When Gerald Healy was surgeon-in-chief at Boston Children's Hospital a few years back, a medical student made a statement that silenced the room:
"Excuse me, Dr. Healy, I think you're operating on the wrong ear."
"That makes your day," Healy, an otolaryngologist, told a room full of physicians and hospital quality leaders at last week's Institute for Healthcare Improvement forum in Orlando.
"Trust me, when I was a medical student, if I had said that to the chairman of surgery, a professor, I wouldn't be here today," Healy said with a grimace. He was referring to the once dominant operating room mantra: “No one questions the surgeon. Not ever.”
That's not the way things work in his OR, says Healy, past president of the American College of Surgeons. "We stopped the case, we went to the record, we found that it was the correct patient and the correct ear, although that patient had some other problems in his other ear. But I asked those in the room to...give this gentleman (the medical student) a round of applause because he could have saved this patient from a very serious error."
"What it said to me was that there was comfort level in that room, they were empowered to do a better job, and that's what this is all about," Healy said.
Healy, who retired last year and is now an IHI senior fellow, said that in his OR, everyone in the room introduced him or herself and was told that if anyone was "not comfortable with what's going on," they were encouraged to speak up. All needed tools were identified so no one would have to go searching later.
The IHI session, so popular there were actually two, tackled the challenging problem of getting recalcitrant surgeons to embrace safety and quality. It was formatted for attendees to go the mike and describe their hospitals' struggles to get surgeons—often the most difficult, headstrong members of any hospital team—on board with time-outs and checklists and to get them to stop being cowboys. No matter if they've been operating for 20 years and have never made a mistake.
Surgeons, non-surgeon physicians, nurses, CEOs, and clinical administrators eagerly rose to speak.
One, Verna Gibbs, MD, a surgeon at the University of California San Francisco/VA Medical Center, who developed a system to prevent retained sponges, explained the surgeon culture she witnesses as one of "monovoxoplegia," which she defined as "the loud voice of one that paralyzes."
"You can say you want to prevent retained surgical toys and tools inside our patients. It's the right thing to do. It's a moral argument. But the view that carries the day is how much is it going to cost for me to adopt this program, versus how much am I going to save from liability coverage or a lawsuit," Gibbs said.
"I can tell you," she continued, "I have been told, 'what is so bad about a little bit of harm? After all, it keeps everybody on their toes.' "
Additionally, when things go wrong in surgery, a surgeon's quick response is often to blame the nurses or techs. The count was their responsibility; they should have been more alert.
Another attendee said that at his hospital, he tried having meetings to improve guideline compliance, but only three surgeons showed up. "How do you go about starting these conversations?" he asked.
"I haven't been able to accomplish that goal with surgeons," said yet another. "I'm not at an academic medical center, and I'm not at a place where, in all due respect, someone takes a checklist and that snowballs through the O.R. and all is peace and happiness and we're going to have a Kumbayah moment."
What happens when the person "who is the toughest holdout is a chief competitor, or the chief of surgery?" another attendee asked.
After the session, Richard Weiner, MD, a panel member and medical director of surgical services at Winchester Hospital, a 229-bed facility northwest of Boston, told me in an interview that he sensed a lot of frustration from those in the room.
"Trying to align and get surgeons on board with quality improvements is a major theme," he says. "They were frustrated that their efforts fell short."
And that to just say 'engage your surgeons' is just not as easy as it sounds, Weiner says. "There [are] still some surgeons who have a 'my way or the highway' attitude. There are still a few cowboys out there."
"Part of it is that when people are busy, they have the misperception that to cut out a step here or there will get them done sooner and on to the next patient. But in reality, if you eliminate steps for patient safety, not only is it risky behavior, but it's also something that could potentially take a lot longer if the wrong thing happens," Weiner says.
Healy emphasized that most surgeons today are not cowboys.
"Little by little, our leaders in American surgery are working hard to change the culture," Healy told me in a phone interview this week. "Are there pockets where you're going to have problems? That's true in every profession."
The fact of the matter is, "Surgeons are very busy people, being asked to do more and more with less and less time, see more patients," Healy says. "It's a whole different system than many of us are used to."
Weiner repeats a phrase he attributed to organizational consultant Charles Dwyer: "Never expect anyone to engage in a behavior that serves your values unless you give that person adequate reason to do so.” That means getting enough data to show them that not getting on board with routines, like checklists and time-outs, can result in harm to your patients.
And that's the take-home message. Healy stresses the importance of "getting that surgeon to think they can be part of the solution."
"You can say, 'Joe or Marylou, I need you to help make sure this policy works. How can we make it more effective?' When people are approached this way, I've never seen that fail."
Weiner and Healy encourage quality leaders to set times at the surgeons' convenience to meet, and put themselves in their shoes, doctors who now face many more, and stricter requirements and more demands on their time for less pay.
This weekend, I was reading the gory details of 14 immediate jeopardy penalties totaling $850,000 against California hospitals that put patients in harms way. Seven were retained surgical items, but one incident at UCSF illustrates the greater problem:
A surgeon operated on a patient's left eye instead of the right one because the operating table was turned 180 degrees and the surgeon said he "got confused."
"No time out was done prior to the beginning of Patient 1's surgery," reads the state report. The coordinator "stated the surgeon was not sure who should initiate the time out and the circulating nurse did not remind him a time out had to be done prior to beginning the procedure."
When a state investigator asked if a time out was done prior to the beginning of the procedure, the surgeon replied there wasn't. "Usually the circulating nurse initiates it," he said.
No healthcare provider gets up in the morning and says, "Today I'm going to do something to hurt a patient." But as long as immediate jeopardies still occur, maybe more surgeons need to get off their high horses. And stop being cowboys.