Most doctors think having video cameras and microphones in their ORs to record surgical procedures is an idea from hell itself: tantamount to having dreaded big brother —who's also a lawyer—standing beside them while they cut.
But videography is a great way to stimulate quality improvement and some say it's poised to take off.
One of the idea's foremost champions is breast surgeon Caprice Greenberg, MD, director of the Wisconsin Surgical Outcomes Research Program. Greenberg wants surgeons to record their procedures much more proactively than they do today, and not just to incent prevention of horrific surgical mistakes.
Greenberg says there's an awful lot OR teams don't realize they could learn from reviewing their own and their colleagues' procedures, such as improving techniques, streamlining efficiencies and even figuring out better ways to recover from surprise disasters.
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"There's the potential for video to be used in a really positive way, to improve the quality and safety of healthcare," she explains. "We're interested in seeing the operation, and linking it to what's happening in the room; we're trying to look at how people interact."
Greenberg says that if hospitals and operators don't take the bull by the horns and drive their own quality improvements, they may be forced to do so. And they won't like that one bit.
For example, at Rhode Island Hospital, state health officials issued a $150,000 fine and a consent decree for the 719-bed Providence facility to begin using cameras in the operating room after five wrong-site surgeries occurred there between 2007 and 2009.
The procedures were not recorded, but were streamed so that they could be viewed remotely, in real time. The consent decree was for all surgeries to be observed for one year, but the hospital has continued the practice on a random basis "to ensure quality and safety," a spokeswoman says.
"My worry," Greenberg says, "is that as surgeons, if we don't try to drive this movement, other people are going to start using this to police what happens, more as a punitive thing, which I think would be really damaging."
She isn't talking about widespread adoption of tiny cameras on the tips of surgical scopes, which most hospitals have today in many of their operating suites for laparoscopic procedures.
Greenberg's talking about high-resolution videography equipment embedded in operating room lights, and other cameras with 270-degree views in the room, and harmonizing feeds from the anesthesiologist's monitor.
They'd be synchronized with hi-fi microphones to "capture a view of the operative field in detail, a view of the entire OR, a dynamic record of the patient's vital signs and various conversations occurring throughout the OR, in synchrony," according to a 2012 report for which she was a principal investigator.
In their study Greenberg and colleagues used all that equipment and received surgeon and patient consent to record 10 complex procedures—nearly 44 hours of video—at Brigham and Women's Hospital. They then got experts to review what they saw, down to every delay, hurried exchange, miscommunication, and misunderstanding. These were tough cases, with expected complication rates of greater than 20%.
Among those 10 cases, recorded from room set-up through patient exit, experts found 33 "deviations," which included 10 delays in the procedure of at least two minutes, 17 safety compromises that put the patients at risk, and six instances in which a deviation included both a safety compromise and a delay.
In one case, for example, lack of communication resulted in misinformation between the anesthesiologist and surgeon about whether a patient, who developed cardiac ischemia, was "bleeding."
Lack of coordination contributed to deviations as well. "Attending surgeons were frequently absent at the beginning of their cases, causing delays ranging from 8 to 28 minutes. Even teams familiar enough with their attendings' preferences to begin without them ultimately reached a point at which progress halted, and they were forced to idly wait," she and colleagues wrote in their report.
Even though the surgeons themselves "had the impression that their cases went quite smoothly, Greenberg says, they ultimately "identified points in the case where it was less efficient than it could have been, and they were spending time figuring out how to move the case forward in a way that could be improved in future cases."
She explains that traditionally, surgeons "finish training and then start operating on our own, and we don't have any mechanism for continuing to look at the way we perform procedures.
"For example, if you have two surgeons who have been in practice for 20 years, who sit down and watch a video of one of them doing the operation, and they talk through different approaches, they can identify things that might broaden their repertoire."
They might be able to position themselves better, use a different tool, or change a sequence of steps.
Some hospitals are already trying these techniques. Greenberg says efforts are underway at a Michigan bariatric quality collaborative, at the University of Virginia, Indiana University, and in the United Kingdom.
Greenberg's idea received support last week from Johns Hopkins surgeon and author Marty Makary, MD.
In a Viewpoint article April 1 in the Journal of the American Medical Association, Makary wrote that recordings can help address "the chronic problem of disruptive behavior," witnessed by 86% of nurses and 47% of physicians in a study of 50 hospitals. "A camera in a procedure room can increase accountability," he wrote, "in the same way that some hospitals currently use cameras to monitor cleaning staff."
In an interview this week, Makary told me that financial arguments hospitals and doctors make in opposition to OR videography "don't make sense" because "over 80% of patients say they want this, and 60% are willing to pay extra for it out of their own pockets."
Concerns about privacy violations or litigation discovery can be shielded because these videos are being kept for peer review, or under patient service organization protections, Makary and Greenberg say.
Hospitals and surgeons know this day is coming, Greenberg believes.
"But it's going to take a culture change. People have a fear of big brother, and that recordings will be used for some sort of performance assessment, or they'll not know they're being videotaped. I've spent an enormous amount of time talking with lawyers and malpractice insurers about these concepts, and most people think the benefits to the healthcare system far outweigh risks.
"They think that if these videos were brought into a legal case, it's much more likely the video will actually demonstrate that standard of care was provided, and be an asset."
Greenberg believes that the nation's hospitals "are on the verge of an expansion of the use of video in the OR, and in other healthcare settings," to improve quality and safety. But alas, she says, "there are still many challenges that we face before widespread use."