Jochen P. Son-Hing, MD, FRCSC
Ethics & Professionalism Committee Member
How do we balance our ethical obligations to our patients and our professional conduct with our peers?
Practicing medicine ethically and interacting with our colleagues professionally often intersect. The SRS realizes this and its Standards of Professionalism document for its fellows is titled: “Ethical Practice and Professionalism.” In this scenario, we will examine a case in which protecting a patient’s best interests may also require directly questioning a colleague’s knowledge and intentions.
You are at the scrub sink getting ready for your OR day when a resident you've worked with, assisting in the next room over, enters to get ready as well. When you casually ask what interesting cases are being performed today, the resident tells you that they’re getting ready to stabilize a burst fracture in a 10-year old. The resident says the pictures are up on the computer. You peer through the window into the OR suite and see a lateral image with what appears to be a classic-appearing vertebra plana (Langerhans cell histiocytosis) of the lower thoracic spine without sagittal deformity. When you question the resident about this, you discover that vertebra plana was never mentioned in the preoperative notes and the resident, in fact, is actually unaware what vertebra plana is.
Upon closer questioning, the patient did not have any symptoms of back pain until a minor fall a few weeks ago, at which point he began complaining of mild mid-thoracic back discomfort. There have been no signs or symptoms of neurological involvement and bracing was never mentioned in the preoperative notes either.
How do you proceed?
The most pressing concern is this scenario is that the patient may be about to receive unnecessary surgery. If the patient sustained a benign soft tissue injury during the “minor fall” and the vertebra plana was discovered incidentally, then the patient did not sustain a “burst fracture” and surgery is not indicated for a neurologically and mechanically stable spine. Since the surgery is scheduled to begin imminently, this scenario does highlight the usefulness of a weekly “Indications Conference,” whereby all the postoperative and preoperative cases can be discussed among colleagues and housestaff as both an educational and quality-control endeavor. In the absence of that, a decision now needs to be made as to (a) whether this case merits further preoperative discussion; and (b) how best to implement that discussion.
Regarding (a), there appears to be enough information presented already to warrant gathering further information. If the patient’s legal guardian is present, permission can be obtained for the concerned surgeon to review the patient’s medical record. However, according to the U.S. Department of Health & Human Services’ section on “Permitted Uses and Disclosures,” a covered entity is permitted, but not required, to use and disclose protected health information, without an individual’s authorization, for situations that include “Treatment, Payment, and Health Care Operations.” Health care operations, in turn, include “quality assessment and improvement activities, including case management and care coordination.” If the medical record suggests the treating surgeon is unaware that this patient appears to have vertebra plana rather than a burst fracture, then the patient’s legal guardian will not be able to provide appropriate informed consent. Furthermore, the patient appears to have been asymptomatic prior to the traumatic incident that led to his presentation. Even if the patient had been symptomatic prior to presentation, surgery is generally reserved for progressive deformity (kyphosis) that is refractory to bracing, which apparently had also not been mentioned in the preoperative medical record. This information needs to be verified.
Regarding (b), tact is obviously important but protecting the patient’s interests is paramount. One cannot lose sight of the fact that appropriate decision-making needs to be conducted for the welfare of the patient. The SRS Standards of Professionalism and AAOS Principles of Medical Ethics and Professionalism in Orthopaedic Surgery provide further guidance, for both the treating and concerned surgeons, relevant to this scenario:
- SRS Standards of Professionalis
Providing Musculoskeletal Services to Patients
Standard 4. A spinal surgeon, or his or her qualified designee, shall present pertinent medical facts and recommendations to and obtain informed consent from the patient or the person responsible for the patient.
Standard 5. A spinal surgeon shall serve as the patient’s advocate for treatment needs and exercise all reasonable means to ensure that the most appropriate care is provided to the patient.
Standard 3. A spinal surgeon shall conduct himself or herself in a professional manner in interactions with colleagues or other health care professionals.
Standard 4. A spinal surgeon shall work collaboratively with colleagues and other health care providers to reduce medical errors, increase patient safety, and optimize the outcomes of patient care.
- AAOS Principles of Medical Ethics and Professionalism in Orthopaedic Surgery
Principle II. Integrity. The orthopaedic surgeon should maintain a reputation for truth and honesty with patients and colleagues, and should strive to expose through the appropriate review process those physicians who are deficient in character or competence or who engage in fraud or deception.
Principle VI. Medical Knowledge. The orthopaedic surgeon continually must strive to maintain and improve medical knowledge and to make relevant information available to patients, colleagues, and the public.
Principle VII. Cooperation. Good relationships among physicians, nurses, and health care professionals are essential for good patient care. The orthopaedic surgeon should promote the development of an expert health care team that will work together harmoniously to provide optimal patient care.
The treating surgeon was paged but did not answer immediately. The surgeon-in-chief was contacted and, in consultation with the family, the case was delayed pending further discussion with the treating surgeon. The anesthesia team and nursing staff were apprised of the delay. Upon arrival of the treating surgeon, the preoperative notes were reviewed and confirmation was obtained that vertebra plana had not been considered in the differential diagnosis. The decision was made to cancel the case. The family decided to follow-up with a different surgeon to discuss management options. The treating surgeon agreed and provided names of colleagues both inside and outside the institution, in keeping with the following standard:
- SRS Standards of Professionalism
Providing Musculoskeletal Services to Patients
Standard 8. A spinal surgeon shall respect a patient’s request for additional opinions.
The SRS Standards of Professionalism can be found on the SRS website in the “Members Only Area” under the “Membership” section. It was adapted for the use of SRS, from AAOS.
Chair: B. Stephens Richards III Committee: Kamal N. Ibrahim, Past Chair; James M. Eule; Timothy A. Garvey; H. Robert Tuten; Christian P. DiPaola (C); Sang D. Kim (C); Olavo B. Letaif (C); Jonathan N. Sembrano (C); Paulo J. Silva Ramos (C); Bekir Y. Ucar (C); Anthony M. Petrizzo; Jochen P. Son-Hing; Jacob M. Buchowski; David A. Hanscom; Steven D. Glassman, Chair Elect; Sherif M. El Ghamry; Hee-Kit Wong