Surgical misadventure: The production and mitigation of serious complications in surgery

This research draws on the Normal Accident Theory literature and on a variety of sociological “shop floor” studies from medicine, aviation, and other high-risk domains to critique and reformulate current views of how adverse events are produced in health care settings. Organizational error is both a category of deviance that is central to the maintenance of professional identity, and a reflection of the maturational and diffusional processes that characterize the growth of high technology. An increasing societal concern with safety stems from the growing complexity, potency, and invisibility of many new technological systems. We must pay attention to the requirements for organizational and individual learning that accompany the growth of technology if we are to control its potential for danger. In the medical context, this translates to a concern with how to impart experience with disease processes and treatment technologies to individuals, cohorts, and social networks of medical practitioners. Statistical models are used to examine adverse events among adult surgical patients at acute-care Pennsylvania hospitals from 1997–1999. Hierarchical nonlinear (multilevel) models are used to predict accidental injury errors, major complications, and death among patients with complications (“failure-to-rescue”). The models incorporate patient-level predictors and hospital fixed effects for risk adjustment. Variation in risk-adjusted patient-level outcomes is then predicted using surgeon-level variables, including measures of experience, case mix, and surgeon-hospital integration. These models provide mixed support for the hypotheses examined. Surgeon specialty certification has inconsistent estimated effects on adverse events, depending upon the outcome examined. More consistent effects are found for various surgeon practice characteristics, including total surgical volume, case specialization, and average admission severity of illness. In general, surgeons who perform more procedures, surgeons whose case loads are more specialized, and surgeons whose patients exhibit a higher level of illness severity tend have better outcomes, net of the characteristics of individual patients. Poor surgeon-hospital integration predicts some adverse events. Physician-specific effects appear to be more important in the prevention of major complications than in the prevention of death once a complication has occurred

Surgical misadventure: The production and mitigation of serious complications in surgery

This research draws on the Normal Accident Theory literature and on a variety of sociological “shop floor” studies from medicine, aviation, and other high-risk domains to critique and reformulate current views of how adverse events are produced in health care settings. Organizational error is both a category of deviance that is central to the maintenance of professional identity, and a reflection of the maturational and diffusional processes that characterize the growth of high technology. An increasing societal concern with safety stems from the growing complexity, potency, and invisibility of many new technological systems. We must pay attention to the requirements for organizational and individual learning that accompany the growth of technology if we are to control its potential for danger. In the medical context, this translates to a concern with how to impart experience with disease processes and treatment technologies to individuals, cohorts, and social networks of medical practitioners. Statistical models are used to examine adverse events among adult surgical patients at acute-care Pennsylvania hospitals from 1997–1999. Hierarchical nonlinear (multilevel) models are used to predict accidental injury errors, major complications, and death among patients with complications (“failure-to-rescue”). The models incorporate patient-level predictors and hospital fixed effects for risk adjustment. Variation in risk-adjusted patient-level outcomes is then predicted using surgeon-level variables, including measures of experience, case mix, and surgeon-hospital integration. These models provide mixed support for the hypotheses examined. Surgeon specialty certification has inconsistent estimated effects on adverse events, depending upon the outcome examined. More consistent effects are found for various surgeon practice characteristics, including total surgical volume, case specialization, and average admission severity of illness. In general, surgeons who perform more procedures, surgeons whose case loads are more specialized, and surgeons whose patients exhibit a higher level of illness severity tend have better outcomes, net of the characteristics of individual patients. Poor surgeon-hospital integration predicts some adverse events. Physician-specific effects appear to be more important in the prevention of major complications than in the prevention of death once a complication has occurred

Disciplinary careers of drug-impaired physicians

Alcohol and drug abuse are among the leading reasons for disciplinary action against physicians by state licensing authorities in the United States. I use event history models to describe the longitudinal patterns in disciplinary actions taken against physicians' licenses by state medical boards in the United States, 1990-2000. Adverse licensure action episodes that included discipline for drug or alcohol abuse were more likely to be followed by license restoration than episodes that did not. However, those restorations were also more likely to be followed by subsequent disciplinary action than episodes that did not include discipline for drug abuse. Furthermore, disciplinary licensure actions for drug abuse were the category most likely to be followed by a subsequent action for the same reason over the longer term (4-11 years). The increased risk of repeat disciplinary action associated with drug abuse may result in part from intensive surveillance of physicians who complete impaired physician programs, through mechanisms that include urine screening. However, it is also likely that the chronic nature of addiction leads to continued risk of relapse even among physicians receiving appropriate treatment.Impaired physicians Event history Drug abuse Physician licensure Physician discipline

Evaluation of missing data in an assessment of professional behaviors

BACKGROUND: The National Board of Medical Examiners is currently developing the Assessment of Professional Behaviors, a multisource feedback (MSF) tool intended for formative use with medical students and residents. This study investigated whether missing responses on this tool can be considered random; evidence that missing values are not random would suggest response bias, a significant threat to score validity. METHOD: Correlational analyses of pilot data (N = 2,149) investigated whether missing values were systematically related to global evaluations of observees. RESULTS: The percentage of missing items was correlated with global evaluations of observees; observers answered more items for preferred observees compared with nonpreferred observees. CONCLUSIONS: Missing responses on this MSF tool seem to be nonrandom and are instead systematically related to global perceptions of observees. Further research is needed to determine whether modifications to the items, the instructions, or other components of the assessment process can reduce this effect

The relationship between direct observation, knowledge, and feedback: results of a national survey

BACKGROUND: Multisource feedback can provide a comprehensive picture of a medical trainee\u27s performance. The utility of a multisource feedback system could be undermined by lack of direct observation and accurate knowledge. METHOD: The National Board of Medical Examiners conducted a national survey of medical students, interns, residents, chief residents, and fellows to learn the extent to which certain behaviors were observed, to examine beliefs about knowledge of each other\u27s performance, and to assess feedback. RESULTS: Increased direct observation is associated with the perception of more accurate knowledge, which is associated with increased feedback. Some evaluators provide feedback in the absence of accurate knowledge of a trainee\u27s performance, and others who have accurate knowledge miss opportunities for feedback. CONCLUSIONS: Direct observation is a key component of an effective multisource feedback system. Medical educators and residency directors may be well advised to establish explicit criteria specifying a minimum number of observations for evaluations

Assessment of professionalism:recommendations from the Ottawa 2010 Conference

Over the past 25 years, professionalism has emerged as a substantive and sustained theme, the operationalization and measurement of which has become a major concern for those involved in medical education. However, how to go about establishing the elements that constitute appropriate professionalism in order to assess them is difficult. Using a discourse analysis approach, the International Ottawa Conference Working Group on Professionalism studied some of the dominant notions of professionalism that can lead towards a multi-dimensional, multi-paradigmatic approach to assessing professionalism at different levels: individual, inter-personal, societal-institutional. Recommendations for research about professionalism assessment are also presented.http://informahealthcare.com/loi/mt