Samir Johna

Patient Safety in Surgical Residency: Root Cause Analysis and the Surgical Morbidity and Mortality Conference—Case Series from Clinical Practice

Although the surgical morbidity and mortality conference (SMMC) has been a core educational venue for surgical education and quality assurance (QA), its current format focuses mainly on human errors rather than system failures, which are responsible for the vast majority of medical errors. To avoid having surgeons seemingly put on trial, root cause analysis (RCA) can be used as an effective way of analyzing system failures and of finding possible solutions for them. Preliminary data confirm the value of RCA in that respect and promise a great potential for improving patient safety away from the culture of blame. Bringing the findings of RCA to the SMMC has the advantage of having both perspectives--human errors and systems failures--thus enhancing surgical education, improving QA, and hopefully improving patient safety. However, although this seems to be a novel approach, several factors should be considered before its implementation, such as the quality of analysis, cost-effectiveness, and actual impact on patient safety. We believe that to maximize learning, sentinel events that currently require RCA should not be discussed in SMMCs until the findings of RCA are available for review. The use of some of the tools of RCA should be considered when discussing nonsentinel events during SMMCs.

The Power of Reflective Writing: Narrative Medicine and Medical Education

There is no doubt that medicine is an art and a science. Today, practicing medicine as science is probably much easier than practicing medicine as art, in light of the dazzling advances in medical technology and informatics. Even before technology gained the upper hand, patients were healed by physicians when most of the remedies were useless if not harmful, and when remedies were driven by theories that did not stand the test of time. To some extent, the art of fostering the sacred physician-patient relationship might have played a major role in the dramatic healing process. The physician-patient relationship is not limited to a comprehensive history and physical examination, a diagnostic workup, and the final discussion about a plan for action. Medicine requires that the physician establish deep connections by which s/he can dive deep into the crying soul of the patient. Healing an ailment is a complex process that must address two domains: disease, which is the alteration in the biologic structure and/ or function of the body; and illness, which is the psychological and social aspect of the ailment. Proper healing starts with open communication between physicians and patients. Patients draw on physicians’ attributes of honesty, integrity, empathy, and compassion to share their stories as they strive to heal. Narrative medicine offers a unique framework to explore and manage the complexity of healing. Its impact extends beyond the physician-patient relationship and into the relationships between physician and self, physician and colleagues, and physician and society. It is no wonder that many medical schools and residency programs have incorporated narrative medicine in the form of reflective writing into their curricula. Our learners, students and residents, are encouraged to be engaged in reflective writing as they search to understand what medical practice means to them, their patients, their colleagues, and society at large. Learners meet with the first author (SJ) on a regular basis to discuss and analyze their short, open-ended narratives. They are frequently asked to reflect on events of their choice that had a lasting impact on them, negative or positive, at any institution where they rotated. We (SJ and AD) are mesmerized by the insight of the learners and depth of their reflective capacity in their quest for self-identity, ideals, and values as they enter the complex environment of medical practice. It is only fitting to share some excerpts from learners’ narratives about valuable lessons from rich experiences in which they found themselves deeply immersed. One learner ruminated over the discrepancy between what we preach and how we act. He described his negative experience tagging along with his attending physician in a busy outpatient clinic. He wrote: I saw a 45-year-old patient with an advanced hepatocellular carcinoma. He came with his wife to learn about the results of his liver biopsy performed with [computed-tomography] guidance. He had no clue what was wrong with him, much less his prognosis. He was smiling and engaged in a conversation with his wife as I walked into the room. I asked him how much he knew about his condition. “They told me I might have a tumor, but I was told that you will be telling me more.” I was in my second month of training and did not feel comfortable breaking the bad news to him. I decided to leave it to my attending. A few minutes later, my attending and I went into the room. After introducing himself to the patient, the attending asked me to bring the ultrasound machine because he wanted to examine the patient for ascites. After he was done, he told the patient that there was no fluid and all this abdominal distension was probably due to an enlarged liver and suggested that the patient [go] to radiology for palliative chemo-embolization. While he was standing next to the door that was half open, the attending asked the patient “So, do you know what is going on with you?” The patient did not say anything but his [facial] expressions were enough for us to tell that he was not aware of how serious his condition was. “You have a very bad cancer and you will die in six months,” the attending said. Surprisingly, just [a] few days before that, the same attending gave us a lecture for an hour about palliative therapy of terminal cancer [patients]. The whole lecture was centered around dealing with terminal cancer patients and breaking bad news. He talked about some personal experiences as well as some skills and strategies of how to build a relationship with your patient[s] and how to earn their trust. “Touching the patient, sitting close to them, smiling, and some other simple things make all the difference in the world for them,” the attending had said. After we left the room, I was thinking of how shocking and overwhelming that was to the patient. I was wondering if being busy can be an acceptable excuse for not showing empathy and

Surgery Resident Training in Endoscopy: The Saga Continues

R ECENTLY, THE AMERIcan Society for Gastrointestinal Endoscopy, the American Association for the Study of Liver Diseases, the American College of Gastroenterology, and the American Gastroenterological Association issued a combined position statement in response to the new guidelines from the American Board of Surgery (ABS) requiring a minimum of 50 colonoscopies and 35 upper endoscopic procedures to be performed by a resident to complete a surgical residency. These gastroenterologic societies purport to be concerned about the quality of training after such experience and therefore believe that endoscopy should categorically be removed from surgical training and possibly from surgical practice altogether. As educators of the next generation of surgeons, we are bewildered by the position of this alliance. We wonder if motives other than competency and patient safety underlie their statement. For critical analysis, one must address 3 intertwined issues: the rationale for this statement, adult learning theory, and endoscopic privileging in clinical practice. Competency is the ability to carry out a set of tasks or roles adequately and effectively, which requires knowledge, skill, and appropriate attitude. The argument against surgical endoscopic training is based on the perception that the number of endoscopic procedures required by the ABS is not enough for the resident to achieve competency. The backbone for this perception is the results of 4 studies that were referenced in the position statement. The first study is a retrospective analysis involving a small number of gastroenterology fellows evaluated during a 3-year training period. The main outcome measure was “achieving more than 90% colonoscopy independence rate.” The authors concluded that only those fellows who performed more than 500 colonoscopies were able to achieve the objective. However, the study did not address other factors that may affect the independence rate, such as billing practices that require the participation of the faculty in critical aspects of the procedure. Ironically, no difference was observed in the adenoma detection rate between junior and senior fellows. The second study examined technical aspects in colonoscopy as a measure of competency using adjusted completion rate and cecal intubation time. The authors concluded that the performance of 200 procedures was needed to reach technical competence. In our opinion, competency never should be judged by number of procedures or time to complete them. The third is a large, retrospective analysis investigating whether colonoscopy volume and the specialty of the endoscopist are associated with colorectal cancer. The authors concluded that endoscopists in specialties other than gastroenterology had high missed cancer rates. Ironically, no association was observed between the number of endoscopies performed and positive cancer findings. The last study is a retrospective review of 2193 consecutive colorectal cancer cases diagnosed during a 3-year period. The authors found that the results of colonoscopies performed by nongastroenterologists were less sensitive compared with the results of those performed by gastroenterologists. This study was designed to determine the relative sensitivity of barium enema compared with colonoscopy for cancer diagnosis. Clearly, none of the referenced studies were designed to evaluate competency; therefore, they do not support the allegation that the ABS requirement for endoscopic training is inadequate. Adult learning encompasses 3 domains. The first is the cognitive domain, used to categorize subject matter according to level of thought, which contains 5 escalating levels: comprehension, application, analysis, synthesis, and evaluation. The second is the affective domain, used to develop and organize levels of commitment (ie, attitude), which contains 5 escalating levels: receiving, responding, valuing, organizing, and internalizing. The third is the psychomotor domain, used to guide the development of objectives at progressive levels of behavior from observation to mastery of a given skill, which contains 7 escalating levels: perception, set, guided response, mechanism, complex overt response, adaptation, and origination. Competency does not require that every learner achieve the highest level in every domain. At graduation, even after fellowship, the level of competency is not expected to reach beyond analysis or synthesis in the cognitive domain, valuing or organizing in the affective domain, and complex overt response or adaptation in the psychomotor domain. The lifelong learning and improvement throughout a physician’s career brings him or her to the top of the adult learning pyramid. The Society of American Gastrointestinal and Endoscopic Surgeons recommends credentialing based solely on documentation of proficiency in a clinical setting. These recommendations rely heavily on evaluation by supervising faculty or a physician preceptor. They also depend on the demonstration of current competence as judged by an unbiased proctor. Nearly half of

Comorbidity and outcomes after surgery among women with breast cancer: Analysis of national in-patient sample database.

83 Background: Evidence is scarce about the influence of comorbidity on short-term outcomes of patients with breast cancer after surgery. The objective of this study was to examine the effect of comorbidity on risk of postoperative complications, prolonged hospitalization (defined as above median length of stay), and in-patient death among women with breast cancer. METHODS National inpatient sample is a nationwide clinical and administrative database. Patient discharges with primary diagnosis code of breast cancer and coincident procedure code for breast surgery from 2005 to 2009 were identified using International Disease Codes 9th edition (ICD-9). Information about demographics, hospital characteristics, comorbidities, stage, surgical treatment, postoperative complications, length of hospital stay, and in-patient deaths was obtained. Comorbidities were identified using ICD-9 codes and used to calculate modified Charlson comorbidity index (CCI) score. We divided patients based on these scores into 4 groups: 0, 1, 2, and 3 or more. Multivariate logistic regression analyses were used to examine risk adjusted association between CCI score and the aforementioned outcomes. RESULTS We identified 75,100 patient discharges with a mean age of 61 years. Compared to patients with a CCI score of 0, as a reference group, CCI scores of 1, 2, and 3 or more increased the risk of post-operative complications by 1.7 fold, 2.6 fold, and 4.6 fold, respectively (p <0.001). Compared to patients with a CCI score of 0, CCI scores of 1, 2, and 3 or more increased the risk of prolonged hospitalization by 1.2 fold, 1.6 fold, and 2.3 fold, respectively (p <0.001). Similarly, Compared to patients with a CCI score of 0, CCI scores of 1, 2, and 3 or more increased the risk of in-patient death by 3.1 fold, 5.4 fold, and 15.8 fold, respectively (p <0.001). CONCLUSIONS After controlling for potential confounders, we found a strong and statistically significant association between comorbidity and outcomes of patients with breast cancer after surgery. Effective control of comorbidity in breast cancer patients may reduce post-operative morbidity and mortality.

Racial disparities in clinical presentation, treatment, and outcome of women with breast cancer: Analysis of national inpatient sample database.

66 Background: Despite the established consensus, guidelines, and treatment protocols, there is wide variability in practice patterns among women treated for breast cancer, leading to variable results, with less favorable outcomes among minorities. The objective of this study was to examine racial/ethnic disparities in stage of disease and comorbidities (pre-treatment factors), surgical treatment allocation (breast conserving surgery [BCS] versus mastectomy [MAS]), and postoperative complication and mortality (post-treatment outcomes). METHODS National inpatient sample is a nationwide clinical and administrative database compiled from 44 states representing 95% of all hospital discharges in the Unites States. Patient discharges with primary diagnosis code of breast cancer and coincident procedure code for breast surgery (BCS or MAS) from 2005 to 2009 were identified using International Disease Codes 9th edition. Information about demographics, hospital characteristics, comorbidities, stage, surgical treatment, post-operative complications, and in-patient death was obtained. Multivariate logistic regression analyses were used to examine risk adjusted association between race and the aforementioned outcomes. RESULTS We identified 75,100 patient discharges with a mean age of 61 years. Overall, 58.3% of women were white, 8.6% black, 5.7% Hispanic, 2.6% Asian, and 24.8% others. Compared to whites, blacks were more likely to present with regional or metastatic disease (1.17, p <0.001) and more likely to present with comorbidities (1.58, p 0.003). Compared to whites, blacks (1.30, p <0.001) and Hispanics (1.20, p <0.001) were more likely to receive BCS whereas Asians were less likely to undergo BCS (0.80, p 0.01). Compared to whites, blacks were more likely to develop postoperative complications (1.35, p<0.001) and in-hospital mortality (1.87, p 0.13). CONCLUSIONS After controlling for potential confounders, we found some racial/ethnic disparities in clinical presentation, treatment, and outcomes. Future researches should examine the underlying factors of these disparities.