Attending surgeons aren't always there

Concerns are being raised about just who is wielding the scalpel
January 21, 2002


BY PATRICIA ANSTETT
FREE PRESS MEDICAL WRITER


Ronald Miller and his family can't help but wonder: Who would select a doctor if they knew the physician would not be in the room -- or even nearby -- for an entire operation?

Questions for your doctor
If you are planning surgery, consider adding a simple question to your list of issues to discuss with your doctor.
"Will you be there for me, doc?"

Patients might want to ask a physician what his or her policy is about determining which portions lesser-experienced physicians-in-training will do, and whether the physician stays in the room to oversee the work.

"If you are signing a permission statement allowing someone to operate on you, it seems reasonable to ask who will do the operation and where the doctor will be," said Dr. Sidney Wolfe, director of Public Citizen's Health Research Group, a consumer health agency in Washington, D.C.

Consumers can report cases involving death or serious injury to the Joint Commission on Accreditation of Healthcare Organizations, 630-792-3700. To review the Oakbrook Terrace, Ill., commission's voluntary system visit its Web site at www.jcaho.org.
If you have Medicare insurance and question whether a physician performed surgery for which he billed the agency, you can file a Medicare fraud complaint with the federal Office of Inspector General, 800-447-8477. Complainants share in a portion of any settlement.

By Patricia Anstett

Miller, 65, of Warren is a quadriplegic, unable to walk or use his hands and arms, after back surgery Sept. 27 at Detroit's Harper University Hospital.

The family sought out Dr. Fernando Diaz, a nationally respected neurosurgeon at the Detroit Medical Center, for the operation.

But two Harper operating room staffers said Diaz only was present for a third of Miller's three-hour operation, leaving the work to four physicians in training as neurosurgeons. Both operating-room staffers said Diaz did not enter the room until at least 11 a.m., long after Miller's neck was positioned for surgery. A leading neurosurgery textbook lists neck positioning as one possible reason why spinal-fusion operations fail.

In an e-mail Friday, after being asked if he was present for the positioning of Miller's neck during surgery, Diaz responded through a spokeswoman: "Positioning took place by the surgical team. I then verified the positioning was correct before the patient was prepped for surgery."

The staffers who said Diaz was not in the room during most of Miller's surgery asked not to be identified to avoid jeopardizing their careers.

Diaz's exact whereabouts before 11 a.m. -- as well as any instructions he gave to the surgery team when he was outside the operating room -- are not known. Diaz split his time then between Harper's operating rooms and his office, located at that time two blocks away at the DMC's headquarters in Orchestra Place. Since July, Diaz has been chief medical officer of the health system, overseeing all physician issues.

Diaz declined a Free Press interview request. He and officials at the Detroit Medical Center, parent company of Harper, said they could not talk about the case because patient records are confidential, even though the Miller family gave the DMC written permission to discuss the case with the Free Press.

But in response last month to several written questions from the Free Press, Diaz said that Harper's academic teaching standards "are in place to assure our training and patient care are of utmost quality."

"In complex cases, there is an immediate accessibility plan that ensures the resident and attending surgeon discuss the case in advance and stay in touch during the procedure," Diaz's statement said. Diaz said he helps patients "understand that the residents will perform the open and closing procedures and that I will be in the operating room during the critical part of the surgery."

Attendance at issue
The Miller case comes at a time when national medical organizations and federal agencies have tried to tighten guidelines about a practice known in medical and legal circles as ghost surgery. The term is used to describe doctors who bill for procedures they do not completely do themselves.

No conclusion has been reached yet about whether that was the case in Miller's operation. There's disagreement, however, over how much time Diaz spent in the operating room during Miller's procedure.

The most recent guidelines were issued in October by the Association of American Medical Colleges, the national organization representing the nation's medical schools. AAMC requires supervising physicians to be "immediately available on site at all times," in "circumstances in which urgent judgments by highly experienced physicians are typically required . . ."

Supervising doctors can "provide adequate supervision off site" for "other, less precarious circumstances," the guidelines say.

The Centers for Medicare and Medicaid, which runs Medicare, also requires supervising physicians who bill Medicare for payment to be present "during all critical and key portions of the procedure and be immediately available to furnish services during the entire process."

Supervising doctors "must direct care from such proximity as to constitute immediate availability," Medicare guidelines say.

Miller has supplemental Medicare insurance, as well as coverage through Aetna and DMC Care, a health maintenance organization.

The federal Office of Inspector General, which investigates fraud, has recovered more than $150 million in the past few years after physicians billed Medicare for work done by improperly supervised residents.

If it does investigate the case, the Office of Inspector General would have to determine whether Diaz billed Medicare for work younger physicians performed and whether Diaz sufficiently supervised residents assisting him in Miller's surgery.

Keeping track
Some institutions, including the University of Michigan Medical Center, ask nurses to log entry and exit times of physicians into a computer, and document which doctors perform various parts of a procedure.

Harper does not have such a system. Nurses are required to sign in and out, but physicians use an honor system that requires them only to dictate brief notes on an operation describing their role in a procedure. The notes are part of a patient's records.

Several years ago, Harper instituted a system requiring doctors to sign a paper when entering and leaving surgery, but the process was dropped because doctors didn't follow it, according to Dr. Donald Austin, a Harper neurosurgeon who has challenged Diaz for 10 years on various departmental issues.

Dr. John Crissman, dean of the Wayne State University School of Medicine, said he considers the U-M system a "good idea." He said he did not know why Harper and other DMC facilities don't require more documentation about a physician's entry and exit times from surgery.

Crissman sought out Diaz for a back procedure five years ago: "He's an excellent neurosurgeon." Asked whether Diaz was present throughout the procedure, Crissman said: "I presume so."

A handy man
Family and neighbors know Miller as an exceptionally kind, friendly man who gave coffee to the mail carrier.
"He was real active, always doing things and puttering around," said Donald Sabalinski, who lives across the street from the Millers in the neighborhood of mostly ranch homes in Warren.

Among family, Miller was such a handyman that his three sons nicknamed him Duct Tape. He and the boys remodeled the family's home, and Miller helped many friends with electrical and plumbing jobs, said his son, Mike.

Miller, who retired in 1994 from Detroit Edison, worked two days a week at a local snow-removal company, doing odd jobs. Since early summer, Miller had lived with numbness and tingling in both hands and feet, and his gait was slightly more wider-spaced than usual, said his wife, Pat, who has worked at Harper for 18 years, most recently as a cardiothoracic nurse.

Miller's surgery was an attempt to stabilize his spine by removing portions of a collapsed disc, the spongy tissue between back bones, then fusing small back bones with bone chips and metal plates to shore up the disc and spinal column.

About 258,000 people underwent spinal-fusion surgeries in 1999, according to the American Association of Orthopaedic Surgeons. Paralysis is rare.

"Spine-fusion surgery to strengthen an unstable spine has been evolving for a long time," said Dr. H. Harvey Gass, medical consultant and chairman of the claims committee for ProNational Insurance Co., an Okemos-based physician insurance company. Much of the outcome depends "upon the particular experience accumulated with a given technique and by a given surgeon," Gass said.

A leading physician reference manual, "Neurosurgery, 4th edition," by Dr. Julian Youmans, estimates that 3.3 percent of the time, myelopathy, or a spinal-cord disorder, worsens after fusion surgery. Neurological deficits after the surgery "are most likely related to surgical trauma, to injury during positioning, or to manipulation of the neck during intubation," in which a tube is inserted into a patient's mouth or nose to aid breathing during surgery, the manual states.

Risks involved
Miller was told that the operation had some severe risks, including paralysis, stroke, heart attack, coma and even death. He consented. He entered the operating room at 7:35 a.m., along with the first four operating room nurses. Surgery began at 9:25 a.m., medical records show.

In addition to Diaz, the operating team included four neurosurgery residents, an anesthesiologist, an anesthesiology resident and seven nurses.

Operating room personnel were concerned about the positioning of Miller's neck during surgery, one of the operating room staffers said. The operation continued when one of the doctors said the positioning was exactly as Diaz had instructed.

Diaz came in around 11 a.m., for a key portion of the surgery in which portions of the disc were removed and bone chips were inserted, observers who were present said. He left before noon, one of the operating room staffers said. The other said Diaz stayed about 40 minutes: "He did not come, except for his little piece."

Diaz called the Miller family in the Harper surgical lounge, before the operation ended at 12:22 p.m., to say "everything was fine" and that Miller probably would go home the next day, Pat Miller said. Relieved, several family members went to lunch.

But within two minutes of the operation's completion, recovery room nurses saw that Miller was unable to move his legs and arms.

Diaz called a second time, around 1:30, Mike Miller said, asking to meet the family in person.

"The surgery went very well but there are some complications," Pat Miller recalled Diaz telling her and two of her sons. He told them he wanted Miller to have a magnetic resonance imaging (MRI) test because he feared Miller's spinal cord was swelling, putting him at risk of severe complications. The MRI confirmed that Miller's spinal cord was swollen and had softened. By 2:30 p.m., Miller was wheeled a second time into the operating room for surgery much like his first.

Diaz told the family that he wanted to try to free up Miller's spinal cord, to give it more room to move. He also wanted to remove bone and insert metal plates on each side of Miller's neck, Pat Miller said. He outlined his surgical plan to the family on a dry-erase board.

The second operation did not go as hoped. Diaz would later tell the family that Miller had lost a lot of blood, and that he was unable to put extra braces in the neck. "But he didn't think there was a problem," Mike Miller recalled Diaz telling the family. "He said he could always go back in later" to insert the metal braces, Mike Miller said.

Internal review
Harper's internal process includes departmental "morbidity and mortality" reviews of cases involving death and serious injury. These are peer review boards, usually attended only by doctors in a particular speciality.

Harper's neurosurgery department conducted its monthly review Dec. 5. Diaz commands a presence at the meetings not only because he once ran the department but because of his job as chief medical officer at the DMC.

Austin, who attended the meeting, said Diaz insisted that he was present for most of the Miller case. This included the important placement of a tube in Miller's nose at the beginning of the operation, through which anesthesia was administered, and for the positioning of Miller for surgery.

Diaz told departmental personnel at the meeting that they did not consider the Miller case a so-called sentinel event because Miller's outcome wasn't unexpected, given a severe, progressive, compression of part of his spinal cord, Austin said.

Sentinel events, according to the Joint Commission on Accreditation of Healthcare Organizations, are medical procedures resulting in death or serious injury. The commission encourages, but doesn't require, hospitals to report sentinel events.

Harper did not report the case, said JCAHO spokeswoman Janet McIntrye. Anyone can report concerns about a sentinel event to the commission.

The agency conducted a preliminary review and concluded that the Miller case did involve a sentinel event. As a result, the agency required Harper to conduct a 45-day review of the case to see whether Harper's standards ensure patient safety.

Harper completed its review Jan. 9, McIntrye said. She said she only could disclose that the hospital officials must write a followup report in six months.

Dr. Joseph Bander, vice president of medical affairs at Harper University Hospital, also attended the neurosurgery meeting. He and Dr. Tammy Lundstrom, chief quality officer for Detroit Medical Center, said they were confident important issues are addressed through the hospital's internal system.

"We have good policies and procedures in place," Lundstrom said.

Bander added: "Whether it's a private physician or chief medical officer at the DMC, the same rules apply."

A lengthy stay
Miller spent nearly two months in the hospital. He developed pneumonia, breathing problems, soaring blood pressure and an intestinal obstruction.

Once stabilized, he was transferred to a spinal cord unit at Detroit Receiving Hospital and eventually to the Rehabilitation Institute of Michigan, both DMC hospitals near Harper. He went home Dec. 12.

His sons built a ramp so they can easily get his wheelchair in and out of the house. Pat Miller is on a medical leave to care for her husband. Miller's brother, Art, and many of his friends, stop by daily to talk to Miller and help him with his therapy.

The family has contacted a Southfield attorney, Lawrence Falzon, because the DMC has refused to give the family Miller's medical records, Falzon said. Miller, a lifelong right-hander, is encouraged that he feels some strength on his left side, and that he can wiggle a toe. Therapy has helped him raise his hands an inch or two. He needs help to hold his hand for a handshake.

"I think I do really well, with all the help I do get" from friends and family, he said. He breathes with difficulty and tires easily, but continues to be hopeful. His most immediate goal is to sit up by himself.

"One day at a time, I guess," he said.


Contact PATRICIA ANSTETT at anstett@freepress.com or 313-222-5021.


MORE HEALTH