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Human Beings Serve Our Patients

Wednesday, March 26, 2003

Our society has changed vastly over the years in both positive and negative ways. Despite constant nonlinear changes, our medical community has evolved in a positive way toward better services for patients through improved hospital care, advancing technology, genomic discoveries, better training, improved medical records, outcomes-based therapy and closer self-scrutiny. No doubt society has demanded some of these improvements, but we as surgeons have always striven for improvements and have been critical of ourselves and most of the time auto-correct to the best treatment course. Similarly, in the past hospitals and university centers have stood by us as partners accepting proportionate criticism and blame for errors and inadequate care. Recently, the Institute of Medicine called us to task to eliminate errors and develop better care paths. At first this seemed to be a draconian wake up-call when aired publicly. However, this really was an important message from concerned peers. We really must champion every professional effort to provide the best care or the entirety of our specialty falls under more "rule-bearing" governmental control.

Each of us as surgeons is no more than a human being - some smarter than others, some better trained, and some better organized. Some have excellent bedside manner and some should improve. However, all are just human beings. Hospitals and academic medical centers are comprised of steel and mortar and lots of human beings. Some people are care givers, some are teachers, some are researchers and some are administrators. Some try to teach, provide care, and do research together in difficult times for an academic "tri-athlete". We are all different, as we come from different cultures and backgrounds, many countries, and many different economic roots. But we are all the same as well - we all are human beings. We make mistakes. Of these mistakes 99% are made by caring, hard-working, and well-trained people. Hospital administrators and academic medical centers also make mistakes and 99% of these are not from intent or ineptness, but are from inadequate internal quality oversight, lack of process, or "smug" security that their organization has a corporate culture so well-groomed that it has minimized to the fullest the chance of making a major mistake. However, even these centers are full of human beings - some self-proscribed as "the best" by institutional association and others earning the title.

Now, where am I going with this over-simplified and obvious diatribe? Cardiothoracic surgeons have the task of performing the most complex operations on the most complex patients. The simplest thing we do is stop the heart and start it again! Nevertheless, in the face of increasingly more difficult operations, we have been able to reduce surgical mortality for coronary, valve, congenital, and transplant surgery to levels unimaginable 15 years ago. More lives are saved than ever. In this complex environment all of us can make non-intended mistakes in our practice in the operating room, in the ICU, or during aftercare.

I have always considered that the victories are the team's -- the nurses, the physician assistants, and the residents--, and the failures are mine, no matter the etiology. This is how the captain of every team should feel! The same should be true for a University Medical Center. When an institution fails a patient and family, the institution must step up immediately and shoulder the majority of the responsibility. The chief of surgery and the hospital president should be available for questions. Unfortunately, when these types of problems arise the outcome often is devastating to the patient, the family, and to society in general. Respect for the general medical community suffers. The level of scrutiny by agencies increases, forcing mandated oversight, the malpractice climate shifts away from tort reform, and we are all viewed as careless. If it happened there, it must be happening in our hospital!

Medical care today is a complex, multi-centered process and not an individual act. It is stewarded by series of human beings. They can, do, and will make mistakes. Recent events in our profession have called this question to my mind. When a young competent surgeon, who participates in a cascade of devastating problems, is singled out as the main instrument of a mistake, then the institution has failed all of us, surgeons and society alike. It is amazing that a large number of human beings can make a large devastating mistake - however, they can because they are human beings. Any industry - any government - any society and any individual can make a mistake, albeit perhaps not as devastating to a patient or family as a medical mistake.

In my opinion it is the responsibility of medical institutions to step up to the podium first when these types of problems arise. Is it fair to society to ruin the career of a well-trained, caring surgeon, with twenty years of service ahead, and who has already provided excellent care to hundreds, perhaps thousands, of patients - who makes an error? Although a surgeon may have been part of, or even central to the cascade of events, that individual cannot be solely responsible. When operations, like organ transplantation, are orchestrated through a complex mult-institutional and multi-agency process involving human beings, then there are greater chances for errors. Thus, the institution must responsibly respond and answer the questions, but in the context that this young surgeon is only a cog in the organization, who participated at the end of a cascade of events. If our hospitals and universities institutions abandon their surgical human beings - who will serve in the future?

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