Blissfully unaware?

Tagged SurgicalPerformance, complaints, Complications; Posted 11 years ago

Last week I attended a marvellous presentation by Professor Gerald Hickson from Vanderbilt University in Nashville, TN. In brief, he talked about us doctors being accountable for our outcomes and actions. Jerry is an ex-Paediatrician who runs a Center for Patient & Professional Advocacy.

To open the evening, he gave a fictional example of a surgeon who declined to be involved in “Time Out”. The surgeon participated in side conversations and continued prepping: “I am tired of all this time out nonsense”. Jerry then asked the auditorium what % of the time a colleague or nurse would report the event to a responsible party or a medical leader and someone senior would have a conversation with the surgeon.

The vast majority of the listeners in the room (in Brisbane, Qld) did not think that someone would report the event and the majority did not think that someone would have a conversation with the surgeon above. Very much to Jerry's surprise.

Vanderbilt established and runs an event-reporting tool. If someone reports an event, a health administrator will touch base with the person involved and have a chat within 24 hours from reporting. Just a 3-minute conversation that would run like this: “Hi, there was an incident you were involved in. Not sure what happened really and I am also not interested whose fault it is. I realise that there would be a second side of the story but I really don’t want to find out what really happened. I just wanted to let you know that I know about it. I trust that you believe in safety as much as I do.” That’s it. No accusation, blaming; certainly no formal proceedings. The chat is informal and will not recorded or minuted.

That is cool; very cool. Wouldn’t it be nice to have informal conversations about sensitive issues? We allow for informal conversations if things go well. Patients send me cards, well-wishes, etc. All of that is informal. I don’t record it, bring it to the medical administrator’s attention. No one does. Negative feedback is always formal. If it is not clearly marked as formal, health administrators will (have to) formalise and escalate it.

Gerald Hickson also mentioned that a minority of doctors account for the majority of complaints – similar to Australian published recently. 1 to 6% of hospital patients suffer an injury due to negligence but only 2% of those patients take legal action. By contrast, two to seven times more patients take legal action without a valid claim and mostly non-financial factors motivate patients to lodge a claim. Some doctors attract more claims than others.

The number of claims strongly correlates with the number of adverse events or surgical complications. Gerald also established a data link between complaints and NSQIP, which is a national organisation collecting data on adverse events. It was news to me that the incidence of complaints and complications correlate strongly.

Not surprisingly - Hickson has shown that the majority of doctors, who attract more claims than average, are blissfully unaware of that fact. In his study, he sends reports to let them know where they stand. In a complaint summary, he lists the number of complaints against the average for the surgical specialty. He even gives them a risk score expressed in numbers as well as in a pictorial.

The ripper is that 75% of doctors who attract an above average number of complaints will revert back to normal and self-regulate once they are aware they are outliers. Only one quarter will progress and will require a formal intervention. This is THE thing: If we are not aware where we stand, we have not got a chance to fix it. Perversely, a lot of other people and organisations collect data on our complications and on complaints lodged against us. We are the ones who should know – but we are not privy to this information.

Lawyers tell involved doctors “Every doctor has two or three legal claims at any one time. We encourage you to consider a claim an occupational hazard”. False. Only a minority of doctors have to deal with legal claims.

The issue is though, that we don’t know. We might know whether we have a claim we need to deal with and if so how many claims we deal with at present. We don’t know how “normal” or “abnormal” that is for our profession.

The same with surgical complications: As doctors we all have to deal with adverse events. How often, most of us don’t know. Even if we would know (lets say we enter all cases into an excel sheet) we would not know how bad our outcomes are compared to our colleagues.  

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