Posts Tagged surgery

The Reverse Operative Consent — a pipe dream

No Surgery Oops

Surgeon to sign at bottom of page.

The reason you need to have surgery is:  _______________________

The name of the surgery is:  _____________________

I have done this same surgery on about ____ patients in the past 3 years.

There is a (circle)  poor, fair, good, excellent chance the surgery will resolve your problems.

The surgery will not fix the following things:

Expect the following short term effects of surgery:

Expect the following long term effects of surgery:

Diagram of surgery:

location of incision

Although I believe the proposed surgery is best, the next best treatment would be the following:

I have accurately told you the most frequent complications of surgery but I do not expect any complications.   Complications are not random events and they always have a cause.   I will do my best to prevent complications and errors by:

  • Following evidence based guidelines
  • Using a pre-op check list
  • Working as a team with everyone in the operating room
  • Following recommendations from the pharmacy and quality improvement departments
  • Being honest about errors and informing you of them immediately
  • Being available for any problems that arise
  • Calling specialists to help with difficult problems

When you are fully awake after surgery I will personally go over the findings of the surgery.  If there are any outstanding test results when you leave the hospital we will call you later to let you know those results.

Our hospital has surgical hospitalists who are available 24 hours a day. Whenever you, your family or the nurses feel immediate attention is needed — just call the following number for their help ____________.

If you need to be in a critical care unit of the hospital I will ask a critical care specialist to consult and coordinate treatment.  I fully support the team approach to severe illness which includes a multidisciplinary rounding program.

Before you leave the hospital we will review all your medications and make sure you know the correct ones to take after you get home.  I will FAX (or send by computer) a full report about your surgery and medications to your primary care doctor on the day of discharge.  And, I will send a copy to you.

We will write down all instructions when you go home but feel free to call me at this number if you have questions or problems: __________________

My nurse will call you the day after discharge to make sure everything is going well.  Your follow up appointment will be just a few days later.

I expect to be away from the hospital during this time: _______________
My associate ______________ will fill in for me during that time, but rest assured, I will take the time to personally go over your situation with my associate so they can fill my role without difficulty.

Signed Dr. __________________________  Date __________________

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Risk of Surgery Lowest on Monday — deadly weekends

chart_1 (6)

Deaths from surgery increase from a low on Monday to a high on the weekend according to a BMJ study just released May 28, 2013.  The researchers evaluated about 750,000 scheduled surgeries and suggest the likely explanation is poor quality care on Friday and weekends.

Friday surgery has a 44% increase in the odds of death within 30 days compared to Monday.  Weekend surgery is worse with an 82%  increase in risk.

The 3-in-1 hospital.   All hospitals are divided into three hospitals because of nurse shift assignments, weekends, holidays and vacations.   And, the tendency for senior staff to gravitate to the weekday shifts.   The hospitals are:

  1. The day hospital
  2. Then night hospital
  3. The weekend and holiday hospital

The day hospital has a full staff with the most senior doctors and nurses available and the operating room working at optimal capacity.

The night hospital has a limited staff of doctors and nurses and limited operating room staff.

The weekend and holiday hospital — this problematic hospital is when  the staff levels are low, the operating room is on a standby, the least senior nurses are working and the weekday doctors are replaced by on-call doctors usually doing double duty (often overworked, not familiar with the patients and sleepy from long night hours).  Furthermore, on-call surgeons may try to delay treatment of surgical complications until weekday surgeons are available.

The real surprise in this study is that the death rate rises as the week progresses.  The cause is not clear but some possibilities include fatigue, surgeons being less available to resolve hospital problems when at an outpatient clinic, afternoon golf, and possibly scheduling patients just discovered to have surgical problems that week in the ER (delay in care).

Another negative factor is the global surgical payment  (surgeons receive one payment for a surgery including all pre- and post- surgical care).  So, unless there is a very equitable system within a group the surgeons who round on weekends are not paid and have little incentive to do more than “howdy” rounds.

How to correct the problem:

  • Hospital actions:  spread the surgical service activity over more shifts and weekends.  At least one third of nursing staff on any shift should have more than 5 years experience.  Pay surgical hospitalists to attend to surgical patients when the primary surgeon is not in the hospital and to service the emergency room at any time.
  • Surgeon actions:  Provide the hospital with a surgical hospitalist who is at the hospital 24/7.  Allow the surgical hospitalist to do surgery on patients admitted from the ER.  Reduce the Friday and weekend workload with more physician staff on those days.  Provide monetary compensation for covering doctors (not just payment in kind).
  • Patient actions:  Ask about whether there is an experienced surgical hospitalist available in the hospital at all times (not just a resident or medical hospitalist).  If not, refuse elective surgery on Friday or on weekends.


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False Positive — what’s not there can kill you.

An x-ray, biopsy or other medical test can have a number of possible results.  The uninformed patient or the unwary doctor can be fooled by some of the possibilities.  How could a little test hurt you — it’s just a harmless x-ray or small biopsy or just a few drops of blood?  There is some underlying truth about a condition we want to know.  Do we have a problem or not, yes or no, cancer or no cancer, pregnant or not pregnant, AIDS or no AIDS and many other questions.

Most people understand if the weatherman predicts rain tomorrow, but no rain comes, we laugh because we know prediction of weather is not always accurate.  Yet we don’t apply the same common sense to medical tests.  If a test predicts a person has cancer we believe it — the sad fact is medical tests are not always accurate.  A test can predict a condition when none is present which is called a false positive.  A test can predict a condition is absent when it really is present which is called a false negative.  A test can predict a condition which turns out to be correct which is a true positive.

So how can a little test hurt?  If the test is a false positive which leads to surgery which has a complication then a person could die.  This is not just theoretical, it happens.  The problem is made worse by a tendency of health care professionals to over-diagnose disease.  For example, if a pathologist is not certain if a biopsy shows cancer the safe thing to say is “possibly cancer” rather than “I don’t know”.  The surgeon says if it is “possibly cancer” the best thing is to “take it out”.  Later, when the patient is missing some body part and no cancer is found the surgeon says “you were lucky”.  Really?  Perhaps the patient should not have had the test in the first place.

In certain circumstances the chance of getting a false positive is higher than the chance of a true positive.  A good example is finding a small spot on a chest x-ray.  Most spots on chest x-rays are not cancers.  Because of the unreliable nature of the chest  x-ray for cancer screening, routine chest x-rays are not advised.

People who study the statistics of medical testing can figure out which tests have the best chances of true results.  This is important information for patients and doctors.  Recently, the PSA test has come under criticism.  It seems the test has a high rate of false positive results and to make it worse, positive results may lead to unnecessary surgery.  In view of the statistics, experts now do not recommend PSA tests for routine screening for prostate cancer.  Hopefully, this will lead to better tests while the old PSA test heads to the history books.

Another important question is whether the result of a test will change treatment.  If not, then don’t do the test.  For example, surgery in the very elderly is dangerous.  So if no surgery would be recommended for a 100 year old person then don’t do a CT scan of the brain.  Is that mean and uncaring?  No, it is taking care not to do tests that lead to harmful procedures.

So, more information is not always better.  It is smart to avoid tests with a high false positive rate.  National guidelines do exist for many tests so search for them on the Internet and as they say “ask your doctor”.

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