Clinical Case for Discussion: You are the Medical Director of a freestanding surgery center. A surgeon at the facility has a serious perioperative complication which leads to a bad outcome. You believe that his management was below the standard of care. What do you do?
Discussion: You put on your best Dirty Harry sneer and say, “Punk, we don’t want your kind in these parts no more.” Then you wake up from your daydream, and deal with the reality of an unpleasant responsibility. Playing policeman with your surgical colleague’s privileges is not on any anesthesiologist’s Top Ten list.
There is a growing trend of surgical cases moving away from hospitals to freestanding facilities. Each of these outposts must have medical leadership. Anesthesiologists are ideally suited for Medical Director jobs, because of their training and expertise in perioperative patient care. In addition, duties include quality assurance (QA) monitoring, setting policies and procedures, preoperative consultation regarding appropriateness of particular patients for the facility, and medical staff credentialing.
The phrase “Standard of Care” is defined as “the level at which an ordinary, prudent professional having the same training and experience in good standing in a same or similar community would practice under the same or similar circumstances.” When a physician is suspected of practicing below the standard of care, the facility he or she is practicing at may initiate an investigation of his or her clinical practice. In addition, if there was an adverse patient outcome, the medical malpractice system may initiate legal action to investigate the physician’s role in the adverse outcome.
This column will discuss only the investigation of the physician by the medical facility, and will not address the workings of the medical malpractice system.
When an adverse patient outcome occurs, the QA system at a surgery center begins with telephone calls to the Medical Director to inform him or her of the event, followed by written incident reports to document the details of what occurred. The Medical Director is responsible for screening for:
(1) errors in the system which contributed to the patient’s outcome,
(2) errors in judgment, or
(3) practice below the standard of care.
Goals are to:
a) improve any system problem which lead to the complication,
b) identify educational opportunities to prevent future incidents, and
c) identify if an individual may have practiced below the standard of care. The medical-legal system defines standard of care as what a reasonably competent practitioner of that specialty would do in the same setting.
What will you do as Medical Director if after careful review of the medical records and incident reports, you believe the surgeon’s management was below the standard of care? Each facility you work at, including a hospital or any surgery center, has a document called the Medical Staff Bylaws. Most physicians throw their copy into a file cabinet and never read it. In a case like we are examining today, the Bylaws are the road map for what to do next. A typical Bylaw pathway might be as follows: (Reference: Bylaws of the Waverley Surgery Center in Palo Alto, California.)
(1) Investigation. The QA committee, with representatives of all specialties, reviews the case. (At different institutions, this committee may have a different name, such as the Medical Advisory Committee, or the Medical Care Evaluation Committee.) They may appoint an Ad Hoc Investigation Committee of relevant specialties to gather facts and circumstances. The Investigation Committee will report back to the QA committee with their consensus.
(2) Interview. The physician is interviewed by the QA committee.
(3) Actions. The QA committee may: a) take no action, b) issue a warning, c) recommend a term of probation, d) recommend a reduction or suspension of privileges, or e) recommend suspension or revoking of medical staff membership.
(4) Request for a hearing. The physician may appeal and request a hearing following suspension or revoking of privileges. An Ad Hoc Hearing Committee composed of unbiased members of the medical staff not previously involved in the investigation is chosen. The physician is physically present for the hearing, and may have an attorney present. The meeting is tape recorded, and all evidence is heard. The majority decision of the Hearing Committee is usually final. A system for appeals exists.
(5) Any suspension or revocation of privileges must be reported to the Medical Board of California, and the National Practitioner Data Bank. Being reported to these two is a very big deal. In the surgeon’s future, every application to every hospital or surgery center, and every medical license renewal would have to include this information.
Despite the obvious perks of stretch limousines, penthouse suites, and groupies, the Medical Director job comes with some serious responsibilities. Investigating another physician’s practice is difficult, time-consuming, and can be emotionally taxing for everyone involved. Ignoring potentially substandard care is a mistake, however, that can result in further mishaps and the possibility of further patient harm in the future.
Dirty Harry exists for doctors too, but it is a system, not an individual, that does the dirty work. The Quality Assurance investigative system is a chore and and obligation for a Medical Director, but it’s an important and essential chore.
Published in September 2017: The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.
In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.
Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.
Nuanced characterization and crafty details help this debut soar.
Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:
Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below: