Bernard M. Jaffe, Professor of Surgery, Department of Surgery, Tulane University School of Medicine, New Orleans, LA
Bernard M. Jaffe, MD
Professor of Surgery
Department of Surgery
School of Medicine
New Orleans, LA
Journal of the American College of Surgeons (JACS)
The challenges of medical practice certainly have changed over the past few years. When I started my career, hospitals were concerned primarily with malignancy, infection, serious illness, and other medical issues that interfered with patients' recovery and wellbeing. I will bet that was true for many of you. Times have really changed, however, and a series of new enemies have emerged. They include hostile plaintiff attorneys, less-than-helpful insurance company authorization nurs?es, antagonistic hospital administrators, and pedantic resident work-hour timekeepers. A 2006 article in the suggests that social scientists may become the next complication in surgeons' lives. In "Impact and implications of disruptive behavior in the perioperative area,"* authors Rosenstein and O'Daniel redefine this topic, extrapolate its potential consequences, and recommend a complex series of protocols to deal with it. The potential impact was so disturbing, I thought it warranted discussion in an editorial.
The data in the article were derived from a 25-question survey completed by the gamut of operating room staff, including attending surgeons, trainees, nurses, anesthesiologists, and technicians, all from a single, large, unnamed medical center. While I recognize that the validity of such methods has gained acceptance, I still have trouble acknowledging information derived this way as data. My specific concerns are that the responses are subjective and undocumented, which leaves considerable leeway for opinion and bias. This was evident in the paper. For example, the authors lumped , , and as positive responses. Nor were respondents required to give specific details or documentation of their observations. Nonetheless, the paper's conclusions were centered on this soft data.
The thrust of the paper is that is common in perioperative areas and interferes with clinical results. As you may imagine, attending surgeons were described as the most frequent offenders, with "witnessed"—but not documented—episodes occurring weekly, 22% of the time. In fairness, nurses and anesthesiologists also were included, but with lower incidences.
It is critical to delineate the reported components of . As examples, the authors mention (from most frequently occurring to least) "yelling, disrespectful interaction, abusive language, berating in front of peers, condescension, insults, abusive anger," etc. Please note that there are no criteria for any of these accusations, and what is considered abusive, condescending, and disrespectful undoubtedly varies among individuals. Thus, what is disruptive is in the eye of the beholder, and perception becomes reality.
It is easy for outsiders to insist that surgeons always control their emotions regardless of circumstance, but that is not realistic. The stress and frustrations can be overpowering when lives are at stake. Surgeons and patients can feel victimized by the errors or inactivity of the nursing staff (among the most frequent complainants) and the administration's failure to provide adequate resources (the behavior monitors). Is it to demand excellence of yourself and the patient care support system when appropriate requests through the obligatory channels fail? The authors of the paper opine that it is, but I will leave that to your discretion.
The Wall Street Journal
The argument that , as defined by the authors, adversely affects patient care is unconvincing. The authors use three components to support their contention. The first is that many respondents reported instances in which they were convinced that clinical care was impacted; these examples, however, were unsubstantiated and nonspecific. To consider such anecdotal reports as data weakens the argument. Second, the authors cite one article as evidence, and this article was published in that venerable clinical periodical, . Finally, employing a two-step analysis, the authors claim that interferes with interpersonal communication and that lack of communication is the leading cause of medical errors. This latter point obviously has merit, but the authors fail to recognize that behaviors they consider disruptive may well have been precipitated by poor communication and that the damage had occurred already. In addition, some of the most talented and effective surgeons with whom I have ever worked were poor communicators, either because of their accents or personalities. Let me assure you that their patients received impeccable care.
The most frightening portion of the paper is its list of "Recommended Protocols" to deal with . These include implementing policies and procedures that define acceptable behavior and delineating punitive administrative mechanisms for those who fail to meet the standard. I know of one outstanding surgeon whose privileges already were suspended for an incident so trivial that it was barely noticeable. It provided the hospital administrators with an opportunity to make an example of him for disagreeing (appropriately) with a policy decision they had made. Fortunately, the matter was reversed, but it took months and a fortune in legal fees.
To assure the success of this policing program, the authors state that "the organization must encourage its employees to report [emphasis added]...and needs to address issues related to confidentiality [and] fear of retaliation?"* Is this Big Brother speaking or a physician communicating with an administrative colleague? The authors argue for the protection of the reporters' rights with seemingly no concern for the rights of those being reported. I was appalled by one critical omission: investigation into the accuracy and relevance of the accusation. What has happened to innocent until proven guilty?
It is easy to imagine one potential long-term consequence of this policy. A nurse, technician, resident, or administrator, of?fended by a surgeon who works hard to provide quality care, takes advantage of the anonymous reporting mechanism and jeopardizes the clinician's career. A battle ensues, with the lawyers as the only victors.
I realize that in writing this editorial, I run the risk of being accused of either being disruptive or tolerating . Let me make it clear, because this could not be further from the truth. As a professional, I neither champion nor condone yelling in the operating room, disciplining juniors publicly, using inappropriate language, throwing temper tantrums, hurling insults, or any other action defined as in the paper. On the other hand, we all need to remember that hospitals are for patients, and there are times when surgeons may offend others inadvertently when advocating for optimal patient care. As long as the response is not unprovoked, rudeness does not become their method of operation, and they do not take repeated advantage, such surgeons should be supported, not criticized. Few historical giants in American surgery were shrinking violets, and all had their share of enemies. I hate to think what their practices would be like today if they were subjected to these proposed guidelines.
J Am Coll Surg.
*Rosenstein AH, O'Daniel M. Impact and implications of disruptive behavior in the perioperative arena. 2006; 203(1):96-105.