AAOS Bulletin - April, 2006

Outcomes a factor in orthopaedic stress

Coping with the “predictable” uncertainty of surgical outcomes

By Ronald A. Ripps, MD, and John-Henry Pfifferling, PhD

Dealing with the “predictable” uncertainty of a surgical outcome can be very stressful for some surgeons. In many cases, orthopaedic surgeons try to deal with this uncertainty by exercising control over as many aspects of the surgery as possible. But in some areas the surgeon has no control. Therein lies the problem

Surgeons who are most anxious about outcomes frequently try to control the impossible, including the commitment, competency and concern of others on the operating team. But the number of variables leading to a successful outcome that are not under the surgeon’s control is legion. High staff turnover, inexperienced staff, the variable quality of collaborating specialists (such as anesthetists or radiologists) and “disinterest” in the efficacy of the operating room are all examples of “administrative” issues that can affect an outcome.

Other unknowns not under the surgeon’s direct control include patient issues—such as an inadequate history, comorbidity, the chronicity of the illness and compliance—the socioeconomic impact and an almost infinite number of confounding genetic and psychosocial variables.

The surgeon’s health status, age-related dexterity and familiarity with the pathology or the technique; the surgical team’s ability to communicate; and the overall anxiety level in the operating room also affect outcomes. As “benign” a factor as inhalation of secondhand anesthesia agents may affect surgical dexterity and sharpness. Such issues require sophisticated, multiparty quality-assurance solutions.

Liability and outcome stress

Fear of litigation and litigation history may compromise the ability of some surgeons to confront multiple risk factors. If the surgeon has had especially adverse and/or emotionally charged experiences with litigation, he or she may adopt more defensive tactics (requiring more tests to be ordered) or take a conservative surgical approach.

Knowing that medical liability lawsuits are traditionally regarded as symbols of mistakes, the surgeon may fear that high-profile litigation will frighten away referral sources. Litigation symbolism is so stressful that litigation stress reduction is not even acceptable. This has created a culture of concealment among medical colleagues and has discouraged discussion of errors, maloccurrences, near misses and poor results. The surgeon labors under the general expectation that every outcome must be good.

By default, medical liability suits have become a peer-review mechanism. Because scolding and shame are often associated with peer review, negative results are not so openly discussed as the scientist-clinicians would like. Surgeons who conceal bad results find that carrying that guilt is exhausting.

Any concessions in tort law may be replaced by equally rigorous government regulations. The social question that needs to be answered is this: Which is more important—emotionally satisfying compensation for a medical “error” or an open system that prevents medical errors in an analytical way?

As defensive medicine increases, there is less time time for quality assessment. Careful, time-intensive peer review is one of the first casualties.

Addressing the issues

It won’t be easy to turn around the old culture of concealment, but a beginning must be made.

All too often a surgeon will attempt to handle a complicated emergency that is over his or her head rather than call in someone more familiar with handling the specific problem. Such behavior is inexcusable. There is no shame in asking for help.

Surgeons need to be taught that fallibility is human. Residents and younger associates need to hear from more senior practitioners that disappointment, including poor “outcomes,” is ubiquitous in a lifetime of practice. Senior physicians need to step in when poor outcomes are possible and help the associate rethink the options or discuss any “mistake” as soon after the fact as possible.

Associates need to articulate their concern for regular, timely and nonpersonalized feedback as a prerequisite to joining or staying in a practice. Medical liability insurers need to reward practices that have efficient feedback mechanisms with financial incentives such as lower premiums.

Finally, it is essential to establish a safe haven for surgeons to discuss and resolve alleged “mistakes.” Assuming that all poor outcomes are the surgeon’s responsibility is neither true nor good science. The chain of causation needs to be determined and the surgeon needs to continue life and practice even in the “not-knowing” state. Help can come from peer counselors, physician advocates, family members and the physician’s attorney.

Surgeons who don’t participate in staff training fail to play a crucial role in quality control. The clash between in-service trainers and the obligation of the surgeon as trainer is rarely discussed or resolved. But we need to create a win-win solution that moves beyond blame.

Surgeons need to promote the concept of the collaborative team, whose plan is always spelled out and whose contingencies are anticipated and common knowledge. Surgical environments offer multiple opportunities for making oneself crazy. It is incumbent upon the surgeon to acknowledge the intensity and to maintain a focused, calm demeanor.

All members of the surgical team need to develop skills in conflict de-escalation and dispute resolution. Extraneous interruptions must be minimized. As simple an intervention as determining the noise sensitivity of the surgeon can help reduce stress. Because each of us focuses differently, why not let others know of your concern?

Ensuring that the surgeon maintains composure and an attitude of life-long learning and incorporating team contributions during patient care requires a team focus. Mastering orthopaedic stress requires regular attention to what variables produce the best focus for the surgeon and aligning them with the variables that produce optimal focus for the operating room team.

Ronald A. Ripps, MD, is past president of the Connecticut Orthopaedic Society. He can be reached at theripps@gmail.com

John-Henry Pfifferling, PhD, is director of the Center for Professional Well-Being and can be reached at cpwb@mindspring.com or (919) 489-9167.

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