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Surgeon behavioral failures key in liability claims.

NEW YORK -- Surgeons are shining a spotlight on their own common behavioral deficiencies as a key preventable element leading to liability claims.

At least one discrete behavioral deficiency was identified in 78% of 460 closed liability claims against general surgeons in a national review of cases involving payouts in excess of $25,000, Dr. E. Dean Griffen reported at the annual meeting of the American Surgical Association.

"These data are interesting in that they show that a technical misadventure in itself is a disaster, surely, but on the other hand, when technical misadventures occur in the presence of behavioral violations, we create a perfect storm," observed Dr. Griffen, a Shreveport, La., general surgeon who chairs the American College of Surgeons' Patient Safety and Professional Liability Committee.

The study involved a closed-claims review panel composed of 40 board-certified surgeons who identified up to five distinct behavioral deficiencies in some cases.

Dr. Griffen defined the behavioral dimension of surgical practice as those elements of care requiring time, patience, commitment, and diligence, rather than knowledge and skill. The most common behavioral failures, in descending order, were inadequate communication with patients; failure to pursue an abnormal sign, symptom, or test result or simple postoperative problem; inadequate assessment of primary surgical problems before surgery; not enlisting consultant support in a timely way; and failure to obtain cross-coverage.

Other common behavioral failures included operating outside one's proper scope of practice, failure to assess comorbidities before surgery, and not checking test results.

Behavioral deficiencies were significantly less frequent in closed claims involving older and emergency patients. For example, patients over age 59 years were involved in 35% of cases that didn't involve behavioral deficiencies but only 25% of cases with behavioral deficiencies. Similarly, patients receiving emergency care made up 37% of cases involving no behavioral violations and only 18% with behavioral shortcomings.

Dr. Griffen's report prompted frank soul searching among his fellow surgeons.

"He has shown who the enemy is--and it is us," commented Dr. James A. O'Neill Jr., professor and chairman of surgical sciences at Vanderbilt University Medical Center, Nashville, Tenn.

Dr. Alden H. Harken observed that patients understand that to err is human, and they accept it.

"What they don't accept is the misbehavior or the behavioral stumble," he continued.

"We surgeons are pretty good with the basic knowledge and the clinical skills. Where we stumble is in the interpersonal skills and the professionalism," said Dr. Harken, professor and chairman of surgery at the University of California, San Francisco, East Bay Campus, Oakland.

Dr. O'Neill said a Vanderbilt closed-claims study showed behavioral deficiencies figure prominently in lawsuits involving all specialties, not just surgeons. Because physicians with behavioral problems have an increased number of liability claims, Vanderbilt now requires that those identified as having a behavioral problem must enter an intervention program or lose their privileges.

Dr. Graeme L. Hammond proposed that all surgeons be required to have a yearly physical examination that includes history to identify incipient medically related behavioral problems.

"There are certain conditions surgeons can slip into without even knowing they're having a problem, such as depression, alcoholism, and diabetes, where they can be perfectly normal and all of a sudden they start making mistakes and can't quite put their finger on the problem," said Dr. Hammond, professor of surgery at Yale University, New Haven, Conn.


Denver Bureau
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Title Annotation:Gynecologic Surgery
Author:Jancin, Bruce
Publication:OB GYN News
Date:Aug 1, 2008
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