The "Call for Help": Intraoperative Consultation and the Surgeon-Patient Relationship
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
ETHICS
The “Call for Help”: Intraoperative Consultation
and the Surgeon-Patient Relationship
Alexander Langerman, MD, FACS, Peter Angelos, MD, FACS, Mark Siegler, MD
During surgical cases, technical errors or unexpected find- to whatever course of action was medically indicated.
ings can result in a legitimate need for additional surgical The consulting surgeon recommends nerve reanastamosis
expertise and may motivate the primary surgeon to “call and vocal cord injection, and the primary surgeon agrees.
for help,” that is, to seek assistance either from colleagues When the procedure is complete and the patient is awake,
or from additional types of surgical specialists. The intra- the primary surgeon explains the injury and introduces
operative consultation, initiated by a surgeon’s “call for the consulting surgeon to the patient so the consulting
help,” inserts an additional consulting surgeon into a surgeon can discuss further care specific to her vocal cords.
doctor-patient relationship that had been established This scenario describing the “call for help” and result-
before anesthesia between the patient and primary sur- ing intraoperative consultation raises 3 critical questions.
geon and places new ethical, legal, and professional duties First, what are the duties of the primary surgeon to the
on the participants. Although we believe these intraoper- patient and to the consultant? Second, what obligations
ative consultations occur regularly at most surgical pro- does the consulting surgeon accept when agreeing to the
grams, we have few data on how frequently this occurs, consultation? Third, can the consulting surgeon over-
who calls whom, what surgical issues prompt such a ride the primary surgeon(s) if there is disagreement on
call, or the outcomes of such consultations. Further, this the next steps of intraoperative management?
topic is not addressed by the major codes of ethics and
professional conduct.1,2 The purpose of this article is to
open a discussion of the topic of “call for help,” and to Definition of intraoperative consultation
propose and outline the duties of the primary and consul- “Call for help” consultations occur after the patient is
tant surgeons in this setting. anesthetized and can no longer participate in the decision
Consider the following scenario: A surgeon takes a to consult. During the surgery, the patient is not aware
48-year-old woman to the operating room to remove a that such a consultation has happened. The reason for
large goiter. During a difficult dissection, the recurrent such consultations are varied: there may be an unexpected
laryngeal nerve is injured. The surgeon calls a colleague anatomic or disease finding; an error or complication; the
with expertise in laryngology for an intraoperative consul- need for an additional technical procedure that may or
tation, and the colleague scrubs in to evaluate the nerve may not have been discussed with the patient preopera-
injury. The surgeons discuss the events that led to the tively; or an unanticipated challenging case that requires
injury and possible courses of action. The primary sur- additional surgical expertise. The consultant surgeon
geon had informed the patient of the unlikely possibility may sometimes observe the situation and provide only
of nerve injury and believes that the patient would agree knowledge or guidance. Often, the consulting surgeon
will scrub in to participate in the operation. The primary
surgeon may continue operating, or he or she may assume
Disclosure Information: Nothing to disclose. the role of co-surgeon alongside the consulting surgeon,
Support: This work was supported by the University of Chicago or the primary surgeon may turn over the case entirely
Bucksbaum Institute for Clinical Excellence.
to the consulting surgeon if the type of procedure needed
Abstract presented at the American College of Surgeons 100th Annual
Clinical Congress, Surgical Forum, San Francisco, CA, October 2014. is far outside the original surgeon’s area of expertise. In
the latter scenario, the primary surgeon becomes an
Received April 4, 2014; Revised May 26, 2014; Accepted July 7, 2014.
From the Department of Surgery, Sections of OtolaryngologyeHead and observer or “bystander.”
Neck Surgery (Langerman) and Endocrine Surgery (Angelos), and the There are other scenarios in which multiple surgeons
Department of Medicine (Siegler); Bucksbaum Institute for Clinical Excel- and/or surgeons not known to the patient participate
lence (Langerman, Angelos, Siegler); and MacLean Center for Clinical
Medical Ethics (Langerman, Angelos, Siegler), University of Chicago in the patient’s care in the operating room. Those other
Medicine and Biological Sciences, Chicago, IL. situations include “team surgery,” surgical training of res-
Correspondence address: Alexander Langerman, MD, FACS, Section of idents, and “ghost surgery.” We distinguish the “call-for-
OtolaryngologyeHead and Neck Surgery, Department of Surgery, 5841
S Maryland Ave, MC 1035, Chicago, IL 60637. email: alangerm@ help” from these other 3 scenarios. In the “call-for-help”
surgery.bsd.uchicago.edu cases, in which intraoperative consultation is necessary
ª 2014 by the American College of Surgeons http://dx.doi.org/10.1016/j.jamcollsurg.2014.07.931
Published by Elsevier Inc. 1181 ISSN 1072-7515/141182 Langerman et al Intraoperative Consultation J Am Coll Surg
and warranted, the key differences are that the primary this scenario, what is important is that the patient is being
surgeon did not anticipate needing to call on a consulting operated on by a surgeon whom the patient did not con-
colleague and the colleague did not have a pre-existing sent to, but whose likely involvement in the case was
therapeutic relationship with the patient. We briefly known before anesthesia. The “ghost surgeon” is acting
describe how the call for help differs from these other 3 as a substitute for, rather than supporting or helping,
scenarios. the surgeon who the patient believed would be perform-
An example of “team surgery” would be a case ing the operation. Further, the original surgeon is not at
involving a thoracic surgeon, general surgeon, and plastic all involved in the surgical care of the patient. Therefore,
surgeon operating together on a challenging transdiaph- ghost surgery requires intentional, premeditated subter-
ragmatic malignancy with chest wall involvement. In fuge as to the identity of the surgeon who conducts the
such anticipated multipart, multispecialist surgery, the operation. This differs from intraoperative consultation,
identity and roles of the various team members were dis- which is a response to an unanticipated need for addi-
cussed with the patient as part of the operative decision- tional expertise and help, as occurred in the opening
making and informed consent process, even if the precise scenario.
tasks of each participant would depend on the intraoper-
ative findings. Important to the ethical conversations Ethics of “calling for help”
around multisurgeon procedures, each surgeon would
Even though the consulting surgeon has not met the pa-
have obtained consent for his or her portion of the proce-
tient before surgery, by participating in a formal intrao-
dure. In this instance, the patient has a relationship with
perative consultation, a new surgeon-patient relationship
each surgeon before the operation, highlighting the signif-
is initiated. The consulting surgeon may become a critical
icant difference from intraoperative consultation, in
or even dominant practitioner in the operative and post-
which 1 or more surgeons are newly involved in the
operative management of the patient, which has further
care of the patient after the patient is anesthetized and
implications for his or her insertion into the doctor-
without previous consent. Even if the consulting surgeon
patient relationship. Surgeons take responsibility for the
operates with the original surgeon(s) as a “team,” as
patient when they are invited to the surgical encounter
occurred after the consultation in the opening scenario,
and accept the consultation.
the consulting surgeon is a “stranger” to the patient and
This heightened surgical responsibility, combined with
this is the major difference from team surgery.
the patient’s inability to actively consent, suggests that the
In surgical training, trainees act under the direction of
ethical framework of “calling for help” far more closely re-
the primary surgeon, and do not bring independent
sembles “emergency surgery” than it does “ghost surgery,”
expertise. Therefore, including trainees in an operation
and the ethical principles that apply to emergency surgery
does not qualify as an intraoperative consultation. The
should apply to intraoperative consultation. The princi-
primary surgeon remains the responsible and primary
ples of beneficence (working in the best interests of the pa-
physician in these cases. By contrast, in intraoperative
tient) and nonmaleficence (doing no harm) are
consultation, the consulting surgeon has a critical role
fundamental duties and social expectations. In both emer-
in surgical decision-making. Consulting surgeons are
gency surgery and intraoperative consultation, partici-
not supervised by the primary surgeon but rather act as
pating surgeons must analyze the case to determine how
independent practitioners working in the best interests
these goals can be achieved. In certain cases, it may be
of the patient.
that the most prudent course of action in an intraopera-
“Calling for help” is also profoundly different from
tive consultation is to end the operation or at least not
“ghost surgery,”3 in which a patient is misled as to which
perform additional procedures.
surgeon will actually be operatingda clear ethical and
The practice of seeking help from colleagues with an
professional violation.1-3 An example of ghost surgery
alternate skill set may even have its roots in the Hippo-
might be an established, experienced vascular surgeon
cratic Oath. Leon Kass4 interprets the clause, “I will not
who tells a patient he will perform a carotid endarterec-
use the knife, not even on sufferers from stone, but will
tomy, but at the time of surgery the patient is actually
withdraw in favor of such men as are engaged in this
operated on by a junior colleague, a new attending physi-
work,” as follows:
cian fresh out of fellowship who has yet to establish his or
her own vascular practice. Although it is unclear when it The physician is.promising not to try himself
was decided, sometime between meeting the patient and to do what he cannot do, even in the face of
taking him to the operating room, the primary surgeon a most severe suffering that might tempt his
has elected to pass this case along to his colleague. In intervention. He willingly turns those in needVol. 219, No. 6, December 2014 Langerman et al Intraoperative Consultation 1183
over to someone competent in the necessary This mandate holds whether the additional procedures
extramedical skill; the Oath thereby also teaches were performed by the primary surgeon or by an intrao-
that we do not simply abandon those we cannot perative consultant. In the latter, the primary surgeon
help ourselves.. Know your limits and let not must disclose that the complication was managed by a
your wishes to help exceed your competence to consulting surgeon. To not do so would be dishonest;
do so.4 nondisclosure is not acceptable. After any intraoperative
consultation, it is appropriate and desirable for the pri-
How to call a good intraoperative consultationdethical
mary surgeon to introduce the consulting surgeon to
duties of the primary surgeon
the patient and family, thereby helping to solidify the
new therapeutic relationship that has formed as a result
In calling the consultation, primary surgeons must abide
of the consultation.
by certain duties to both their patients and colleagues.
The primary surgeon also has duties to the colleague or
First and foremost, the duty to the patient on the oper-
colleagues “called for help.” He or she first must be
ating table is the highest responsibility in intraoperative
completely forthcoming to the consulting surgeon about
consultation. As part of the surgical pact with their
medical history and operative findings before the consul-
patients, surgeons promise to carry out the procedure to
tation as well as the nature of the unexpected complica-
the best of their ability while the patient has submitted
tion or, if one occurred, the intraoperative error. This
to his or her care. In the setting of an unanticipated
allows the consultant to participate from a well-
finding or complication that requires additional expertise,
informed position and ensures the best care for the
the surgeon’s selection of the best colleague to assist in
patient. Although such candor can be difficult for the pri-
care of the patient constitutes appropriate fulfillment of
mary surgeon in the middle of a complex operation that is
this promise to the patient.
going badly, this delivery of accurate information is a
On the contrary, failure to “call for help” may fall short
necessary ethical step in the “call for help.”
of fulfilling the surgeon’s duty to the patient. Adverse
The intraoperative setting is the most common place
events may require prompt treatment, and there is legal
for surgical errors to occur,7 and surgeons have a “fierce
precedent supporting urgent action in the setting of
ethic of responsibility” regarding their role in causing
adverse events.5 A surgeon should not be reluctant to
such errors.8 Yet the primary surgeon must temper the
call on a colleague for help. This acknowledges the col-
desire to “right the wrong” with a prudent approach to
league’s expertise and serves as an opportunity to help
the clinical issue. A large part of the purpose of intraoper-
the patient and to learn how another physician thinks
ative consultation is to obtain independent and objective
through a clinical issue (even if no formal surgical action
expertise from a colleague. With rare exception, the pri-
is taken as a result of the consultation).
mary surgeon retains decision-making authority as the
Once the operation is complete and the patient is
physician to whom the patient consented. Already,
awake and alert, the primary surgeon has a further
many consent forms include a clause permitting the sur-
duty to disclose to the patient the event or events that
geon to perform additional procedures “as necessary,”
led to the consultation. If it is an unexpected finding,
suggesting that in unanticipated circumstances, the pri-
then the information is critical for the patient to under-
mary surgeon is entrusted to determine the necessity of
stand. If the reason for a consultation is a complication,
unplanned surgical interventions. However, the primary
the complication constitutes an “adverse event” that
surgeon has a duty to seriously consider the opinion of
theoretically could have been prevented, and therefore
the intraoperative consultant, even when the 2 surgeons
must be “disclosed.”6 There is precedent for ethical man-
disagree about the best approach. In emergency situations
dates to also disclose any unanticipated additional
far outside the expertise of the primary surgeon, such as a
procedures:
previously unknown abdominal aortic aneurysm that is
Disclosure is called for whenever the adverse discovered to rupture during a routine cholecystectomy,
event involves providing a treatment or procedure it would be appropriate for the consulting surgeon with
without the patient’s consent. Patients have a the relevant expertise to assume decisional authority.
fundamental right to be informed about what is
done to them and why. For example, if a patient How to respond to an intraoperative consultationd
undergoes an additional unanticipated procedure ethical duties of the consultant
while under anesthesia, disclosure is required The ethical duties of the surgical consultant to both the
regardless of whether the patient experiences patient and the primary surgeon in a “call for help”
any ill effects.6 have not previously been delineated, but can be derived1184 Langerman et al Intraoperative Consultation J Am Coll Surg
Table 1. Ten Commandments for Effective Consultation9 consulting surgeon is inserted into the middle of a tense
I. Determine the question. case. The consultant should first determine the reason
II. Establish urgency. for the call by taking time to assess the situation and to
III. Look for yourself. discuss with the primary surgeon the exact nature of the
IV. Be as brief as appropriate.
V. Be specific. “call for help.” This necessarily involves determining if
VI. Provide contingency plans. the consultation requires emergency action and deter-
VII. Honor thy turf. mining if the consultant has the necessary expertise to
VIII. Teach.with tact. adequately respond to the consultation. Consultants
IX. Talk is cheap. and effective. should also look for themselves by scrubbing in and aug-
X. Follow up.
menting the careful discussion about the exact nature of
events before the consultation, with an independent re-
from the ethics of consultation medicine. When an intra- view of the patient’s anatomy and any available imaging
operative consultation occurs, much like any consultation, or data that may inform the decision-making process.
the consultant’s relationship to the patient “.is superim- An intraoperative shift such as this requires that all
posed on an existing and continuing physician-patient parties reconsider the original surgical plan. Once an
relationship.”9 This superimposition is much more acute amended surgical plan has been developed in conjunction
in the operating room setting because of the inability of with the primary surgeon, the consultant should use his or
the surgical consultant to form an independent relation- her expertise to provide contingency plans. The consul-
ship with the patient before completion of the surgical tant is already entering a situation in which unanticipated
intervention. The consultant has not previously met the issues have occurred and should be especially attuned to
patient and relies on the primary surgeon to represent the possibility of further unexpected events.
the patient’s wishes and values. In this situation, the The intraoperative consultation may also be an oppor-
consultant can fulfill his or her ethical obligations by tunity to prevent future unanticipated problems for other
following the spirit of consultations in primary care rela- patients cared for by the same primary surgeon. If the pre-
tionships, and by “.serving as exclusive agent neither to sent problem was avoidable, the consultant may teach,
the patient nor the primary physician, but rather by with tact, recognizing that we are all fallible and that sce-
serving the original physician-patient relationship from narios that lead to errors are often clearer in hindsight.
which the request for consultation originated.”9 However, despite any misadventure, the consultant
The consultant also has duties to the primary surgeon should also continue to respect the role of the primary
who initiated the consultation. Being called for help is a surgeon as the initiator of the original surgeon-patient
sign of respect and an invitation to serve both the patient relationship and maintain communication with the pri-
and the primary surgeon in a special way. Even if this mary surgeon until the consultation and postoperative
intraoperative consultation is directed nonspecifically to management have concluded. Finally, consultants are
an on-call specialist, it acknowledges the specialist’s not itinerant surgeons1 and therefore have a duty once
unique skill set and knowledge base. As a result of the pri- they have participated in the surgical care of the patient
mary surgeon’s duty to be forthcoming and transparent, to follow up, to make sure that any special postoperative
the consultant will also potentially witness a raw account instructions are followed, tests are ordered, and the pa-
of a failure or learn of a colleague’s shortcoming. When tient’s questions related to their portion of the surgical
responding to this “call for help,” intraoperative consul- procedure are answered.
tants should therefore comport themselves professionally A special consideration in responding to intraoperative
and with collegial humility while following the funda- consultations due to errors is liability control. Consulting
mentals of any good consultation. We describe the com- surgeons may feel their duties to the primary surgeon or
ponents of a good intraoperative consultation in the hospital system conflict with their duties to the patient
following paragraphs based on Goldman’s “Ten com- and society. There is no room for “covering up” errors in
mandments for effective consultation” (Table 1).10 the ethical behavior of a physician, and if egregious or
As mentioned earlier in this article, it is an honor for repeated errors occur, there may be some responsibility for
consulting physicians to be called. They have been soli- the consultant to report this to the hospital chief of staff
cited for their clear thinking and expertise. It is important or state medical board. Consulting surgeons must remember
for consulting surgeons to maintain this clear thinking that they were not present at the time of error and only
despite any urgency in the scenario or in their colleague’s know its aftermath. When contemplating what to document
tone. Remaining thoughtful and contemplative is key in in the medical record and what to discuss with the patient
all operative scenarios, but even more so when the and family, consulting surgeons should limit themselves toVol. 219, No. 6, December 2014 Langerman et al Intraoperative Consultation 1185 truthfully reporting the facts as they know them first hand Returning to the scenario at the start of this article, the since initiation of the consultation, and not conjecture about 2 surgeons conducted themselves in a manner appropriate the events that led to the consultation or the skill or inten- to the situation. The primary surgeon fulfilled his duties tions of the primary surgeon; such questions would be to his patient to act in her best interest by calling the appropriate to refer back to the primary surgeon. consultation and to his colleague by being forthcoming Despite establishment of a new surgeon-patient relation- about the adverse event and later, by facilitating his intro- ship as part of the consultation, the pre-existing primary duction to the patient. The consulting surgeon sought surgeon-patient relationship should take precedence in assent from the primary surgeon regarding the course of the event of a disagreement between the primary and action and then acted on the primary surgeon’s behalf consulting surgeon. It seems counterintuitive for a surgeon by intervening on the patient. After the procedure was to call for help from a colleague and then disregard the col- complete, the consultant established a relationship with league’s advice. However, in the absence of emergency sur- the patient and accepted shared management of her post- gical issues (eg, uncontrolled major vessel injury that the operative care. primary surgeon is not qualified to manage), the primary Although the 2 surgeons appropriately fulfilled their surgeon is the one to whom the patient has entrusted his duties, the decision to proceed with interventions on the or her well being, and the primary surgeon therefore retains patient’s behalf without explicit consent raises another final decision-making responsibility until the patient can be important question. What are the limits of substitute awakened and decide for him- or herself. decision-making for nonemergency situations on the As a conclusion to this discussion, we wish to describe a part of primary and consulting surgeons? The surgeons real-world example provided by a recent report of a surgi- might and perhaps should have discussed any potential cal specialty service specifically dedicated to intraoperative additional interventions with the patient’s family mem- consultation for bile duct injuries.11 This report demon- bers before proceeding. Furthermore, patients with strates adherence to the principles of good intraoperative advance directives may have placed limitations on the consultation outlined above and maintains the distinction additional procedures that might be performed should between intraoperative consultation and “ghost surgery.” unexpected events occur. The decision-making process Physicians from the Liver Unit from the Queen Elizabeth when considering additional interventions during surgery Hospital in Birmingham, UK reported their experience will be addressed in a future publication. with 22 on-table repairs of bile duct injuries. Theirs is a “travelling” service so the bulk of requests for intraopera- Conclusions and recommendations tive consultation came from surgeons at other hospitals. This article has described a common occurrence in sur- Their protocol for consultation is as follows11: First, an gery: the primary surgeon’s “call for help” to a surgical unanticipated bile duct injury occurs, followed by the pri- colleague. These intraoperative consultations demonstrate mary surgeon contacting the liver service, initiating a call integrity on the part of a primary surgeon who acts in his for help. Based on evidence that on-table repair is superior patient’s best interest and should be seen as an honor to to delayed repair of bile duct injuries, consent is presumed the surgeon who is called. These events also contain great based on best interests, and the patient remains under learning opportunities for both participants and should be anesthesia awaiting arrival of the consultant. The consul- welcomed as part of exemplary patient care. We believe ting specialist then arrives and either performs or reviews a that by describing a structure for the intraoperative postinjury intraoperative cholangiogram, thereby con- consultation, such “calls for help” will be seen for what ducting an independent review of the clinical data and they are, as a way to help the patient and as a way to participating in the decision-making regarding the care work constructively with colleagues. To this end, we of the patient. The consulting specialist next assumes re- have outlined the circumstances in which such a request sponsibility for part of the surgical care of the patient may arise and have contrasted this “call for help” with by performing an on-table repair and additional proce- “team surgery,” surgical training of residents, and “ghost dures as necessary. Finally, the consulting specialist re- surgery.” We have described in detail the duty of the pri- mains a part of the postoperative care of the patient, mary surgeon to the patient and to the consultant who an- either accepting complete management in complicated swers the “call for help.” We have also outlined the duty patients by transferring them back to the Queen Elizabeth of the consulting surgeon to the patient and to the pri- Hospital, or by maintaining shared management and mary surgeon and have provided examples of good following up on the patients in clinic after discharge. In consultations. both cases, the patient is made aware of the injury and Our central conclusions are as follows: first, based on role of the consulting surgeon in his or her care. the principle of beneficence, it is always appropriate for
1186 Langerman et al Intraoperative Consultation J Am Coll Surg
a surgeon to seek help from a colleague when additional REFERENCES
surgical expertise is needed; second, once the consulting 1. American College of Surgeons Statement on Principles. Avail-
surgeon accepts a consultation and participates in a pa- able at: http://www.facs.org/fellows_info/statements/stonprin.
tient’s care, a new surgeon-patient relationship is formed, html. Accessed on April 2, 2014.
2. Code of Medical Ethics of the American Medical Association.
with its attendant obligations; third, because the primary 2012-2013 Edition. Chicago, IL: American Medical Associa-
surgeon is the physician to whom the patient consented, tion Press; 2012.
the primary surgeon usually retains ultimate decisional 3. Holmes MK. Ghost surgery. Bull N Y Acad Med 1980;56:
authority regarding further interventions. The exception 412e419.
to this rule is when a new, unexpected, emergency surgical 4. Kass L. Toward a More Natural Science. Chapter 9: Is there a
medical ethic? New York: Simon and Schuster; 2008:236.
issue involves special expertise for which the primary sur- 5. Simcuski v Saeli. 44 N.Y.2d 442 (1978).
geon is not qualified to participate. We emphasize that it 6. Cantor MD, Barach P, Derse A, et al. Disclosing adverse
is imperative the patient be informed postoperatively that events to patients. Jt Comm J Qual Patient Saf 2005;31:5.
an intraoperative consultation occurred and about any ac- 7. Gawande AA, Zinner MJ, Studdert DM, Brennan TA.
tions taken after the procedure. Analysis of errors reported by surgeons at three teaching
institutions. Surgery 2003;133:614e621.
8. Bates DW, Gawande AA. Error in medicine: what have we
Author Contributions learned? Ann Int Med 2000;132:763e767.
Study conception and design: Langerman, Angelos, 9. Siegler M. Medical consultations in the context of the
Siegler physician-patent relationship. In: Agich G, ed. Responsibility
Acquisition of data: Langerman in Healthcare. Holland: Springer; 1982:141e162.
Analysis and interpretation of data: Langerman, Angelos, 10. Goldman L, Lee T, Rudd P. Ten commandments for effective
consultations. Arch Intern Med 1983;143:1753e1755.
Siegler 11. Silva MA, Coldham C, Mayer AD, et al. Specialist outreach for
Drafting of manuscript: Langerman on-table repair of iatrogenic bile duct injuriesea new kind of
Critical revision: Angelos, Siegler ‘travelling surgeon’. Ann R Coll Surg Engl 2008;90:243e246.You can also read
