"ghost surgery"

[Ailan]

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.

[CritterLover, BSN, RN]

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.

if i were to need a simple surgery, lets say a tubal ligation, (since that is fairly simple and elective), i would not have it done at a "teaching hospital." i would more than likely have it done at an op surgery center. (the major reason for this, to me, is that op surgery centers cater to patients that are having simple procedues, they get you in and out, and delays are less likely [though delays could still happen]).

[color=#483d8b]before the surgery, i would ask my surgeon if he/she was doing the entire procedure, and if not, who else would be participating. since there is a very good chance the surgeon would be an ob/gyn, i would ask if they were on-call for deliveries that day, and if so, who would be his/her backup if my surgeon were to be otherwise occupied with an ob issue at the time of my scheduled surgery. or would i have to wait in pre-op until my surgeon was available?? (for the record, unless i had an "issue" with one of the parteners in that group, i'd just as soon have someone else do the surgery than wait). i would also ask if there were going to be med students/residents involved, and if so, what their involvement would/could be. if i objected to any of that, i'd make certain my surgeon knew, and i'd put my objections in writing.

[color=#483d8b]at the surgery center, i would ask about the mda/crna/srna. i'm not opposed to being "put to sleep" by a srna, and i'm not opposed to nursing students/sales people watching (unless i knew them personally -- just me). i would ask, though.

[color=#483d8b]however, if i had to have major surgey, i'd approach things differently. lets say i had to have an esophagogastrectomy. this is a very complicated procedure requiring two specialties -- thorasics and general/onc surgery. i would want it done at a major teaching hospital, and i'd expect that residents/medical students would be involved. i'd ask if the attending was going to be "present" or only "available." i'd ask what the "minimum" level of experience was guaranteed to be present during the surgery. (different facilities have different supervisory requirments. at one hospital i worked at, the residents couldn't operate alone until their 4th year. at another, it was 3rd year for some surgeries). and again, i'd ask about all of this way before hand, at the office consultation. if i was diagnosed while in the hospital, then i'd ask as far in advance as i could.

[color=#483d8b]if i wasn't happy with those answers, i'd ask about changes. "i'm not comfortable with you not being in the or the whole time. can we change that?" i have the right to ask -- though i might not get the answer i want, and then i have a decision to make -- have the surgery anyway, or look for a facility and surgeon to accomodate me.

[color=#483d8b]if any med students were going to be present (and i'd be expecting that some were going to be present) i'd ask what their role would be, as well. i could be wrong about this, but surgery rotations are pretty competative. most medical students are going to be doing one of three things: watching, holding things, or working the "sucker" (suction). they are pretty much considered to be "slave labor." they might, if they are really lucky, get to help close. and honestly, if i'm that sick, i don't care who is weilding the staple gun.

[color=#483d8b]there are many things that are good about residents doing the surgery. one is oversight. they have answer to someone on a daily basis -- not just to a peer review committee should something go bad. (this is one of the reasons why i almost always loved working with residents in an icu setting. they are held accountable). a second is that they are learning the newest techniques; they keep up with what is current in best practices. they don't just do a surgery a certain way because that is how they always did it.

[color=#483d8b]as for the "conditions of admission" you have, did you need to sign it? if so, then you could have lined out any part you didn't agree with. (if i objected, i'd have lined out the "patient hereby consents thereto" part, and asked to speak with someone about my objections).

[color=#483d8b]as for the pelvic exam issue, i don't know if that is still done. if i were having gyn surgery at a teaching hospital, i'd probably ask. i agree that this is something that a patient should have to give explicit consent for, but that is because it isn't an essential part of the procedure, so to me it isn't covered when i give permission for a medical student to "participate." if i were having pelvic surgery, i don't think i'd object to a student inserting the speculem (or whatever is used) as "participation," but i'd feel abused if they all were lined up and each got a try (which is what i seem to remember happening in that cnn story, though it has been a while since i read that). (for the record, i had a pelvic exam done by a student[fnp student] once [while awake, as part of my annual exam] and i have to say that having students do their first one while the patient is general anesthesia isn't such a bad idea)

[color=#483d8b]i understand that not everyone knows what questions to ask, but that is true anytime we get involved with something we arn't experts in. oh, the questions i wish i had asked when i bought my house.

[color=#483d8b]i'm really trying to emphasize that i don't think students/residents participating in surgeries is such a bad thing. it isn't as though they send a medical student (or first year resident) in and say here -- go do this appendectomy. there are degrees of participation and involvement. to me, that is the "price" that is paid for having surgery done at a teaching facility. the benefit is the experts in the field, the research being done, and the available technology.

[Ailan]

I've learned so much from this thread. I think you're all great. Your patients are very lucky indeed:cheers:

Critterlover, I'm printing out your suggested questions for the surgeon before surgery. It's going in my hospital file. Thanks for that!:paw:

[RN60453]

I just began a new OR job in a teaching hospital and was an extern in the OR for a year before taking an RN position. I know that all the patients that have surgery in this hospital are worked on by an attending and a resident and quite possibly a med student as well as an anesthesia attending and his resident and med students that may follow them. I don't see it as a problem that they are not on the consent because the residents always introduce themselves before the procedure, the surgical residents even do the 24 hr physical before the surgery starts and anesthesia residents start the IV lines. In essence the patient meets almost everyone that will be in the OR room except for the scrub. If patients have an issue on who will be in the room it is within their rights to refuse. From what I was told at another teaching hospital when the same question came up, is that patients enter a teaching hospital knowing that it is a teaching institution and will be worked on by students and residents. How that works for people entering the ED i don't know.

[subee, MSN, CRNA]

I've learned so much from this thread. I think you're all great. Your patients are very lucky indeed:cheers:

Critterlover, I'm printing out your suggested questions for the surgeon before surgery. It's going in my hospital file. Thanks for that!:paw:

Ailan: you sound like a mature person who realizes that life is imperfect. Once people can accept those three words, they can move on to being comfortable with reality. The process of what happens to a patient in the OR will never be perfect, never ever, ever. We're just humans working in a very intense environment where you don't get to eat, pee or relax when you want. The large majority of staff wants to have as easy a day as possible. So that means that you have to work very hard to keep the karma good - when bad things happen to patients, its a disturbing day for everyone. Its all a great big assembly line except that you can't leave a sandwich inside the product you're working on.