Black Box in the Operating Room

[BurghStudent]

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http://www.thestar.com/news/gta/201...ack_box_poised_to_change_medical_culture.html

A Toronto surgeon who is working to adapt black box aviation technology to track surgeries and improve patient outcomes says preliminary results are promising.

In Dr. Teodor Grantcharov’s operating room, “the whole room is wired.” Cameras and microphones capture movement and conversation, and patient data, such as heart rate and blood pressure, is logged automatically by a data recorder similar to black boxes used on airplanes to record flight data.

The surgery box, which is actually blue, is poised to change medical culture and practice, said Grantcharov, a minimally-invasive surgeon at St. Michael’s Hospital and professor at the University of Toronto.

Once surgeons finish their medical training and begin practising independently, “nobody watches us, nobody coaches us and nobody provides feedback,” he said.

This lack of feedback, as well as the pressure for surgeons to appear as though they never make errors, is not serving the medical community, Grantcharov said.

“Changing the culture starts with admitting or being transparent about our deficiencies.”
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On the one hand, in terms of educational purposes, I see the utility of this system. However, I can't shake off the feeling that this will be used for other purposes. Use your imagination, it's SDN.

 

[05silvergt]

Malpractice attorneys are probably salivating over the thought of this.

 

[VisionaryTics]

"Once surgeons finish their medical training and begin practising independently, “nobody watches us, nobody coaches us and nobody provides feedback,” he said.

This will 100% be used only for medicolegal purposes. Who is going to sit down and listen to the tapes? What use will they be? And we already have a record of vitals/physiologic state: it's called the anesthesia record. Which I'm sure anesthesiologists spend hours every night pouring over to improve their skills.

It's like everyone freaking out about the NSA tracking all our emails and phone calls. Even if they did track all that, there is so much data that it overwhelms the ability of human agents to turn it into actionable intelligence.

 

[theseeker4]

http://www.thestar.com/news/gta/201...ack_box_poised_to_change_medical_culture.html

A Toronto surgeon who is working to adapt black box aviation technology to track surgeries and improve patient outcomes says preliminary results are promising.

In Dr. Teodor Grantcharov’s operating room, “the whole room is wired.” Cameras and microphones capture movement and conversation, and patient data, such as heart rate and blood pressure, is logged automatically by a data recorder similar to black boxes used on airplanes to record flight data.

The surgery box, which is actually blue, is poised to change medical culture and practice, said Grantcharov, a minimally-invasive surgeon at St. Michael’s Hospital and professor at the University of Toronto.

Once surgeons finish their medical training and begin practising independently, “nobody watches us, nobody coaches us and nobody provides feedback,” he said.

This lack of feedback, as well as the pressure for surgeons to appear as though they never make errors, is not serving the medical community, Grantcharov said.

“Changing the culture starts with admitting or being transparent about our deficiencies.”
------

On the one hand, in terms of educational purposes, I see the utility of this system. However, I can't shake off the feeling that this will be used for other purposes. Use your imagination, it's SDN.

I can see the malpractice trial now; "dr. X, here you are, laughing and joking over my client's body while he is open on the table, moments before he almost bled to death. Do you think your relaxed and unprofessional demeanor in the operating room contributed to my client's unfortunate outcome?" Malpractice lawyers would love this.....

 

[operaman]

Yeah this is a non-starter without legislation protecting this data from being discoverable in litigation. There are already protections in most states for things like M&M. Without that, no hospital is ever going to let this in their OR because of the institution's liability, not to mention the surgeon's.

 

[Psai]

No thanks. Don't need more surveillance in my life

 

[Roxas]

This will 100% be used only for medicolegal purposes. Who is going to sit down and listen to the tapes? What use will they be? And we already have a record of vitals/physiologic state: it's called the anesthesia record. Which I'm sure anesthesiologists spend hours every night pouring over to improve their skills.

It's like everyone freaking out about the NSA tracking all our emails and phone calls. Even if they did track all that, there is so much data that it overwhelms the ability of human agents to turn it into actionable intelligence.

Even if they probably don't listen to it doesn't make it okay. That goes for both situations.

 

[Psai]

I think we should have black boxes in malpractice attorneys offices

 

[DermViser]

This will 100% be used only for medicolegal purposes. Who is going to sit down and listen to the tapes? What use will they be? And we already have a record of vitals/physiologic state: it's called the anesthesia record. Which I'm sure anesthesiologists spend hours every night pouring over to improve their skills.

It's like everyone freaking out about the NSA tracking all our emails and phone calls. Even if they did track all that, there is so much data that it overwhelms the ability of human agents to turn it into actionable intelligence.

Exactly. These tapes are 100% discoverable in a court case. No question. Feedback my butt.

 

[Psai]

This will 100% be used only for medicolegal purposes. Who is going to sit down and listen to the tapes? What use will they be? And we already have a record of vitals/physiologic state: it's called the anesthesia record. Which I'm sure anesthesiologists spend hours every night pouring over to improve their skills.

It's like everyone freaking out about the NSA tracking all our emails and phone calls. Even if they did track all that, there is so much data that it overwhelms the ability of human agents to turn it into actionable intelligence.

It's hard enough to get people to read my progress notes and give constructive feedback

 

[DermViser]

Yeah this is a non-starter without legislation protecting this data from being discoverable in litigation. There are already protections in most states for things like M&M. Without that, no hospital is ever going to let this in their OR because of the institution's liability, not to mention the surgeon's.

I've heard some hospitals have cut out M&M for this very reason. I remember when we rotated and there were M&M conferences in Surgery, no paper, recording devices, etc. were allowed.

 

[operaman]

I've heard some hospitals have cut out M&M for this very reason. I remember when we rotated and there were M&M conferences in Surgery, no paper, recording devices, etc. were allowed.

Yeah I think the way the law is written for M&M, anything taken OUT of the room or discussed later is fair game. The plaintiff's atty can subpoena those records or those people to testify to what was said outside of M&M. My guess is some of those hospitals got burned through one of these loopholes and just shut the whole thing down.

Which is a shame because M&M and the like serve a wonderful purpose and likely have lead to better outcomes and more careful surgeons over the years. There's also the fun for students to watch the senior resident stand up there and defend a decision that was clearly made at the attending level while everyone pretends the resident called all the shots. It has a distinct Emperor's New Clothes vibe to it.

 

[Kahreek]

I can see this having a many legal obstacles to being implemented. Because the fundamental goal of it is completely different from aviation use.

 

[DermViser]

Yeah I think the way the law is written for M&M, anything taken OUT of the room or discussed later is fair game. The plaintiff's atty can subpoena those records or those people to testify to what was said outside of M&M. My guess is some of those hospitals got burned through one of these loopholes and just shut the whole thing down.

Which is a shame because M&M and the like serve a wonderful purpose and likely have lead to better outcomes and more careful surgeons over the years. There's also the fun for students to watch the senior resident stand up there and defend a decision that was clearly made at the attending level while everyone pretends the resident called all the shots. It has a distinct Emperor's New Clothes vibe to it.

Yes, watching General Surgery M&M as a student, was quite hilarious. To see a surgery chief resident have to defend someone else's decision making was absolutely ridiculous. Or even worse, having to defend what was done on a surgery case that occurred BEFORE they took over the census at the beginning of the month (M&M happened to fall at the beginning of the month).

 

[DermViser]

We have the most junior resident involved in the index surgery present the M&M. It's even less fun being a few weeks into PGY2 doing what you describe. Monthly.

Even more ridiculous. As if Surgery M&M isn't already a preying on the weak hazing to begin with.

 

[SouthernSurgeon]

Yes, watching General Surgery M&M as a student, was quite hilarious. To see a surgery chief resident have to defend someone else's decision making was absolutely ridiculous. Or even worse, having to defend what was done on a surgery case that occurred BEFORE they took over the census at the beginning of the month (M&M happened to fall at the beginning of the month).

At our M&M, the presentation is done by the primary operating resident.

If there were two residents involved in the case, the proper etiquette is for the senior resident to "fall on the sword" even if it was really the junior resident's complication.

That said we still do end up having to defend someone else's decision making a lot. E.g. if the overnight trauma team decides not to operate on someone when they first come in, then you as the day team have to take the patient to the OR as they decompensate. Then at M&M you have to try and explain why the patient's operation was delayed for 18 hours...

But overall our M&M is really benign, and I actually think it is tremendously educational because you get to hear attendings talk through their decision making thought process.

 

[DermViser]

At our M&M, the presentation is done by the primary operating resident.

If there were two residents involved in the case, the proper etiquette is for the senior resident to "fall on the sword" even if it was really the junior resident's complication.

That said we still do end up having to defend someone else's decision making a lot. E.g. if the overnight trauma team decides not to operate on someone when they first come in, then you as the day team have to take the patient to the OR as they decompensate. Then at M&M you have to try and explain why the patient's operation was delayed for 18 hours...

But overall our M&M is really benign, and I actually think it is tremendously educational because you get to hear attendings talk through their decision making thought process.

So then what do you do? Just blame the overnight team and throw them under the bus? I seriously don't know how residents tolerate a surgical residency. It's one thing to be blamed for **** that you did, but to ALSO be blamed for **** you didn't do?

 

[PL198]

can you guys explain M&M a little? I understand what it is, but don't see why colleagues would basically attack each other. I get the whole " bettering patient care" and all that, but it seems like the risks for these proceedings are much greater than the potential benefit.

 

[SouthernSurgeon]

So then what do you do? Just blame the overnight team and throw them under the bus? I seriously don't know how residents tolerate a surgical residency. It's one thing to be blamed for **** that you did, but to ALSO be blamed for **** you didn't do?

Well as I said, our M&M is pretty benign. So the idea of "blame" is pretty inaccurate. It's a patient management discussion forum. And admitting/evaluating our own mistakes is pretty core to being a surgeon. I actually really look forward to it because it is a great chance to hear multiple attendings' thoughts on how to manage a difficult situation.

But anyways...the magic codeword for when a decision was made that you weren't involved in is "It was discussed and decided..." or something of that nature.

For a long time it used to be taboo to make any mention of the fact that someone other than yourself made the decision (since obviously a surgery resident is in the hospital 24/7 taking Q1 call 😉 ). But that has faded away.

If presented with this kind of scenario, what I would usually say is something like this:

"The patient was seen and evaluated by the on-call team overnight and based on their clinical condition at that time, the decision was made to support them with antibiotics and continue to re-evaluate serially but that an operation was not indicated at that time. However, over the next several hours the patient continued to decline; we therefore elected to take them to the operating room for an exploratory laparotomy in the morning."

Everyone in the audience knows what you mean; but you were somewhat deferential to the overnight team since you weren't there at the time. The grey-haired attendings make some comments about the importance of timely operative intervention. Everyone moves on with life.

We have talked about trying to make some rules about the person who "made the decision" doing the presentation. But that's kind of nebulous and could lead to some silly arguments between residents. Much easier to stick with you cut it, you own it.

 

[SouthernSurgeon]

can you guys explain M&M a little? I understand what it is, but don't see why colleagues would basically attack each other. I get the whole " bettering patient care" and all that, but it seems like the risks for these proceedings are much greater than the potential benefit.

M&M varies a lot from program to program in the way it is structured.

It at most places isn't an "attacking" forum. It's a quality improvement forum.

Most surgeons consider it very central to the mentality of being a surgeon.

I don't understand what you mean by the risks of the proceedings. M&Ms are non-discoverable.

 

[DermViser]

can you guys explain M&M a little? I understand what it is, but don't see why colleagues would basically attack each other. I get the whole " bettering patient care" and all that, but it seems like the risks for these proceedings are much greater than the potential benefit.

http://www.kevinmd.com/blog/2013/05/morbidity-mortality-conference.html

 

[DermViser]

Most surgeons consider it very central to the mentality of being a surgeon.

And that would be?

 

[SouthernSurgeon]

And that would be?

Taking ownership of your patients and acknowledging the tremendous responsibility (and potential for major mistakes and even death) of cutting someone open. Discussing and admitting when you've f^*ked up is a part of that

A good read on the subject is "forgive and remember"

 

[VisionaryTics]

And that would be?

Forgive and remember.

 

[VisionaryTics]

Taking ownership of your patients and acknowledging the tremendous responsibility (and potential for major mistakes and even death) of cutting someone open. Discussing and admitting when you've f^*ked up is a part of that

A good read on the subject is "forgive and remember"

Beat me to it.

 

[DermViser]

Off the top of my head:

(1) Understand the complications you encounter and their origins

(2) Explain your management decisions, and acknowledge when those decisions result in adverse outcomes for patients

(3) Discuss errors and adverse outcomes publicly (so-to-speak), to educate other surgeons on steps they can take to prevent the problem from happening in the future

(4) Keep abreast of current research that is directly applicable to the clinical decisions you make

Our M&M has calmed down the last few years, but it still remains fairly contentious at times. Our surgeons are not shy about pointing out errors made by their colleagues, even if they "go through the resident" to make their points. When differences of opinion arise, it can get a little bit ugly. But again, this is our culture, and we do not attempt to sweep differences of opinion under the carpet. I've presented at more of M&Ms than I care to think about (the story above was paraphrased, but not made up). It is not fun, and it is very stressful, but I have always seen its value as a teaching tool and a form of penitence. (I once presented a case where I burned a patient with a cast saw; that was probably one of the worst moments of my residency, but Lord knows I deserved it).

In the not-too-distant past, we had a M&M that was directly caused by the primary team (Medicine) changing a particular medication in the middle of the night, completely against all known guidelines. Despite multiple invitations, not a single member of their department showed up to M&M to discuss it, nor were we permitted to attend theirs (if they even do it). Personally, I think our approach is better.

That I know of, Internal Medicine definitely does not do an M&M conference - but I believe that it's a cultural thing. Surgery has the mentality of "I'm responsible for everything that happens to this patient". IM does not have that much of a connection, so to speak, for a patient. I am not at all surprised that they did not attend a Surgery's M&M, and honestly, I don't blame them.

 

[DermViser]

Forgive and remember.

I didn't know it was an actual book or at least I would have thought it was a fiction novel. lol.

 

[SouthernSurgeon]

That I know of, Internal Medicine definitely does not do an M&M conference - but I believe that it's a cultural thing. Surgery has the mentality of "I'm responsible for everything that happens to this patient". IM does not have that much of a connection, so to speak, for a patient. I am not at all surprised that they did not attend a Surgery's M&M, and honestly, I don't blame them.

Both the medicine departments I've been exposed to (my med school and my residency) definitely have an M&M. It's just very different stylistically. The thing is medicine doesn't "do" things for their patients as often as we do.

I also presented a case where I operated on a patient after a complication from a bedside procedure done by a medicine resident. The patient died. I emailed the involved medicine resident and he came to the M&M. And looked like he wanted to jump off a roof while I was presenting the clinical course.

Another time we had a patient code on the table from an anesthetic complication. The anesthesia resident and attending both came to the conference and discussed the case and management with us.

We also do a quarterly combined M&M with internal medicine. It usually ends up being some BS about joint management protocols for SBOs or complicated gallstone disease.

 

[DermViser]

I also presented a case where I operated on a patient after a complication from a bedside procedure done by a medicine resident. The patient died. I emailed the involved medicine resident and he came to the M&M. And looked like he wanted to jump off a roof while I was presenting the clinical course.

Another time we had a patient code on the table from an anesthetic complication. The anesthesia resident and attending both came to the conference and discussed the case and management with us.

Did the surgeons ask questions of the medicine resident?

Was the anesthesia attending there bc he was actually at the case?

 

[SouthernSurgeon]

Did the surgeons ask questions of the medicine resident?

Was the anesthesia attending there bc he was actually at the case?

Nobody asked the medicine resident questions - I just let him know the case was being discussed since it had been "his" patient and I knew he had taken it hard. He came out of personal interest/investment.

The anesthesia staff and resident were explicitly asked by our dept to come and discuss the complication. The anesthesia attending wasn't there at the start of things (from what I understand, it wasn't my case) but was called to the room stat when things went downhill. The patient in that case did fine thankfully.

 

[cbrons]

I think we should have black boxes in malpractice attorneys offices

I think we should put malpractice scumbag attorneys in a black box


Sent from my iPhone using SDN Mobile

 

[DermViser]

Meh, they're the only ones who hold physicians accountable. Our licensing boards and professional organizations are just one big blue wall.

Wrong. Even medical licensing boards have lawyers on them.

 

[Raryn]

That I know of, Internal Medicine definitely does not do an M&M conference - but I believe that it's a cultural thing. Surgery has the mentality of "I'm responsible for everything that happens to this patient". IM does not have that much of a connection, so to speak, for a patient. I am not at all surprised that they did not attend a Surgery's M&M, and honestly, I don't blame them.

The IM program at my medical school and the IM program I'm currently training at most certainly do do M&M. It's a fairly benign proceeding and we don't do it as often as the surgeons (one time each during our third year), but it's a good opportunity to learn from a patient's clinical course and possible mistakes made during management.

By the way, it's an RRC requirement for internal medicine to either have M&M or QI conferences, so I doubt all that many programs just skip it entirely.

Residents must have the opportunity to participate in
morning report, grand rounds, journal club, and morbidity
and mortality (or quality improvement) conferences, all of
which must involve faculty.

 

[MrChance2]

This is a complex issue...one part of it I would be concerned about...is what is best for the patient on the operating table always the most lawsuit avoiding move? If these two things are not virtually identical I really don't think this is a good move.

 

[DermViser]

Do you have a state license? Read your newsletter of board actions. Licenses get pulled for serious felonies. Grossly negligent care gets a "letter of concern," and then only after a malpractice payout is made. It's not about where the lawyers are. It's about somebody saying, "What this doctor did was wrong." We do a piss-poor job of policing our own.

Yes, bc negligent care usually is subjective and depends on the outcome.

 

[DermViser]

Except when it's obviously not. Really, read the board actions in your state. Amazing how many say, "Physicians actions did not meet standard of care, letter of concern is issued."

They also send stupid sanctions like not doing CME, or whatever, where you pay a fine. Just money grabbing.

 

[colbgw02]

What is the appropriate response from a licensing board for a single episode of not meeting standard of care?

 

[DermViser]

What is the appropriate response from a licensing board for a single episode of not meeting standard of care?

Pulling one's license apparently. 🙄

 

[DermViser]

When it results in the death of a patient, presumably more than a strongly-worded letter.

Yes, and who defines the standard of care? The medical board? The specialty society?

 

[DermViser]

Look, I wasn't being sarcastic, you need to read the disciplinary actions from your state board. The letters clearly detail the clinical case and areas where standard of care was not met. They also specify that an independent, board certified physician reviewed the case and agreed with the finding. These are not "tweener" cases; these are pretty egregious. I can post a few if you want.

I wasn't being sarcastic either. It's a serious question. Who defines standard of care - the medical board or the specialty society?

 

[colbgw02]

When it results in the death of a patient, presumably more than a strongly-worded letter.

That's not an answer. A fine? Suspension? Revocation?

Besides, if the punishment is based on the results, then it's no longer just about the standard of care, but also about outcomes. How do you propose a licensing board handle a physician who is repeatedly negligent, but just so happens to not have any bad outcomes?

 

[DermViser]

The medical board that gives you your license, in appropriate consultation with the specialty society that grants your board certification.

So then does someone from your specialty on the board review your case?

 

[Tired]

That's not an answer. A fine? Suspension? Revocation?

Yes, yes, and/or yes.

Besides, if the punishment is based on the results, then it's no longer just about the standard of care, but also about outcomes. How do you propose a licensing board handle a physician who is repeatedly negligent, but just so happens to not have any bad outcomes?

Are you suggesting that the outcome should not influence the sanction? I would strongly disagree with that.

 

[Tired]

So then does someone from your specialty on the board review your case?

Yes, in the letters they specify that an independent, board certified physician from the specialty most relevant to the case reviewed the records and agreed with the finding that treatment/diagnosis/whatever did not meet standard of care.

 

[PL198]

Yes, yes, and/or yes.



Are you suggesting that the outcome should not influence the sanction? I would strongly disagree with that.

Why? The amount you were negligent doesn't change based on if the patient dies or not. I don't see why outcomes would affect it.

 

[Tired]

Why? The amount you were negligent doesn't change based on if the patient dies or not. I don't see why outcomes would affect it.

That makes zero sense to me. Proportionality would argue that the level of harm inflicted should dictate the level of punishment that results.

 

[DermViser]

That makes zero sense to me. Proportionality would argue that the level of harm inflicted should dictate the level of punishment that results.

So if someone dies it's 100% due to negligence on the part of the practitioner, regardless of age?

 

[Tired]

So if someone dies it's 100% due to negligence on the part of the practitioner, regardless of age?

No. Again, that's why boards do investigations, and utilize outside independent physician review before making a determination.

My objection is to the minimal "punishments" imposed in these cases, not the investigatory mechanisms.

 

[DermViser]

No. Again, that's why boards do investigations, and utilize outside independent physician review before making a determination.

My objection is to the minimal "punishments" imposed in these cases, not the investigatory mechanisms.

So what should they get on their first offense? Revoke their license?

 

[colbgw02]

Yes, yes, and/or yes.

I could get one board with a fine. A single offense doesn't warrant suspension or revocation of one's license for me. I've sat on the risk management committee of my hospital, in judgment of other physicians, and I can tell that mistakes are made mostly, sometimes even negligent mistakes, by good physicians. Single offenses deserve recognition of the mistake and re-training, and sure - let the board hit 'em in the wallet if they're so inclined. But suspension or revocation is drastic and should be reserved for a when pattern of negligence is evident.

Are you suggesting that the outcome should not influence the sanction? I would strongly disagree with that.

It depends on who is doing the sanctioning, but overall, no, I'm not suggesting that.

More importantly, I'd like to point out explicitly that breach of standard of care and outcome are distinct, albeit related, entities. Negligence (the legal term for breath of standard of care) needs to be identified, corrected, and sometimes punished irrespective of whether or not it led to a bad outcome. Conversely, an isolated failure to meet standard of care by an otherwise competent physicians doesn't necessarily require punishment just because the outcome was bad - at least not by the licensing board. The licensing board ought to have more discretion and leeway than just say, "welp, the patient died and you messed up this one time, so hand over your license". In those instances, the patient has an alternative remedy - the courts.

I'd also like to point out that licensing boards aren't the sum total of our self-policing. We also have specialty boards and hospital privileging, the latter of which typically requires some sort of peer review. Add to that malpractice torts, and we have an additional - albeit extrinsic - layer. So, it's not exactly telling the whole story to just point to a licensing boards actions and point out how weak they typically are. They're not the only cog in the machine. So for all those strongly worded letters, how many of those physicians lost their job? Had their privileges curbed? Now have to be supervised for certain procedures? Were required to undergo additional or re-training? Had to pay out a big malpractice settlement?

And while there's some redundancy in the different tiers, I see the licensing board primary functions as 1) provide the public a direct method of accountability that falls short of a tort and 2) to lend legal teeth to sanctions that hospitals/insurance companies cannot provide. But sometimes those other checks on the system work, which outwardly make the licensing board come off looking soft.