Thursday, August 03, 2006

When Surgery SUCs

Several years ago, when I was chairman of the Surgical Quality Assurance Committee, the hospital medical director came to one of our meetings. We have a problem, he said. The Joint Commission on Accreditation of Hospitals had, on its recent inspection, given our hospital a list of criticisms, one of which involved unnecessary surgery. That, of course, got my attention, even though I've often said unnecessary surgery gets a bad rap: it's easier than the needed kind (nothing like disease to complicate things), and healthy patients generally do better than sick ones. NOTE: kidding.

The problem, it turns out, was not that they'd uncovered instances. It was that there was no requirement that surgeons include surgical indications (the reasons for doing a given operation) in the operative reports. We had six months to implement a solution: they'd be back to recheck at that time. OK, I said, we'll do it. Forget that it's stupid. Because if a surgeon is willfully going to do an operation he knows is unnecessary, he certainly'd have no compunction about lying into the record. Moreover, times had long since changed: if people see something fishy in the OR, they talk, they report, they get things changed. Nurses ain't stupid; and not only do they no longer stand up when the doctor walks into the room, they (rightfully) see themselves as advocates for patients. Not that doctors don't, of course.

So, no problem. There are published lists of indications for any given operation. Surgeons can dictate into the record why they're doing a thing, people in medical records can compare their reasons to those lists. Everybody's happy. (Being the passive aggressive type I'd often say things like: "operation: appendectomy; indication: appendicitis." Some operations pretty much go without saying. Or so one might believe.) We got the word to the surgeons, everyone complied. As stupid hospital rules go, this one was pretty benign, and even sensible, more or less.

Time: six months later. Place: SQAC (pronounced squawk) committee meeting. Speaker: the medical director, again. Saying, guys, they came back, and they don't like your system. It doesn't work. What do you mean, I ask. It's not working, he repeats. It's not finding unnecessary surgery. Long pause. VERY long pause. Dick, I say (it was his name, not a declaration). Does it occur to you that the reason we're not finding unnecessary surgery is that we're not DOING unnecessary surgery? C'mon, says Dick.

The rest of the meeting is somewhat of a blur in my memory. The minutes of the meeting, assembled by the staff secretary, were tastefully discreet. Something like "discussion ensued." It's possible there was one less serviceable chair in the room at the end than there was at the beginning. There may have been suggestions made that, even for a surgeon, were anatomically impossible. Had they been, the minutes of the meeting, and the report of the inspectors would likely have required decontamination before handling again. I guess it boils down to this: regarding the suggestion that we come up with a better plan, I demurred.

What I did was, I formed a new committee. The Surgical Utilization Committee, or SUC. You know how it's pronounced. It never actually met, and it pretty much had a membership of one. But it did produce a memo, distributed to every doc on the medical staff. Copies are no longer extant, but the following is a pretty good rendition:

TO: Combined Medical Staff
FROM: Surgical Utilization Committee (SUC)
RE: Unnecessary Surgery

A recent hospital inspection has found a deficit amongst our staff regarding finding and identifying unnecessary surgery, and the SUC committee has been charged with correcting the problem. In order to comply, we are going to have to find ways to produce more unnecessary surgery in our community, and your input is requested

Preliminarily, we offer the following possible solutions:

1) One surgeon in the community will be assigned to do nothing but unnecessary surgery. The designated surgeon could be chosen by lottery, or on the basis of case-load. Logically, it would seem best to select the surgeon doing the fewest cases.

2) The task of performing unnecessary surgery will be rotated evenly among all surgeons, on a monthly basis.

3) Certain operations will be designated as always unnecessary. Left inguinal hernia, for example.

4) If non-surgeons are interested in helping, they would be welcome. While not always unnecessary, operations done by them would not be done well, and that might suffice, for inspection purposes.

In order to help understand the scope of the problem, we are asking that the following questionnaire be filled out. Signatures are preferred, but anonymous forms will be accepted.

I currently do unnecessary surgery _____ times per week.

I prefer to do unnecessary surgery:
___ in my office
___ at the surgery center
___ in Seattle

I would be willing to do unnecessary surgery
___ exclusively
___ occasionally
___ never (NOTE: this may not be an option, given the current situation, but, as with all staff decisions, your input will be filed somewhere.

Thank you for your support of our medical staff. Please return completed form to the staff secretary.

The staff mailboxes were on a wall in the doctors' lounge. I got there early, and took a seat and a cup of coffee. As docs trickled in and checked their mail, I observed this: the medical docs, seeing something referring to surgery near the top of the page, tossed it in the garbage without looking at it. The surgical types read it and had a good laugh. One of the family docs read it with increasing agitation, and finally spun around, shaking, and saying, they can't do this! They can't do this!! This is terrible!!!

I don't suppose it accomplished much in the greater order of things. But I never changed the indications monitoring system, and I never heard any more about it. Sometime, if I get brave enough, I'll tell you about the notice I distributed similarly, and which was mysteriously pulled from all the mailboxes by five in the morning...


Dreaming again said...

toooo tooo tooo funny!!!

Allen said...

Perfect post: Good topic, good writing.


Anonymous said...

Hilarious! JCAHO, and all of the other ubiquitous acronyms are what they're feeding us this session in college. I hope you don't mind, but I'm going to provide a link to that post for my fellow classmates.

Seriously looking forward to hearing about the "notice" you mentioned at the end of your post!

origin said...

Good post, now....
Tag! You're it...

Rita - Supporting Safer Healthcare said...

Well, we Schwab's can always be counted on for opinions!

See mine on this topic here:

Rita Schwab
(no relation as far as I know)

Greg P said...

Some of the regulations of the Joint Commission are like handing you a piece of rope with instructions on weaving it into a noose so they can hang you with it.

Mother Jones RN said...

You are too funny. Thanks for putting a smile on my face before I return to the hospital for another long shift:-)

Mother Jones RN

Andrew McAllister said...

Hi Sid,

Thanks for visiting "To Love, Honor and Dismay" and for leaving your comment. You're right, with respect to thinking ability at any given time, that saying does explain a lot.

All the best!

Anonymous said...

I wanna hear about the other memo!

And I volunteer to be a non-voting member of SUC!

Anonymous said...

Thanks for a great laugh!! Actually, that sounds surprisingly like something I did once... I'll have to write about it some time.

Anonymous said...

Dr Sid,
Don't hold this against me, but in a previous life I was a hospital administrator. Thank God it was before the BORG of Medicine (JCAHO) came into existence.

If you don't mind I'm going to snag that post, format it and hand it to my surgeon, who is also a colleague of my husbands, at my appointment tomorrow. He and the husband has been wrestling with a variation of this monster recently. I know they both need a laugh.

Mary Lu


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