if he had had an open wound, I would have known better to prescribe antibiotic therapy to prevent endocarditis.  In that situation I might well have been negligent.  So what do you guys want?  That I have an expensive medical consult on all my cases?”
     
A committee member took me, a medical consultant, off the hook.  “No, you have a good track record for using consultants.  But if you had taken the time to review the discharge summary of the previous admission, you would have been a lot farther ahead.”
   
“No disagreement there and I do like your recommendation that old records be made available with all due haste.  You guys earned your keep with that one.”  (He was being sarcastic since he knew we received no compensation for the committee’s work.)  “As to how Carl broke his leg, I took him at his word that he tripped on the stairs.  If his son pushed him, that’s between them.”  The reader must remember this was in the 1970s before doctors accepted the responsibility for preventing violence in the home.  None of us in the room was sensitive enough to take up the gauntlet.
       
“Lastly.  ‘Sexual impotence?’  You got to be kidding!  No patient is ever going to admit he’s worried about that.”
     
Again, none of us was equipped to give a lesson in the psychodynamics of trauma.  All I could do was to say, “Well, maybe once in awhile you might just ask.”  And I did add the well-known adage that “the patient knows how he feels but not what he’s got; the doctor knows what he’s got but doesn’t know how he feels.”
 
“So now the committee will recommend routine psychiatric consultation on all my fracture cases?
 
I closed the meeting thusly.  “I’m in line to be Staff President next year.  You can make that question your first agenda item as the new chairman of the Quality Control Committee.”
 
Years ago I took a course on “Psychiatry for Internists.”   It was given by a friend, Bob Plesset; I enjoyed it thoroughly.  After the last session, I thanked Bob and added that it would be wonderful if he could repeat the course, but for an audience of surgeons.  He replied, “Listen, Dave.  If I have emotional problems, I’ll go see my internist and if he can’t help, I’ll go to a psychiatrist.  But if I have a surgical problem, I want to be operated on, not by someone who will waste precious anesthesia time by deliberating on all the implications of what he’s doing, but rather by the best man for the job, an out and out bastard.”
 
Maybe we should have left Larry alone.  If Dr. Plesset were right, we would have achieved nothing by trying to change him.  Who knows?  If successful, we may have created an impotent surgeon.