A question all surgeons should ask of themselves and their colleagues
The following case report is true. It is mine. I am sharing it to shed light on an area of patient safety that all physicians and surgeons must consider. If we do indeed learn best from the mistakes others make, I hope this will be a lesson for thousands of surgeons.
As a fellowship-trained spine surgeon, I have great empathy and sympathy for my patients, because I have also sustained disk herniations and radiculopathy. In fact, some years ago, I underwent 3 months of nonsurgical therapy. Because my condition did not respond to the treatment, I decided to undergo a laminectomy and diskectomy.
At the time, I was a very busy spine surgeon and I had patients who were scheduled for surgery during the following few months. I knew that I would probably be out of the office for 3 weeks after my surgery, and out of the operating room for 6 weeks. I contacted the patients who were scheduled for surgery after my date of surgery and offered them alternatives. They could wait for my return or I could refer them to another surgeon. Almost 100 percent decided to wait for me.
But I also had three patients who were scheduled for spine surgery on the date of my surgery. I explained that I would be undergoing spine surgery on the same day as they were scheduled. I offered them the option of rescheduling at a later date with me or with another surgeon sooner. All asked why I couldn't perform their surgeries before I underwent surgery. I hadn't given much thought to that option, so I agreed with their requests.
So on the day of my surgery, I neither ate nor drank after 4 a.m. I performed three lumbar spine operations, which all went well. At 1:30 p.m., after taking the last patient to the recovery room, I went to the preoperative holding area and became the fourth lumbar spine surgical patient on the schedule. The next morning, I got out of bed and walked down the hall to perform postoperative checks on my patients. It was patient care to an absurd degree.
In retrospect, I now know I made an asinine decision. I was an impaired surgeon, and everyone in the operating room knew it. I was in pain (although on no pain medications). I was starved of any nutrition (solid or liquids) for 9.5 hours. My name was clearly on the surgical schedule as a patient. If I was not smart enough to stop myself, why didn't someone else?
The TeamSTEPPS response
Having been through TeamSTEPPS ® (Team Strategies and Tools to Enhance Performance and Patient Safety) training, I now realize that my team (the entire operating room staff) and I lacked situational awareness and mutual support.
TeamSTEPPS training teaches that situational monitoring requires mutual respect and team accountability, providing a safety net for the team and patient. Among other things, the team needs to look for signs of fatigue, workload, and stress among all its members. There is even an "I'M SAFE" checklist that every team member can use to measure his or her own preparedness and "health," as well as that of other team members (Table 1). In retrospect, I can definitively state that I scored "yes" to at least three—if not four—of the checklist elements (I, S, F and E).
So why did no one stop me from performing three surgeries before undergoing my own surgery? True, the incident occurred many years ago, before healthcare organizations were cognizant of high reliability principles, high resiliency, and patient safety programs such as TeamSTEPPS. However, the same or similar events could and probably do still occur.
The image of the physician/surgeon as invincible or superhuman still exists. Although residency training programs are addressing this issue by placing limits on hours, in many cases, residents don't fully adhere to the strict hour limitations. Residents complete their training without fully accepting patient safety principles.
One resident told me "rules are made to be broken." In some programs, admitting to being unable to complete a task—emotionally or physically—due to fatigue is considered a sign of weakness.
In some professions—driving a truck or bus or piloting an airplane—strict hour restrictions are easy to monitor. It is much more difficult in health care. Tracking resident hours may be possible, but how much work is done off the clock? Even more problematic are the work hours of attending physicians. How many consecutive days can an orthopaedic surgeon (or, for that matter, any physician) safely take call? If a physician is on call Friday, Saturday, and Sunday, and Friday and Saturday calls are busy and stressful, how well will that physician perform on Sunday?
As I've delved into the world of high resiliency, high reliability principles, and TeamSTEPPS, I've realized that I didn't always practice the principles that I'm preaching today. I now know better and am hopeful that some of my actions couldn't occur today. I hope my story helps increase awareness and creates self-reflection to prevent patient harm. I was very fortunate; in my near-miss situation, no harm came to any of my patients, but the potential was there.
Michael R. Marks, MD, MBA, serves as a mentor in the AAOS Communications Skills Mentoring Program and TeamSTEPPS, and is a member of the AAOS Patient Safety and Medical Liability Committees. He can be reached at firstname.lastname@example.org