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September 2017

Ethics Corner

Kamal N. Ibrahim, MD, FRCS(C), MA
Ethics and Professionalism Committee Chair

The committee publishes in each issue of the newsletter a case of possible ethical or professionalism dilemma and invites members to send their comments. Please send your comments to info@srs.org. The committee will collect all responses, summarize and publish them in the subsequent newsletter.

In this issue Tim Garvey, MD presents an ethical dilemma that could be faced by any surgeon and was not previously explored.

Two cases recently presented ethical challenges regarding never speaking derogatorily about peers out loud with patients and their families during consultations. Cambridge dictionary defines derogatory as, “showing strong disapproval and not showing respect”. In both cases we felt obliged to be open, and inform the patients that the medical advice that they received, was sub-standard. It was not, that we just “respectfully disagreed”, but that rather, we believed that the treatment recommended was truly not appropriate.

Case 1:
A 45 year old millwright had a 7 month history of classic  right S1 radicular pain, with a positive SLR, a right sided HNP at L5-S1, 80% right leg pain, 20 % LBP, and failure of non-operative care. He sought our 2nd opinion. He had NO deformity on standing radiographs. His MRI did additionally show Modic endplate changes at L3-4 and L5-S1. His 1st surgical consult read, “In my hands, he would be best treated with Smith-Peterson osteotomies, and a 2 level AP fusion.” We performed a micro-discectomy and the patient is doing well. We stated to the patient that the proposal “did not make sense”, as there was no objective deformity on which to perform “an osteotomy”, and that a fusion was not indicated, especially a two level A/P, where there was potential 3 level MRI changes.

Case 2:
An 83 year old man with classic pseudoclaudicatory back and leg pain, had multilevel stenosis and spondylosis on imaging. His walking was limited to one block, and sitting was comfortable. He had neurosurgical consultation, which led to his having a 4 level discogram, with all levels rated at 7/10 or higher. In a non-sequitur, a 2 level fusion was recommended. We openly opined that while the discogram was in general “not absolutely contraindicated”, we did not believe in this case that it should have been done, and that the recommendation for fusion was not at all appropriate. If any surgery were to be considered, a decompressive procedure may be an option. This led to the family questioning why an expensive and painful test had been performed, and we acknowledged that we believed that the testing was not appropriate, and that it should not have been done.

In both cases, with fellows present, we did note openly what would be perceived as derogatory statements, i.e. not gratuitously demeaning, but not specifically respectful, concerning surgical care. In both cases, we sent copies of our consults to the original surgeon who gave the 1st opinion. There is an effort now to develop standardized language by peer review committees with respect to competing surgical opinions, with specific thought as to being respectful, and to medico-legal implications.  However, in what most SRS members would find as egregiously flawed treatment recommendations, should we, “Never speak ill” of our peers?

Comments from some of the committee members:

  • One has to remember that, it is a fine line between questioning others’ opinion and making derogatory remarks, which will reflect badly on the surgeon himself (don’t do unto others what you don’t want to be done to you)
     
  • In the U.K. We now have mandated multidisciplinary meetings (usually neurosurgery, Orthopedic, oncology, radiology and pain physician) to discuss any case where the proposed treatment is more complex than a one level fusion. Although the funding is not yet absolutely dependent on this process yet, it is intended to be in the future (for both public and private funded patients).

    We already experience some areas of concern in how to phrase the recommendation of the MDT in the permanent record. We are aware of the need to reflect a variety of opinion - sometimes strongly felt- without prejudicing the professional standing of colleagues or undermining a future medico-legal defense position should a complication arise.

    Careful and non-emotive use of language is required. I have considered the need to perhaps create a stock of standard phrases to reliably reflect opinion in a non prejudicial way.

    For example, in the described cases we might have recorded
    "Opinion was divided"
    "Higher risk surgical options should be reserved for a revision surgery"
    "The additional benefit of fusion is not clearly established in this case"
     
  • These are good cases to present & we all face these scenarios from time to time. Did the 2nd opinion surgeon & trainees simply inform the patients that they felt the original advice was inappropriate or did they openly belittle the 1st surgeons in the presence of the patients? The former is not derogatory on its face, the latter certainly is.

Chair: Kamal N. Ibrahim Committee: John P. Lubicky, Hilali Noordeen, Brent D. Adams (C), Jason Bernard (C), Ryan D. Muchow (C), Timothy S. Oswald, James M. Eule, Timothy A. Garvey, H. Robert Tuten, B. Stephens Richards III, Jochen P. Son-Hing