"ghost surgery"

Published

I was wondering if any of the O.R. nurses have heard of the term "ghost surgery".

(full article can be found here)

http://upalumni.org/medschool/appendices/appendix-37.html#fnB407

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(synopsis of article)

.......patients are routinely lied to implicitly or explicitly as to who's actually going to perform the surgery.

1) 50-85% of surgery in teaching hospitals is performed by residents

2) some residents performed surgery without direct supervision

3) most patients were unaware of the degree of resident's participation, and

4) consent forms did not give patients sufficient notice of the degree of residents' involvement.[408]

A surgeon defends this practice in an editorial in JAMA:

"As long as the attending surgeon is in the operating room and assures himself [sic] that each task is carried out expertly, he is 'doing' the operation.... It is neither possible or necessary to explain this in detail to every patient.... American surgeons need be neither apologetic nor defensive about our training methods."[411]

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Just wondering if you have witnessed this being practiced in the O.R. where you work, and if you think that keeping it secret from the patient is ethical.

Specializes in O.R., ED, M/S.

I haven't seen that where I work, but I am sure it is done at large teaching hospitals. I think with the new JACHO rules that apply to surgical consents where everyone that is involved in the procedure has to be named on the consent and the patient has to be told about everyone from student nurses, sales reps to PAs that will be in the room or directly involved in that patient's surgery. Nothing should be kept from a patient, I think this is very decieving and wrong. I think if I thought a certain surgeon was to perform my surgery and he/she had given me Informed Consent to this fact and in fact someone else had done the majority of the procedure, can you say MALPRACTICE! This has to brought up early where the patient has that right to refuse surgery based on this info.

found this interesting thread in a surgeon's blog discussing this subject. If anyone's interested, here it is

https://www2.blogger.com/comment.g?blogID=30499448&postID=3416202238189729765

Specializes in ER, ICU, Infusion, peds, informatics.
i haven't seen that where i work, but i am sure it is done at large teaching hospitals. i think with the new jacho rules that apply to surgical consents where everyone that is involved in the procedure has to be named on the consent and the patient has to be told about everyone from student nurses, sales reps to pas that will be in the room or directly involved in that patient's surgery. nothing should be kept from a patient, i think this is very decieving and wrong. i think if i thought a certain surgeon was to perform my surgery and he/she had given me informed consent to this fact and in fact someone else had done the majority of the procedure, can you say malpractice! this has to brought up early where the patient has that right to refuse surgery based on this info.

i haven't heard of this, neither have i seen it in practice.

listing everyone that could/would be involved in a case on the consent is a complete impracticality. when i was a student nurse, sometimes it wasn't know until the last minute which case i would be observing in. i'm sure the same is true for med students/residents. at that point, it would be too late to change the consent. the patient could be sedated.

it also probably isn't practical to determine ahead of time who will be doing what during the surgery.

i've never worked in the or, but i have worked in sicu in teaching hosptials. it wasn't unusual for a resident to be called out of a case to attend to someone in icu. another resident would then step in for the surgery (on certain rotations, the residents' primary responsibilities would be care of the icu patients rather than the actual or time. they got to do the surgeries when they could, but if someone had to go to the icu to take care of a patient, it was usually them, unless the fellow took pity and went instead).

no one wants to be "practiced" on; but it a reality that someone has to be a surgeon's first operation.

most consents are worded to allow for "others" to participate in the surgery. i can't think of hour our consents are worded, but something to the effect of "i agree to allow dr. ____________ and/or his/her associate and/or designee...."

it should be "common knowlege" that if one is going to be a patient in a teaching practice, and is going to have surgery in a teaching hospital, then medical students/residents are going to be participating in one's care and surgery. that is part of being a patient in a teaching facility. i'm aware that this is an idea that escapes some people, however, and i do agree that it needs to be more explicitly explained to patients that residents will indeed be participating in their surgery. that needs to be part of the "informed" consent education the (attending) surgeons go over. however, it isn't practical to name specific people, because that may well change at the last minute.

thanks for the interesting "insider" comments. I'm absolutly convinced that if patients were informed ahead of time that student doctors would have hands-on participation in the operation, there would be a lot of upset patients or cancellations. I had one operation so far. The consent paragraph that said that "other" medical or hospital personnel might be involved in the operation was pretty vague. And, what patient, just before an operation, reads or even understands the whole stack of paperwork that they have to sign. You just sign where you're instructed because we're so nervous and want to just trust everything and everybody.

I have run by my friends who have had operations and asked them if they were aware that the operations they had might have been done by student doctors, and not one of them believed me. They thought at most they just observed, or practiced on cadavers or indigent patients. I insisted that it's true for even private patients at teaching hospitals. I could see that I was upsetting them, so stopped talking about it. Really, we civilians have no idea how new doctors are taught. The doctors and hospitals have kept their methods so under wraps for a very good reason - because they know if everything that actually happens in the OR were an open book, there would be an uproar by the public.

Just curious for all you nurses in the know: If you had an operation at a teaching hospital, what questions would you ask of the doctor, and would you be allowed to request changes in OR protocol?

Specializes in ER, ICU, Infusion, peds, informatics.
just curious for all you nurses in the know: if you had an operation at a teaching hospital, what questions would you ask of the doctor, and would you be allowed to request changes in or protocol?

anyone has the right to "line through" any part of the consent they do not agree with.

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[color=#483d8b]if i want dr. joe, and only dr. joe to do my surgery, i can line through the part about his associates/designees before i sign, and the hospital/physician has to follow those wishes, if they are going to do the surgery. this also means that dr. joe's partner can't do the surgery, either. i only saw this happen once, when i was a nursing student. the surgery went ahead.

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[color=#483d8b]i believe that dr. joe would be able to decline to operate on me if i made those conditions, but i'm not sure anymore.

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[color=#483d8b]there is a part on our consents about taping/photographing procedures for continuing medical eductation. i have seen this lined through, more than once, but not often.

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[color=#483d8b]there is also a part of our consents that talks about allowing observers/students to be present during the procedure. again, the patient does not have to agree to this part of the consent.

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[color=#483d8b]as far at the comment on patients really knowing/understanding the papers they sign, you are going to get me off on a tangent about how it is part of every patient's responsibility to not only read the consent, but understand it and ask questions until they do. it is our responsibility (mostly the attending physician's responsibility) to provide that education, but the patient needs to activly participate and let us know when they don't understand or have questions.

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[color=#483d8b]i have very little sympathy for those who don't read, blindly sign, and then tell us later (after the fact) that they didn't understand.

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[color=#483d8b]do you sign financial papers without reading them first, as well????

Specializes in O.R., ED, M/S.

Well, the new consents being used by hospitals I work at do have the spaces to name ALL involved in the surgery. I know it sounds impractical but this is the direction JAXHO is going with complete informed consents to the patients. Maybe it is only in California where things seem to be ahead of the game. I think where Dr X is doing the surgery and Dr y is assisting, Dr Y's name should be included. Also any PA who is a regular with Dr X should have their name included. Sales reps are different because any of them could show up, but the patient should be told and shown on the consent that a rep from Zimmer or DePuy will be there. Students especially nursing don't need to be named but patient's should always give permission for such observers. Also it is not our responsibility to educate the patient on the surgery they are about to recieve, it is the surgeons under Informed Consent. Our resposibility lies only with the patient being competent and alert and that they sign correctly. Understanding what they sign is the patient's and what they discussed with the surgeon. If they do not understand then the surgeon needs to talk with them again. The consent manual for Calif is as thick as the New York phone book and very complex, believe me I have had to read and decipher alot of of the material. Consents are getting a bit to complicated and it is hard for patients to understand the majority of the material and we just make it more difficult with all the rules. I know teaching hospitals tend to be more flexible in the scheduling but in non-teaching ones rules have to be followed.

Critterlover,

Informed Consent is the responsibility of the Attending Physician, not the patient. The patient has the RIGHT to informed consent. AMA Ethics dictate specifically that student involvement must be DISCUSSED with the patient (AMA Policy E-8.087 Medical Student Involvement in Patient Care). Remember folks, there is a big difference between "Consent" and "Informed Consent".

From my perspective there is absolutely no way that I would let a Dr. I had never met operate on me, let alone an unnamed Med Student. I want to not only know their name but to meet them in person beforehand. If a faciltiy is "too busy" to even put involved caregivers names on a form then it's a place I don't want to be.

Yes, as the public becomes more aware about the monkey business going on with the consents (withholding until 1 minute prior to being wheeled in to the OR, un-named personnel, observers, reps, students, cameras) there will be outrage which will invoke change. As an example look at the numerous States who enacted laws about unauthorized pelvic exams being performed on anesthetized patients by Med Students in the aftermath of a 2002 CNN story.

Specializes in ER, ICU, Infusion, peds, informatics.
critterlover,

informed consent is the responsibility of the attending physician, not the patient. the patient has the right to informed consent. ama ethics dictate specifically that student involvement must be discussed with the patient (ama policy e-8.087 medical student involvement in patient care). remember folks, there is a big difference between "consent" and "informed consent".

from my perspective there is absolutely no way that i would let a dr. i had never met operate on me, let alone an unnamed med student. i want to not only know their name but to meet them in person beforehand. if a faciltiy is "too busy" to even put involved caregivers names on a form then it's a place i don't want to be.

yes, as the public becomes more aware about the monkey business going on with the consents (withholding until 1 minute prior to being wheeled in to the or, un-named personnel, observers, reps, students, cameras) there will be outrage which will invoke change. as an example look at the numerous states who enacted laws about unauthorized pelvic exams being performed on anesthetized patients by med students in the aftermath of a 2002 cnn story.

sigh.....

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[color=#483d8b]yes, informed consent is the attending physician's responsiblity.

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[color=#483d8b]that is actually what i wrote:

[color=#483d8b]as far at the comment on patients really knowing/understanding the papers they sign, you are going to get me off on a tangent about how it is part of every patient's responsibility to not only read the consent, but understand it and ask questions until they do. it is our responsibility (mostly the attending physician's responsibility) to provide that education, but the patient needs to activly participate and let us know when they don't understand or have questions.

when i wrote "our responsibility," i was speaking as "us" as health care workers. it is mostly the attending physician's responsibility; we as nurses can assist in giving that information (ie, answer additional question). so can medical students and residents. but it the attending physician's responsibility to give the information.

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[color=#483d8b]however, my point is this: the patient (and/or family, if the patient is having difficulty understanding) is not a passive recipient in the process. they need to communicate to us what they don't understand, so it can be clarified. a surgeon may have a "standard lecture"on the risks/benefits/purposes/alternatives to a particular surgery that they have developed over the years. this lecture may work for 90% of his patients, but how is the surgeon going to know about that other 10% unless the patient asks for clarification?

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[color=#483d8b]i can't tell you how many times i've gone in to a patient's room to get a consent signed. i'll ask "has dr. x talked with you about this surger?" when i get a "yes," i'll say "i have the consent form for you to sign. do you understand what is going to happen? do you have any questions that need to be answered before you sign this consent, agreeing to the procedure?" almost without fail, i get a "yes, i understand, and no, i don't have any questions." the consent gets signed. then i find out later that the patient actually has significant questions about the upcoming surgery/procedure.

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[color=#483d8b]yes, the patient has a right to informed consent, but the patient also has a responsibility to let us know when they need more information, and to not just sign the paper placed in front of them.

Specializes in ER.

If a student is doing a procedure I think the patient should not be charged. But then we get issues about two tiered care, and poor people getting the students- which is not the intention. I don't know what the answer is.

I'm looking at the "Conditions of Admissions" form that I had to sign before my surgery at a teaching hospital in Los Angeles (oh, what the heck, it's no secret - Cedars Sinai) Of the many conditions, the one that fits this discussion is No. 5 - Teaching Hospital.

"Patient acknowledges that the hospital is a teaching hospital and as such the training of physicians and surgeons, nurses and other health care personnel takes place at the hospital. Patient understands that nurses, physicians and other health care personnel in training may participate in the operation or special diagnostic or therapeutic procedures specified above under a supervising physician or surgeon, and Patient hereby consents thereto."

It seems too me that the part that says "the training of.........and other healthcare personnel" gives permission for the practice pelvic exams on anesthesized patients that I've read about that takes place in the OR.

(I've accessed a lot of articles about the subject. Not that I understand fully, but it seems that with all the uproar a few years ago about the practice, the most that came from it was a "recommendation" that hospitals get "explicit" permission from the patient. It doesn't say "required", so maybe the hospitals still do it secretly unless a patient objects.)

the part that says...."other health care personnel in training may participate in the operation" seems to give permission to anybody in training to perform surgical procedures on the patient."

the part that says......"procedures specified above under a supervising physician or surgeon..." ( Isn't the Chief Resident the supervising physician if the surgeon isn't in the room? ) If so, then it gives him the right to set the protocol.

There is no place on this form to fill in names or other types of people who might be in the OR. There is no place to opt out. I read one article where a surgeon justified having his high school son and 2 of his friends observe an operation because he was trying to get them interested in medicine.

I'm just curious, what part would you cross out if you didn't want those practice pelvic exams to take place.

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