Friday, April 27, 2007

I've Seen Ghosts

As a med student, I did a few circumcisions, in the free-hand style. Later, as an intern, on one occasion I had just finished a very well supervised hernia repair, along with which the adult patient had requested a circ. My attending couldn't have cared less about doing, helping with, or observing that part of the deal. "You can handle it, can't you?" Spoken through his back, and then through the door as he exited the OR, it wasn't really a question. Adult circumcision isn't the same, I discovered, as doing it on an infant. To my horror, I left the man's shaft looking on one side like a pink banana after some monkey had partly stripped back the first section of the peel. The feeling remained in the frontmost of my mind for the remainder of my training. When I helped, I stuck around.

A reader asks what I think about "ghost surgery." Complicated answer: depending on terminology, I'm ok with it. Simple answer: it's complicated.

First, the semantics. For one thing, I think the reader and I are not talking about the same thing: to me, "ghost surgery" implies deception and dishonesty. It means borderline, if not actual, criminal behavior. "Ghost surgery," as I've understood it, is the happily rare practice of a (usually less-than-competent) surgeon lining up patients for operations, telling them he'd be doing it, then having it done by others while he was somewhere else, collecting the money. (In a related arena is "sham surgery," wherein a patient is faked into thinking something was done when it actually wasn't. There was a time when such things were done hemi-demi-semi honestly, as a way of testing for the placebo effect of an operation. On the other hand, when I was in med school, there was a later-infamous "surgeon" who did so-called brain surgery at a nearby osteopathic hospital. Until they'd show up at our institution where xrays showed no skull entry under their scalp scars, they believed he'd done something in their brains. They'd paid for it; monetarily, and otherwise.)

As I infer it, by "ghost surgery" my reader meant something different: being operated on at teaching hospitals by surgeons-in-training; and there's an implication of failure fully to inform people of the extent to which such surgery will be done by the trainee instead of their presumptive surgeon. Whatever the proper term for such a thing is (the operative part, not the informing part), it's that of which I'm in favor. And which is complicated. Without it, I'd be nowhere.

Part of the question we can dispense with easily. There's no excuse for not letting a patient know a trainee will be doing all or parts of the surgery. Which is not to say it's always been clearly laid out, nor that in every instance in every location under all circumstances it now is. And whereas a patient ought to have the right to opt out, to demand that their surgeon will do every bit of their operation, I think a surgeon ought be free to tell his or her patients that in coming to a teaching institution, they must expect and accept that such supervised operating will take place and that if they want the knowledge of that surgeon and the support of that institution, they must agree to it or go elsewhere. In the best of worlds, that would be worked out well in advance of the patient showing up for surgery.

Surgeons are made, not born. It's a long process. When I was applying for surgical training, one of the places I checked out -- which is now very highly regarded -- was on probation and in danger of losing accreditation from the American Board of Surgery, or College of Surgeons, or something, for failing properly to supervise residents doing surgery. (I figured if I couldn't get in anywhere else, surely I could there.) The place I chose (and which chose me) was quite the opposite -- and its approach is entirely the norm now: baby steps. Interns are allowed little bits of operating at first: close the skin, place a clamp here or there. When it's apparent they can handle a knife and fork without spilling food in their laps, they may get to do an "intern's case." A hernia repair, for example. The attendings are there, describing every step and, in fact, holding tissues in such a way that there's no possible misstep. Truth is, I "did" many hernias without a clue as to what was really going on, so carefully were the moves orchestrated. Which brings us to the complicated part. At some point, you have to have your umbilical cord cut.

My friend just soloed for the first time after a few months of flight training. Had he crashed, most likely he'd have only taken out himself. In surgical training, there does come a time when you operate without an attending in the room. He or she is close at hand; but there you are. It doesn't happen, however, until you've shown yourself to be ready, over a period of several years, and with many an attending signing off. Still, as opposed to flying for the first time, the danger is not to oneself.

I love to teach. In training, by the time I was Chief Resident I was the "supervisor" on many an operation done by a junior. I was, if I may say so, good at it. There were times when I called in an attending, but not often. And the cases, by definition, were not the biggest of the big; if they were, I'd be doing them myself, with an attending there much if not all of the time. (Most Chiefs relished doing as many big cases alone as they could. I figured it'd be soon enough that I was on my own and I wanted to pick the brains across the table for as long as possible.) In my private practice, the teaching I did was at the tail end, when I mentored newly-hired surgeons. In those cases it was their patients and I was providing pointers, sharing a few tricks. Letting them know how a four-hour total colectomy with J-pouch could be done in two. Had it been my patient, I'm not sure I could have let them actually do parts, given my need for speed. (Controlled speed, may I add!) More paradox.

Inevitably, there are classes of care. Time was, there were "charity patients" and "charity hospitals." One can argue the ethics, but it was understood that patients there were "teaching cases." Nowadays, there's still a difference between "private patients" -- meaning those with insurance and who've come specifically to see a particular surgeon and who are admitted to that person for surgery -- and "clinic" patients, meaning those that came to the hospital clinic and were seen there by residents, under the supervision of an attending. Mostly, those patients are uninsured or are on some form of assistance. At a teaching institution, whether private patients have residents doing parts of their operations depends on the attending. Some let residents assist only, never doing any part; others let trainees do parts, or even all of an operation. No private patient would have any surgery done without the attending there and breathing heavily down the neck of the resident. Clinic patients well might. It needs to be made clear; yet it needs to be.

Does care suffer in training institutions? No, mostly. Yes. Ironically, I'd say having a surgical resident participate in your surgery is the least likely arena in which problems occur. The supervision is eyeball to eyeball, hand on wrist. My most influential technical mentor (you can read all about him in "Cutting Remarks"), without exception let me, when I was Chief Resident, do every one of his operations, and he had some pretty hoidy-toidy patients. But he was literally at my side (as opposed to across from me like everyone else in the world), controlling and cajoling as if wired directly into my head.

In training, operations take longer, and time under anesthesia adds up to problems in a small percentage of patients. Still, it's in the hours outside the OR -- especially the wee ones -- that problems may occur. May I hasten to add, that applies equally -- more, in fact -- to the medical wards. Again, there's irony. In no community hospital are there as many doctors present around the clock as there are in teaching places. If I get run over by a truck, get me to a trauma center in a university setting. If there are a few people running around with minimal experience, so are there plenty with plenty. It's the humdrum stuff that's more likely to be delegated down, to people without the experience to recognize what's going on and who therefore fail to call for help.

Safeguards break down anywhere. In a community hospital, when there were problems with my patients, I was the one called, not an intern. That's better, as long as I got the call. It didn't always happen.

When I was in training, I believed evangelically that the best surgical care anyone could get was right there, not despite but because of all of us trainees and attendings in the mix. After a couple of years in practice in a community hospital, devoid of students at any level, I came to feel the exact opposite (meaning the best care was in that community), and I still do, except for certain highly special situations. It's a hell of a paradox. If my reader has made it through my ping-ponging thoughts to this point, I imagine she's more concerned than when she asked the original question. Scary, huh?


DocInKY said...


This post is so spot on. I remember my residency days 'doing' my first hernia as a PG1. Talk about cut and sew on the dotted lines (My attending drew the lines!) I did not understand hernias until I took an intern through his first in early July when I was chief at our VA.

Later in fellowship, I learned more about doing Fem-tib bypasses and carotids taking PG4s through those cases. Then I taught as an academic surgeon for several years. Let an intern do significant parts of an AV fistula - then they could handle (with my supervision and assistance) a straight forward carotid - then handle an AAA as a chief. There 'graduation exercise' was to take a PG3 through a fem pop with me scrubbed in as essentially a second assistant. Sometimes, it was hard to keep my hands quiet and my mouth appropriately shut. In all these cases, my patients were clearly told about the resident roles they would perform. I had more employees of the medical center come to me, even knowing that.

Now I am in private practice. Older, wiser, and shorter OR times!


Anonymous said...

Everyone always talks about the downside of having residents and students in your care. But of course there are also the downsides to private practice as well. If there is one thing academia does reasonably well it is assure a baseline minimum of quality. In private practice there are occasional whackjobs still practicing to standard of care... 20 years ago.

I recently had to decide where to send my mom for surgery. Simple cases definitely go to private practice - I'd rather have an attending doing it than the PGY3 that's going to get it, quite frankly. Complex cases definitely go to academics - I'm certainly not asking my local general surgeon to do his first Whipple in 10 years on me. The question is then the middle - where do you go for cases that aren't particularly unusual but carry some real degree of risk? Cervical fusions, for example. It's hard to say, really, and it varies on the procedure and the available people.

I ended up finding some hotshot academic guy and had a little chat with him beforehand about how things were going to be. It went fine.

unsinkablemb said...

I've always wondered about this. I used to work in a large university hospital where it was common practice to leave residents alone at certain points during a procedure. It made me very uncomfortable, but I was a brand new nurse scrubbed in so who was I to argue. I was always relieved when I was paired with a seasoned circulating nurse who knew when to call the attending back into the room!

Anonymous said...

Well, it's not like one goes to bed as a PGY5 who should never be left alone on a case and wakes up an attending for whom it is A-OK. It would be far worse if residents were never unsupervised; imagine if their first unsupervised experience was as a junior attending with no backup.

Our current system works pretty well as far as I can see. The fact that the attending ultimately takes the hit if something goes awry keeps things sensible.

Emily said...

I appreciate the importance of teaching the next generation of doctors and the necessity of hands on training. And, thanks to your explanation, I'm now relieved that the inexperience of these new doctors is for the most part backed up so no harm comes to the patient.

But if residents are allowed to perform all or most of an operation, is it then a futile effort for the patient to seek out a top-notch high volume surgeon when they won't have a chance at getting the fruits of all that experience, except for over-the-shoulder guidance to the surgeon-in-training. The patient won't have the senior surgeon's skilled hands performing the operation, and if the novice doctor is on his own, there is no one there to make the wise judgment calls before a step or misstep is executed. It's like the best a patient can hope for is an adequate operation with plenty of backup should a crisis occur.

And what about the long hours these interns and residents have to put in. Is it possible that a fatigued intern or resident could be handed a scalpel at hour 18 of his 24 hour shift?


Midwife with a Knife said...

I liked that post. An attending of mine used to say to the patient, "Dr.Resident may be performing the procedure, but I'll be there the whole time making sure that he does everything just the way I would do it." Also, one of our attendings used to tell her private patients that her practice was affiliated with a teaching hospital and if she didn't want residents involved in their care, they should transfer to a different practice.

emily: It's possible and common. I'm a fellow, and I will routinely do c-sections and procedures after having been up for 30+ hours. It's probably not the best way, but it is what it is. I can actually do routine surgeries without really thinking about them. A routine c-section is automatic. The problem with fatigue is when you're doing something a little unfamiliar or when you have to make real decisions. That can be tough when you're exhausted.

medstudentgod (MSG) said...

My dad recently underwent surgery and during his follow up with the surgeon he asked about the pannus of skin where the sutures were. The surgeon looked, uttered: “Wow, how’d that happen?” and proceeded on with the exam. My dad and mom knew then that the resident had closed while the surgeon had left. It’s something they were well aware of, but it still sounded funny for the surgeon to say that.

Greg P said...

One of the things that's come about in recent years is the mounting evidence that for various procedures, especially more risky ones, the risks relate inversely to the number of procedures of that kind the surgeon does in a year, and there is little doubt that is true across the board.

This has led to a push to withhold or restrict privileges to do these. But it seems worrisome that this whole issue of training new docs doesn't come into the final recommendation. There also seems to be a risk of some using this to keep out competition.

Let's say you are the major group doing some tricky procedure -- how would a new surgeon ever come up with the numbers to justify getting privileges if he didn't join your group?

Sid Schwab said...

Greg: the numbers thing is an interesting subject. In fact, it's a good idea for a future post. Like you, I don't think it's at all black and white.

LLL said...

Here's a situation that I've sometimes wondered about:

A friend of mine was sent by her doctor to Big Name Ivy League Medical Center for lung cancer surgery. It turned out that she had a very slow growing tumor, and she needed no further treatment for it.

The day after the surgery, the chief resident came by and said from then on, he would be taking care of her. For the 6 days she was in the hospital, she never saw the attending surgeon. She was also told that since they had used surgical glue to close her up, that she would not need to have any more appointments with the surgeon, so no follow-up appointment was scheduled for her.
And that's the last she ever saw of anyone involved in her surgery. Her discharge instruction from a younger resident were 'just go back to your regular life. If you feel like dressing up and going out to dinner, go right ahead'(I'm not joking about this).

It was always my impression that the attending surgeon has to see you at least once a day while you are in the hospital, and that he/she can't turn 100% of your care over to residents. I also assumed that, for a serious surgery like my friend had, that there would be a follow-up visit with the attending surgeon, and that these things aren't decided by whether they used glue or staples/stitches to close a person up.

Or am I just naive about these things?

I'm not impugning the surgeon's skills in the operating room. It just seems like his responsibilities ended as soon as he took off his latex gloves.

(My friend has health insurence, so it wasn't as if her's was a charity case.)

Sid Schwab said...

LLL: in my opinion, your friend's experience -- even though it sounds like she got a good operation -- is embarrasssing. I'd certainly have been seeing the patient in the hospital, at least once, and always would want office followup unless there were reasons why the patient chose not to (out of town, etc.) I don't think there are actual "rules." On the other hand, it's about being available, answering questions, and, just as importantly, finding out what the patient is going through after the operation.

Anonymous said...

Well, here’s my experience with a teaching hospital. 3 years ago an ovarian mass was found on a scan. My gyn referred me to a gyn/onc surgeon at a major private hospital affilliated with a university medical school in my city. This hospital has a comprehensive cancer center. A hysterectomy was performed along with removal of lymph nodes. Yes, it was cancer. During my chemo treatments, I had periodic physical checkups done at the hospital. I never saw the surgeon during those appts, but rather a different person showed up each time to ask a few questions, and then a pelvic exam. After my chemo ended, I continued with these checkups for about a year.
During all those appts, I assumed the person giving me the exam was a doctor. One time a young man came in, asked me to get on the table, about 30 seconds went by with no activity (I couldn’t see his face due to the sheet covering my knees). He got up, excused himself and left the room. He then re-entered with a nurse, who stayed and guided him through the procedure. When he finished, he was literally sweating. I asked the nurse to stay behind to explain why this person had to have guidance. She then informed me that these people giving me the pelvics were medical students. When I protested that every one introduced themselves to me as “doctor”, and that I even assumed they were gynocologists, she said that students are encouraged to do that to “put the patient at ease.” Needless to say, my head was spinning at that point. To think that the surgeon actually accepted the findings of these students, considering that I had cancer, stopped all future visits. (I forgot to mention that I had full health insurance)

Flash forward 6 months, I had a recurrence, a malignant lesion was found by my regular gyn during a pelvic exam. How could I not think that this could have been found earlier if all those checkup pelvics had been done by a real doctor. When I expressed my suspicions to the gyn, his defensive responses were the beginning of circling of the wagons.

Now, reading here that it’s common for sleep deprived residents to perform surgery, sometimes without supervision, has put me in a deep depression. I am tempted to access my medical records for information, but don’t really want to discover that my surgeon may not have even been in the operating room. I’ve come to the sobering conclusion that the patient at a teaching hospital is nothing but a prop to be practiced on.

Tom said...

What did the Medical Board, DHS and the insurance company do when you reported the brain surgery that did not happen?

Emily said...

Wow, I think the story by that woman was pretty scary.
Are you saying that she was stupid for believing that
the students were real doctors? It seems tome she was led on. and
considering the grim prognosis
for her type of cancer, I think your remark was a cheap shot.

tran said...

I wonder what the sales pitch is to convince the insured patient to accept a student surgeon to operate on him. Or is bait and switch. Now I know the questions to ask if I ever have an operation.
But I'm really curious who are the lucky people who actually get the qualified surgeon to do the operation in a teaching hospital.

LLL said...

My Blue Cross insurer's policy explicitly states that an attending doctor can only bill for an office visit when he/she is physically present with the patient in the same room at some point during the visit. Being 'available down the hallway' does not count as being physically present. Hence, office visits in which the patient only saw a resident or medical student cannot be billed to the insurer. And the patient is not required to owe a copay, either.

In the case of anon above who has ovarian cancer, billing her insurer for the office visits where she did not see her attending physician, is insurance fraud.

But unless a patient brings this to the attention of their insurer, a doctor who engages in this practice will get away with it.

Anonymous said...

Honestly, that story is so bizarre as to make me question the veracity of it. I have never seen nor heard of anything like sending in medical students as the only person to see someone on a post-cancer checkup; the very idea is ridiculous.

The perils of teaching hospitals are easily overstated by people who've never seen it from the other side. It might sound scary, but I really can't think of any time I've seen bad outcomes from the attending stepping out - they usually have a solid sense of when a resident is ready to be on their own for a bit and they usually don't do it at critical times. Like I said, one doesn't go to sleep as a PGY5 who should never be alone on a case and wake up as an attending and it's suddenly fine. The key thing isn't whether the attending in the room or not, it's whether or not you've got someone to call in if something unusual happens. That's what separates a senior resident from an attending, not the routine but the rare.

SeaSpray said...

Ohhh ... Dr. Schwab..I don't know what to say...

You know my story. Your last 3 paragraphs have me perplexed.

I didn't ask your ghost question, but it is a question I will present to my surgeon if I go in that direction. I still need to schedule the renal scan and then I will know.

I am still confused about your opinion, community-vs teaching hospital. The hospital I would be going to is a designated trauma center for the area and my understanding is that there would be more OR support for a high risk surgery.

Dr. Schwab - can you do a girl a favor? Can you pull out your magic surgery wand, wave it in my direction (east) and make this all go away? Thanks. :)

Good post.

Anonymous said...

A reader said: "The key thing isn't
whether the attending in the room or not, it's whether or not you've got someone to call in if something unusual happens."

Couldn't egos get in the way here. Might not the resident waste precious time by trying to get it right or correcting a mistake before admitting defeat and calling in the attending.

Anonymous said...

As a current surgical resident, it's disappointing to see the alarm in some of the lay opinions of surgical training. I can only speak for my shop and where I was in medical school, but I have never seen residents left unsupervised during critical parts of surgery. I have seen surgical fellows starting cases alone, but keep in mind that a fellow is a fully trained general surgeon who is taking further specialized training. As far as attending supervision during cases, it's substantially more intense than the uninformed layperson would think. For the most part, surgery is not technically demanding. Anyone who can sew and tie thread, cut with an exacto knife, or use tweezers has the dexterity to do a lot of surgical moves. The attending's role in teaching cases is to guide every move, every cut, every placement of a stitch. The fact is that in a lot of surgeries, you need an assistant to operate. The cuts and stitches a resident performs are equivalent in effort to what an attending would do; the only difference is that the resident doesn't necessarily know where to place them in every situation and the attending shows him or her exactly where. Recently a full professor of surgery in my program needed his hernia repaired. Instead of seeking out a "hotshot" community herniologist, the surgery was done at the teaching hospital by one of his junior partners in his division and an intern. More importantly, teaching hospitals have a social contract with society to provide the future with trained doctors. If no patients allow themselves to be operated on in teaching hospitals, 20 or 30 years from now when the current crop of attendings retire, who will be there to fix your perforated ulcer when you come into the ER in the middle of the night with a rigid abdomen?

Anonymous said...

RE: Ghost Surgery
Is it legal to have a patient sign a consent form while the patient is under the influence of Midazalom?

Sid Schwab said...

It's a good question, to which I don't have a ready answer. I'm no lawyer, a fact about which I've never had regret. I'd guess, in the eyes of the law, it'd depend on lots more than the single fact of midazolam.

I've written about informed consent in other places on this blog. In one of those posts, I said this, which I still believe:

Looking at comments on my previous post, and knowing from my own experiences, it's apparent that consent is a much cloudier issue than those who urge those forms upon us would have us think. Both for doctors, and patients. What we say, what they think we say; what they heard, what we think they heard -- it's as flimsy as a curtain of fog. When you're sick as hell, any consent you give is subject to the effects of the illness, maybe the drugs you're getting. Even when it's an operation planned well in advance, it still is questionable what "consent" really means. I've seen the fear-glazed eyes, whose opacity blocks words. Consent is just a concept, a hall of mirrors. It's vapor.

The point is, I think there's no such thing as fully informed consent, unblighted by the circumstances surrounding whatever illness or procedure is in question.