Laparoscopy Today

Keynote Address: Adaptive Innovation

FROM THE 16TH SLS ANNUAL MEETING AND ENDO EXPO 2007, SAN FRANCISCO, CALIFORNIA, SEPTEMBER 5–8, 2007

PRESENTED BY JOHN KENAGY, MD, MBA

John Kenagy, MD, a vascular surgeon broke his neck. “Despite the system, said Kenagy, “I had good outcomes.” The system got in the way; but, the good outcome was because of people going the extra mile. He is walking, talking, and has no impaired movements. However, he cannot practice surgery, so he went into management. He helps managers find solutions. It is important to understand that future success is based on one’s ability to adapt to a changing environment, said Kenagy. Current organizations will stall or block adaptive change. According to Clayton Christensen, it is almost impossible for established companies to be innovative. When an industry transforms, it starts at the low end, not the high end. But it is difficult for management leaders to make the leap from the high end to the low end. Toyota is so successful because it is “designed to adapt.” How can a company become adaptive? What is adaptive design? It is adaptive innovation and Toyota combined.  First, establish an operational framework that fosters high performance and innovation focused on the patient. Second, eliminate ambiguity, assumptions, work-arounds, and tradeoffs. Third, develop every person’s skills, knowledge, creativity, and problem-solving ability. Fourth, embrace the team. And fifth, make inquiries if things aren’t working smoothly. Key points to remember are the following: senior management must decide where it wants to be; realize that advice of experts is usually useless; discover the adaptive spectrum of opportunity; inventory what you’re doing and rebalance your opportunities; execute your intentions; and the role of management needs to be revitalized. Adaptive units always outperform others. “It is not the strongest who survive,” said Kenagy, “but the most adaptable.”

The Interviewing Process

GUSTAVO STRINGEL, MD   

According to Webster's Dictionary, a job interview is “a formal meeting in which one or more persons question, consult, or evaluate another person.” During our professional lives, we all are subjected to the interview process. It is important for the process to establish the reason for the interview. Is it for a professional purpose, or perhaps for personal, business, or other reasons? I will focus on the professional aspect of interviewing, mainly related to our careers in medicine. In this first article, I will limit the discussion to the interview process from the point of view of the candidate.

GETTING THE INTERVIEW:
Resume or Curriculum Vitae?

The key to opening the door to any potential job opportunity is one's resume or curriculum vitae (CV). The resume is generally preferred by business organizations, while the CV is more commonly used in medicine. At the same time, executive healthcare jobs often appreciate the value of the resume.
The CV is a long document that narrates the professional life of a person in significant detail, and it literally translates from Latin as “course of a life.” The CV describes almost all the most important events in the life of the person, including place of birth, marital status, family, education, past positions, qualifications, publications, presentations, awards, and social contributions.

The resume is a brief account of personal, educational, and professional qualifications and experience. It should be short and powerful, list one's professional experiences in reverse chronological order going back 3 to 5 years, and generally not exceed a period of 10 years. The potential employer is more interested in the last few years of a job candidate's life unless there were significant achievements in other periods that are relevant and worth highlighting. It is important to include words such as leadership, teamwork, motivation, management, creativity, experience, and career goals. The general guideline is that a resume should not exceed 3 pages.

The choice of resume or CV depends on the particular situation. Both formats are important and reflect one's professional life, so these documents must be prepared well and with special care. There are professional agencies that can help to polish resumes or CVs, which are important not only for a job search but also for promotions and marketing. It is important to remember, however, that while these documents will open the door for a job seeker, resumes and CVs will not secure the job.

FIRST CONTACT:
The Phone Interview

The telephone call is often the first interview, and a common procedure for recruiters to screen potential candidates. I, myself, dislike telephone interviews because I feel they can give the wrong impression of a candidate. The interviewer may be biased by the tone and quality of one's voice, accent, and other variables. I do poorly in telephone interviews perhaps because I am self-conscious about my foreign accent.

The reason for the interview must be clear. It makes a difference if one is being interviewed for one's technical skills, social skills, experience, management ability, etc. If a surgeon is being interviewed for his or her surgical skills, it is not so important how the job candidate sounds on the telephone. If a telephone call about an interview comes at a bad time, one should not hesitate to tell the caller that another time, such as later in the day, would be a better time to talk. However, one must be mentally ready to be interviewed at any time when actively searching for a job.

INTERVIEWING IN PERSON

The job is generally won or lost during the interviewing process. Dress for the occasion! As a general rule, men should wear a conservative suit and tie, and women should wear a conservative dress or suit. I might add that every year during the interviewing season at hospitals and medical schools it is impressive to see all the young people in dark suits-despite the fact that after they are accepted into their programs, they are never again seen wearing suits.

It is advisable to prepare a number of questions pertinent to the job. Most recruiters recommend not talking about money during the first interview. Discussion of this matter should be reserved for the negotiation period. It is important to be on time for one's interview. If the interviewers are late, do not be impatient. Be prepared for any type of interview.

There are 2 main types of interviews, the traditional interview and the behavioral interview. The traditional interview consists of general questions. Experts argue that this type of interview does not predict the future performance of the individual. The candidate can usually get away with telling the interviewer whatever he or she wants to hear, even if it does not reflect the candidate's true feelings or experience. Examples of traditional questions and request for information may be: How do you describe yourself?; What are your professional goals?; How do you describe yourself in terms of your ability to be a team player?; Give me an example of your successful accomplishments; Tell me about the salary range you are looking for.

The behavioral interview is based on the following concepts: Situation or Task, Action (taken) and Results (achieved). It is often called the STAR (or SAR) technique. Some of the areas covered by behavioral interviews include decision making and problem solving, leadership, motivation, communication skills, interpersonal skills, organizational and social skills, and behavior in a stressful situation.

The behavioral interview is preferred by many organizations and most large organizations, as it has been said that the most accurate predictor of future performance is past performance in similar situations. During the behavioral interviewing, the interviewer tries to evaluate how the candidate will respond to a particular situation.

The kinds of questions and requests for information in the behavioral interview include: Describe a situation in which you were able to use persuasion to convince someone to see things your way; Give an example in which you were relatively quick to make a good decision; Give an example of a time when you went above and beyond the call of duty; and describe a recent unpopular decision you made and what the result was.

Examples of behavioral interviewing questions and techniques for preparation that can be found on many educational Web sites on the Internet.

It has been said that candidates who prepare well for behavioral interviews will also perform well during traditional interviews. Use of behavioral answers is well received even by inexperienced interviewers. Large organizations that invest time and resources preparing behavioral interviews attract the best candidates.

Interviews can also be categorized as structured or unstructured and be conducted in groups or on a one-to-one basis. The structured interview consists of predetermined questions. The unstructured interview is spontaneous and leaves the line of questioning to the interviewer's discretion.
Group interviews can be conducted with a large or small group. The typical large interview is conducted by a search committee. I have been interviewed by large groups and have interviewed individuals as part of a large group. I find that large groups do not conduct effective interviews. There is little room for spontaneity or little time to ask any meaningful questions. In such groups, the local candidate has the advantage, because he or she knows the players and in many occasions may have political or social ties with some of the members of the group.

As a general rule, most physician interviews are casual and unstructured. The interviewer may ask all kinds of questions about one's skills, training, and experience. The advantage of interviewing physicians is that the medical boards that grant state medical licenses have generally conducted a thorough checking of the individual and credentials are not an issue, unless a particular red flag merits further investigation. At the same time, there are many questions that an interviewer is not allowed to ask. It is illegal to discriminate based on sex, race, national origin, marital status, sexual preference (in 16 states and the District of Columbia), religion, age, or disability. It is important to remember that while being interviewed, one is also interviewing the potential employer.

Address reprint requests to: Gustavo Stringel, MD, 21 Addison St, Larchmont, NY 10538-2744, USA, Telephone: 914 493 7620, Fax: 914 594 4933, E-mail: gstringel@aol.com

Gustavo Stringel, MD, is Professor of Surgery and Pediatrics at New York Medical College. He has published and often presents on laparoscopy and thoracoscopy in children. He serves on the editorial board of JSLS and sits on the SLS Board of Trustees.

Recommended Reading

1. Linney BJ, Wesley Curry W. Essentials of Medical Management. American College of Physician Executives; 2003.

2. Jackson T, Ellen Jackson E. The New Perfect Resume. Random House; 1996.

3. Gilmore DC, Hellervick L, Janz T. Behavior Description Interviewing. Allyn and Bacon; 1986.

4 Byham W, Pickett D. Landing the Job You Want: How to Have the Best Job Interview of Your Life. Three Rivers Press; 1999.

5. Dawson R. Secrets of Power Persuasion. Prentice Hall; 1992.

6. Pontow R. Proven Resumes: Strategies that Have Increased Salaries and Changed Lives. Ten Speed Press; 1999.

7. Reed JW. Selling Yourself: How to Write the Perfect Resume. Pod Book Publishers, 2005.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

JOURNAL WATCH: Outpatient Surgery Magazine Four-Day Workweek

How to Convert to a Four-day Workweek • Geier A. August 2005: 22-23. According to the author, over time a compressed four-day surgical schedule will greatly improve productivity and profitability by decreasing under-and overutilization. The author explains staffing needs and staff preparation for the transition.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

JOURNAL WATCH: Outpatient Surgery Magazine Grow Your Bottom Line

Grow Your Bottom Line Without Doing One More Case • Ellis S. November 2004:26-35. Highlights 10 coding, billing, and collections strategies. From insurance verification to denied claims, the author instructs readers on how to handle the issues that eat away at their bottom lines.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

JOURNAL WATCH: Outpatient Surgery Magazine Facility Facelift

Does Your Facility Need a Facelift? • Cook D. September 2004:34-47. Transforming your surgery center or office using some of the 20 ideas presented in this article could enhance your patients’ experience and raise their level of customer satisfaction. The author discusses indoor and outdoor environments and covers everything from the OR to the staff lounge, custom curtains to soothing sounds.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

Audiovisual Aids: Friend or Foe?

MAKING A PRESENTATION

GUSTAVO STRINGEL, MD

At a recent international meeting, I had 12 minutes allotted for my presentation. Early, on the morning of the presentation I followed my ritual. I inspected the podium, connected my laptop to the projector and the main computer, and found that everything was working perfectly. I had worked extremely hard on this presentation and had incorporated outstanding audiovisual material. I was ready to start and waiting for my first Power Point slide when to my dismay, nothing happened. The computer failed. Within a few seconds, three audiovisual engineers tried to correct the problem. The moment I realized that this was not going to be accomplished in a timely fashion, I started my presentation without audiovisuals. Luckily I had followed some of my own advice and had practiced my presentation until it was nearly memorized. I delivered it in 10–12 minutes as scheduled and people congratulated me after the meeting because of my creativity in the face of adversity.

It is difficult to imagine a modern presentation without audiovisual aids. Computer assisted presentations have become very sophisticated, including video clips, interactive sessions, and teleconferencing. During informal presentations, the speaker can exercise his or her own discretion about topic length, the style of the presentation and the extent of interaction with the audience. As a general rule, the speaker is in command because he or she is an expert in the field and the audience, aware of this, is more receptive. The speaker can use a variety of audiovisual aids and has time to deal with potential technical problems with the audiovisual equipment.

For other more formal presentations such those at national and international conferences, strict rules may need to be followed. The topic is preselected and well defined, and the speaker has a specific amount of time allotted to deliver the talk. National and international meetings, congresses, and symposiums are attended by people from different cultural and linguistic backgrounds which makes the audiovisual material even more important. Effective use of audiovisual aids requires that your entire presentation be well prepared and rehearsed. Know the scheduling details: exact time allotted, starting and ending times, and whether there is a question and answer period.

All associations now demand that presentations be computerized using Power Point. One way to transfer 35 mm slides to a digital format is to scan your slides using a slide scanner; but the scanners are expensive, and the quality of the product is sometimes disappointing. I prefer to photograph the projected slide using a digital camera; use a good quality screen and a tripod.

Find out how you are going to be positioned with respect to the projection screen and audience and whether you will have the freedom to walk around the podium with a portable or wireless microphone.

Bring your own laptop AND a copy of the presentation on CD-ROM or DVD.

Test the podium, microphone, laser pointer and other necessary equipment the day or morning before the presentation. Communicate with the audiovisual technician to ensure that your computer or video is compatible with the provided equipment.

Find a position in front of the audience that allows you to check the projection screen during your presentation.

Do not hesitate to ask for help. At large meetings an audiovisual technician is usually readily available. If there is no technician available, some of the audience members could be of assistance and may volunteer to help you.

Audiovisual aids can make an enormous difference in the delivery of your message. My advice, however, is that you be prepared for computer problems to leave you without your audiovisual aids. Memorize your main topics. Memorize and practice your opening and closing. Have a written copy of your main topics or a printout of your slides handy. Prepare one or two vignettes or personal stories to make the audience feel more comfortable and connected to you.

Overall, don’t panic, and be creative. The audience wants to listen to your message.

Suggested Reading

Colin R. Accelerated Learning. New York, NY: Dell Publishing. Bantam Doubleday Publishing Group Inc; 1985.

Stringel G. Making a Presentation. Laparoscopy and SLS Report. 2003;2(2):25-27.

Address reprint requests to: Gustavo Stringel, MD, 21 Addison St, Larchmont, NY 10538-2744, USA, Tel:
914 493 7620, Fax: 914 594 4933, E-mail: gstringel@aol.com

Gustavo Stringel, MD, is Professor of Surgery and Pediatrics at New York Medical College. Dr. Stringel has published and often presents on laparoscopy and thoracoscopy in children. He serves on the editorial board of JSLS and sits on the SLS Board of Trustees.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

Making a Presentation

NOT JUST SHOWING SLIDES

GUSTAVO STRINGEL, MD

Everyone is eventually asked to make a presentation. Some people are natural presenters, and the task is easy for them. Others, however, have great difficulty speaking in public. A presentation is not a speech; it is not just showing slides, figures, or facts to an audience. A presentation is more complex and involves a series of dynamic aspects. A presentation often has the impact of an audience’s impression of the character and personality of the presenter and many times will influence the present position and future standing of the person. We often judge a person based on his or her presentations. Ron Hoff defines a presentation as “a commitment by the presenter to help the audience do something—and a constant, simultaneous evaluation of the worth of that commitment by the audience.”

As physicians, we are often asked to make presentations related to our specialty. We are experts in this field and generally have no problem delivering a reasonable presentation. I once heard a definition of an expert as “a guy from out of town with a bunch of slides.” It is amazing how difficult it is to present topics that are not directly related to our area of expertise in the medical profession. Even talking about ourselves can be taxing. I recently attended a course given by the American College of Physician Executives where I was asked to make a 5-minute presentation by myself, with no audiovisual assistance. I was given 5 minutes in which to present my most important accomplishments and the skills that were necessary to achieve them. It was one of the most difficult presentations I have ever made. The 5 minutes passed very quickly, and I was forced to economize time, measure my words, and know exactly what I was going to say before I said it. I selected the subject, wrote the outline, memorized the introduction and the conclusion, and practiced my presentation many times, until I could deliver it in 4 minutes and 45 seconds. It was a humbling and excellent learning experience.

I have been making presentations all my life, in a few different languages. Now, I will present some of the experiences and hints that have helped me feel more in control and in contact with the audience.

Subject. Always know exactly what the subject is and why you are presenting it. If you are invited to speak, ask for details. What are the expectations? If you are asked to select the topic, choose something that you are totally familiar with, an area where you are considered an expert. The name of the game is preparation. To present with authority, you must prepare the subject.

Audience. Analyze your audience. You must know your audience’s characteristics, age demographic, gender, degree of education, and more. Are you presenting to colleagues? Does the audience understand medical terminology?

Time Yourself. Do not go over your allotted time. Nothing is worse than a speaker who continues to go on and on past his or her time allotment. If you are asked to give a 30-minute presentation, plan to talk for 25 minutes. It is always better to stay under your time. An educated audience will always appreciate the extra time. It is impolite and inconsiderate to other speakers to be late in your presentation. The only way to stay on time is to practice.

Practice Makes Perfect. Before you talk to the audience, talk to yourself. You can practice in front of a mirror or use a video camera. You can also give your presentation to a small group of friends or relatives or a spouse or significant other. Ask for advice and criticism. A spouse, relative, or a good friend will tell you what you need to improve.

Practice your posture, stand erect, do not move excessively, and select your space. Using hand motions and other gestures is good but should not be overdone. Do not let your eyes wander during the presentation. Select a point in the audience or 2 or 3 different people, and talk to them.

Select appropriate clothing. Avoid scratching yourself, playing with a pen or other object, jingling keys, and other obnoxious mannerisms.

Speech. Your voice should be loud and clear. If you have a microphone, you need to speak softly and close to the microphone. If no microphone is available, then you must speak loudly enough to be heard. A remote microphone attached to your lapel will give you the great advantage of movement, enabling you to gesture with your hands and body, and make better contact with your audience. A stationary microphone, especially if you are speaking on a podium, will limit your motion. Be aware of this situation and avoid standing still like a tree or statue. Try to occasionally move away from the podium to keep contact with your audience. Above all, be a dynamic speaker.

Interactive. It is fine to be an interactive presenter, but you must analyze your audience first. Is it the type of audience that is capable of interacting with you, and likely to do so? Interaction will keep the audience interested, but it can derail your timing. If you like interaction, you must practice first. I recently attended a presentation where the speaker claimed from the beginning that he was going to be making an interactive presentation. We in the audience prepared ourselves accordingly. He opened the presentation by showing a short video clip of a popular movie and asking the audience to identify it. He rewarded the winner with a piece of candy. From that point on, however, he continued with a 60-minute scientific presentation and never again interacted with the audience. At the end, he showed another video clip and rewarded the participant with another piece of candy. Was this truly an interactive presentation?

Audiovisual Aids. A variety of audiovisual aids, such as overheads and transparencies, slides, flip charts, and computer-generated audiovisuals, are available that can be useful in a presentation. You must always ask about the availability of different aids ahead of time. Computer-generated audiovisuals, especially Power Point, are now almost universally available. I was recently invited to South America to give a series of presentations. I had Power Point presentations, but I made the mistake of assuming that my hosts would not have the computer equipment necessary to display them, so I converted all my power point presentations to slides. To my surprise and embarrassment, I was the only speaker with slides. I learned a lesson from the experience: always ask what kind of equipment is available. When in doubt bring both slides and your Power Point presentation. Always bring your laptop and a CD with your presentations and video clips. Make sure your computer is compatible with the available equipment. If you have a Mac, bring your adapter or connecting cable. As a general rule, Power Point presentations run better directly from the hard drive, but it is always wise to have a back up.

Keep visual aids simple. Generally, a blue background is best. Avoid complicated backgrounds, as they can be distracting from the main subject of your presentation. The lettering should be big enough for the audience to read. As a general rule, letters in a 24-point font size are recommended. You can save time by attaching pictures, figures, or video clips to your slides, but if the picture is important, show it alone. Computer-generated presentations have become very sophisticated. You must stay within your limits of sophistication and technical expertise. Do not overdo it. A simple laser pointer is absolutely necessary. I often carry my own laser pointer to my presentations.

Do not apologize for spelling or similar errors. For one thing, you should always do a spell check before your presentation. If you must clarify something, do it without apologizing. Most of the time, the audience will not notice the error until you point it out. You, not your slides, should be the center of the presentation. It is acceptable to have notes to guide you. Avoid the tediousness of reading the presentation verbatim. Use the notes to guide you; do not let the notes distract the audience. I recently attended a presentation by Barbara Linney, Vice President of Career Development for the American College of Physician Executives. She is a master presenter. She had notes in her hands throughout the presentation, but we did not notice them until she pointed out to us how she was holding them. She did it inconspicuously and skillfully and did not let her notes take away from her presentation.

Taking Off and Landing. The most important times of your presentation are comparable to the take-off and landing of an airplane. You can make it or break it right from the beginning or at the end. Always practice and memorize the first 60 to 90 seconds of your presentation, and always allow time for a strong closure with conclusions. Beware of lengthy, unnecessary, or overstated introductions. Do tell the audience the plan or contents of your presentation. Always introduce yourself and your position in a simple, matter-of-fact way. Acknowledge people who have collaborated with you, as well as personalities, guests, chairpersons, or presidents of the association who invited you to make your presentation. Do not forget to smile and look relaxed. Some speakers regularly practice relaxation breathing and exercises before the presentation. Breathing is extremely important in pacing your presentation. If your presentation is long, request a glass of water to moisturize your throat and take a brief pause during your speech.

When you are running out of time, be prepared to close; do not wait until the moderator asks you.

Humor. A sense of humor is always good. Do not start or end your presentation with a joke unless you are a natural comedian and good at telling jokes. Although making humorous remarks keeps the audience happy and interested, do not over do it. The same goes for cartoons. Tasteless or difficult-to-understand cartoons will only detract from your presentation. Pictures of family or beautiful scenery are generally well accepted, especially if they are related to the presentation.

Evaluation. It is extremely important to look at the evaluation from the audience. You should request it from the organization that invited you to make the presentation. If you have a bad evaluation, then you should find out the reasons why and correct them. If your presentation made an impression, then you will get a good evaluation. An important presentation always merits an evaluation. You can always ask for an honest opinion from members of the audience or organization for your educational feedback.

I hope that the experience with presentations that I have acquired over many years can be of help, especially to new speakers aiming to improve the quality of their presentations. Remember that aids for presentations constantly change and improve. We must continue to educate ourselves and always aspire to improve our presentations. If you make an excellent presentation, then accept the praise and be proud.

Address reprint requests to: Gustavo Stringel, MD, 21 Addison St, Larchmont, NY 10538-2744, USA. Tel: 914 493 7620, Fax: 914 594 4933, E-mail: gstringel@aol.com

Dr Gustavo Stringel earned his medical degree at the National University of Mexico in Mexico City. He interned in Toronto, Canada, at St. Michael’s Hospital and did his surgical training at the Gallie Program at the University of Toronto. Dr Stringel also completed a fellowship at the Hospital of Sick Children in Toronto. He is currently Professor of Surgery and Pediatrics at New York Medical College and Attending Surgeon at Westchester Medical Center in Valhalla, New York.

Dr Stringel has presented and published on many topics in the areas of Laparoscopy and Thoracoscopy in children. He has been a member of the Society of Laparoendoscopic Surgeons for six years and currently serves on the Editorial Board of JSLS.

Suggested Reading

Hoff R. I Can See You Naked. A Fearless Guide to Making Great Presentations. Kansas City, MO: Andrews and McMeel; 1991.

Hoff R. Say It in Six. How to Say Exactly What You Mean in Six Minutes or Less. Kansas City, MO: Andrews and McMeel; 1996.

Linney BJ. Improve your presentation style. Physician Executive. Am Coll Physician Executives—J Med Manage. 1991;17(1):23-25.

Walters L. Secrets of Successful Speakers. New York: McGraw-Hill; 1993.

Walters L. Secrets of Superstar Speakers. New York: McGraw-Hill; 2000.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

Decreasing Operating Room Inefficiencies in Advanced Laparoscopic Minimally Invasive Surgery

Use of Monitoring Worksheet “Scorecards”

BEVERLY A. JOHNSON, RN, BSN, JACQUELINE CAREY, RN, CHRISTINE HANLEY, RN, W. PETER GEIS, MD

Operating rooms are expensive to utilize, equip, and manage. Patients undergoing complex laparoscopic minimally invasive surgery utilize numerous amounts of highly technical equipment and specific disposable supplies. This process often yields costly surgical procedures. Monitoring of all resources used in conjunction with the sequence of surgical procedures has enabled our operating room to decrease inefficiencies, to eliminate waste, and to collect data to improve our patient care and further improve the process. Recording of key performance perspectives using actual start and end times of case setup, including intubation, positioning, the sequence of surgical events, and the use of disposable supplies provides us a collection of data that allows assessment of each sequential event and implementation of improvements in each sequential event.

Our operating room staff actively provides input into case setups. Concerns and issues occurring during the procedure are recorded and discussed, and solutions are initiated. The staff’s knowledge has increased since they actively provide input into case setups with application to all aspects of surgical procedures. This data is discussed at team meetings and provides an avenue for education of the operating room staff. The staff has experienced an empowerment and accepted a broader range of responsibility. Goals for improving case efficiency are set. Collaboration with other surgeons enables team goals to be reviewed and reinforced. Time frames of procedure outcomes are benchmarked.

The scorecards also provide a mechanism to assist with the choreography of the surgical suite. Since the procedures utilize an abundance of equipment, our preprinted forms provide a time efficient tool to eliminate the guesswork from determining the placement of equipment. Case setup time has averaged a 6-7% time decrease since the use of scorecards. Data collection on “resources used” allows critical discussions regarding further improvement to eliminate wasting of supplies.

Finally, collaborating with other surgeons on the importance of procedural monitoring using a scorecard has fostered a relationship with our surgeons, anesthesiologists, and staff that is positive, productive, and rewarding. With the use of scorecards and good teamwork, operating and supply costs were reduced by 7% in 2001.

Case Monitoring Worksheet pg1

Case Monitoring Worksheet pg2

Case Monitoring Worksheet pg3

This paper is a synopsis from the Best Poster Award at Endo Expo in New Orleans, September 2002.

Address reprint requests to: Beverly A. Johnson, RN, Saint Peter’s University Hospital, 254 Easton Ave, New Brunswick, NJ 08901 Telephone: 732 745 8600 ext. 5184, E-mail: bjohnson@saintpetersuh.com

The use of scorecards at Saint Peter’s University Hospital, New Brunswick, New Jersey began with the appointment of our current Chairman of Surgery; Director of the Minimally Invasive Skills Learning Center, W. Peter Geis, MD, in July 2000. Beverly A. Johnson, RN, BSN, Perioperative Instructor, Christine Hanley, RN, CNOR, Laparoscopic Team Leader and Jacqueline Carey, RN, CCRN, Director of Perioperative Services, spearheaded with Dr. Geis the identifiers on the scorecards. The goal of the scorecard is to monitor the use of appropriate resources, monitor surgical events, and improve patient outcomes. Figures shown are for a right colon resection: top left, front of worksheet; bottom left, back of worksheet; bottom right, room setup worksheet.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

Where Does the Art of Medicine Fit Today?

LEGAL ISSUES

HARRY REIN, JD, MD

This is a jurisprudence column, and you may wonder whether or not the philosophical approach regarding the practice of medicine discussed herein has anything to do with law or surgical technique and skill. Do personality and the art with which one practices the doctor-patient relationship have anything to do with medical malpractice? They certainly do and are pervasive in the courtroom. Personality and the philosophic approach to patients have a great deal to do with the discovery process, and it almost always is one of the bases of a patient seeking legal help. Litigation in the health care fields has leveled off. It seems that there are fewer claims and lawsuits this year than in the past few years, but I don’t think that is necessarily true in the “newer procedure” specialties. Perhaps this is because there is more willingness to discuss fault in these fields or because those litigating such specialties are becoming more informed and more sophisticated. But doctors in active practice, such as those developing newer procedures involving minimally invasive surgery, tell me that medical malpractice lawsuits they see affect most of the fundamental aspects of patient care. You become much concerned with this litigation, either consciously or subconsciously, because of all the publicity you constantly hear, mail you continuously get, and most recently, due to the increasing malpractice insurance premiums. We clearly become concerned with medical malpractice when it is time to pay the premium. Risk management seminars are required in some states; but they, along with our medical journals, unfortunately do not discuss those things which affect doctors the most. What seem to be disappearing are “art of medicine” discussions and teaching methods implementing the doctor patient dialogue techniques; they have been displaced by laparoscopic entry techniques, newer laser beams, and an overwhelming array of microsurgical instruments. We therefore wonder if the art of medicine ever existed except to merely fill in those spaces where the science, technical knowledge, and mechanics of medicine left a void. Surely the “art of medicine” of which we speak so reverently refers primarily to the doctor-patient relationship. It lives and is well, needs to be nurtured, and must survive. However, most other forms of patient care are becoming truly scientific, including even many of the psychiatric disciplines. Certainly most if not all of laparoscopic surgical care is scientific, technical, and mechanical. No one can claim that it is the art of medicine when the laser is directed (or misdirected); no one can claim that it is an art form to dissect an ovary or to insert a first trocar or to clearly visualize the ureter. Unless we say that the learning and proper application of these skills is an art form, we must mean only the personal relationships. The malpractice defense in every case, “...medicine is an art form and not a science...” is disappearing, although still used. The elders among us with years of practice might consider the change undesirable. Yet it is no longer accurate to say that the amount of knowledge a physician possesses and his surgical skills are an art. They are a scientific application of the current state of knowledge.

Doctors have increased public expectations by educating, promoting, and advertising. We now accept that defensive medicine merely means good medical care, consideration of our patients’ persona, and following certain basic rules and procedures in our medical practice similar to what we do in daily living. Professional liability, a better phrase than medical malpractice because it seems to create less emotional reaction and far less anger, is merely a system by which we are held accountable for our actions as everyone should be. We must learn to accept it. It is an equalizer, some say. That is, others are watching us. We have not been used to this. Doctors did not have others watching, do not like others watching, resent being questioned or challenged by anyone, and in particular, resent the testing that accompanies the discovery process by someone in a different profession outside the academic arena of medical grand rounds.

A former Florida senator friend of mine told me that when she was in the hospital, she could sense the “imperial walk” and aura approaching her room down the hall. There are positive aspects to this point of view. Perhaps that was what is still meant by the art of medicine, the doctor-patient relationship. Patients can benefit from positive influences and total control by the physician over the health care management of that particular illness. This benevolent dictatorship-  if that is what it is- has historically done a great deal of good and accomplished much. There are also dictators who are feared but against whom there is revolution when the fuse is lit. The fuse is what is known as the “triggering process,” that which begins investigation into the medical care of an unhappy patient with a bad result. It rarely is the bad result, the injury, the second operation, or the failed procedure, which brings the patient to a lawyer. It is something, which happened between the doctor and his patient, between his representative and the family, or perhaps best put, due to absence of “art” in the way he dealt with the emotional moments that needed him the most.

With that in mind, we then look at the concept of accountability for all people and may well be able to say that those who seem to care less end up paying more for improper actions. The system is not only intended to compensate for losses, but also to deter negligence and to improve substandard practices. The system asks for compensation, but is always directed at those other parts, which are only discussed obliquely in the courtroom. Perhaps the practicing physician does not have the opportunity to short-cut compensation for losses, but he certainly has the opportunity to deter negligence and to elevate substandard practices to higher levels. This should be the intent of quality assurance departments, risk management, continued medical education, and improved teaching practices at all levels of medical education. Physician controlled, health care provider managed, hospital initiated quality assurance efforts have not worked well enough, are not pervasive throughout our country, and do not change in response to others’ faults and failures. This concept is totally under doctor control and if properly managed could without more, cut malpractice losses by fifty percent. Until we take control of teaching each other and recognizing inferior quality and lose the fear of showing the way to our peers, the deterrence of negligence and the elevation of substandard practices through medical malpractice litigation will continue. Some feel it must continue for the benefit of patients, since so called self-policing has failed. Look around your own community to determine which physicians have been chastised, had their licenses revoked, or have been taken under an education wing to improve their techniques and practices. For the most part, regulating boards and peers find it easier to go after doctors who abuse drugs, rape patients, act otherwise feloniously, or earn too much money through excess surgical procedures. Is it not interesting that the overwhelming majority of chastised physicians- chastised by their peers-  are from the various minorities who practice among us and that “Mr. Clean” is rarely among them? Is it because he is clean, or is it because he belongs to the right organizations? Human nature causes these errors. If we teach standards to control damage, if we emphasize accepted methods throughout the community to which all must subscribe, and if malpractice cases, litigation, claims, complaints, and adverse reactions become part of the teaching process rather than the enemy, the situation will change.

Our system must provide behavior modification processes for physicians instead of defensive behavior. The defensive posture is aggressive, angry, destructive and creates anxiety; but it can create a good framework for education. Positive behavior modification means deriving something good from every adverse reaction, preventing a harm because of every previous malpractice case, improving the quality of care because of every previous adverse reaction, preventing recurrences, and using patient complaints as teaching guides rather than calling such patients noncompliant. Even the clinical pathologic conferences, which might still exist in some institutions, do not focus adequately and selectively on the professional performance of the doctors as much as on the poor outcomes and complications. The key questions, which must always be asked, are: Was the event foreseeable (even remotely)? What could have been done to prevent it? Were there signs and symptoms as the adverse reaction was developing? Was more attention paid to the minor, albeit more common causes of such signs and symptoms? What if the procedure that initiated the bad result had never been done?

The cost of doing business includes medical malpractice insurance premiums, and all doctors know all their costs well. In my interviews with dozens of physicians and in my conversations with hundreds of doctors on these subjects, they never include the emotional stress, the fear, the anxiety, the anger, and its spin-offs as the costs of doing business. These are greater costs. They can be controlled by the physician himself and are not in the hands of the economic spiral in which we find ourselves. This pervasive problem began when medical malpractice became a major topic of conversation in 1975. Since then we have been following false prophets.  We have challenged, fought with, resented, and developed an adverse relationship with those on whom we depend most of all, our patients. Elders of generations gone by used to teach us that if we take care of our business properly, it will take care of us. It is impossible to properly take care of your patients if you consider them your enemies or if you fear them. Patient are not your enemies; they are, and will remain your best friend, the finest juror you can find, and the person who wishes to sue you the least. Believe it. Consider medical malpractice litigation for what it really is, something other and more than you perceive it. It is a mechanism with which patients catch your attention, ask you to change your ways, and let you know of their dissatisfaction.

I say you in the generic sense. We must learn and profit from everything that happens to our colleagues. Don’t think of medical malpractice litigation as a lawsuit that occurs every time something goes wrong. You know that is not true and can prove it to yourself by merely looking at all the adverse reactions you have had in your career which have resulted in satisfied patients, that is, at least satisfied with your approach to the problem. You may be angry, and you may point a finger at the system and at plaintiffs’ attorneys to no avail. Physicians have tried since 1975 to change this, but we have now wasted 20 years aimlessly acting out and pursuing legislation adverse to our patients’ interests. Remember that the only one who counts is the patient. Behavior modification, changing our thought processes, and looking at the problem objectively while searching for palliation, if not a cure, requires that we protect the patient, take care of the patient, keep the patient our friend, while remembering that if we properly take care of our business it will take care of us. Knowledge is power. With power we get control. With control we can elevate habits and practices to safer medicine and reinstitute the art of medicine by eliminating some of the triggers that result from a breakdown in the relationship when the strongest sense of caring is needed.

Address reprint requests to: Harry Rein, JD, MD,
1877 Wingfield Dr, Longwood, FL 32779, Telephone: 407 333 4444, E-mail: DrRein@USCourt.com, Web site: www.uscourt.com

Dr Rein writes and actively teaches medical malpractice to health care providers and is “of counsel” to several dozen law firms. His publications include The Primer on Soft Tissue Injuries, The Horizontal Review of Medical Records, and his Medical Malpractice Thoughtbook. Dr Rein developed the SLS Postgraduate Course “Annual Law School for Doctors,” now entering it’s third year. The program teaches doctors how to regain and maintain control, save time and money, prevents and relieves anxiety by recognizing, preventing, and mitigating harm and knowing what to do when it happens. From experiences with over 12,000 cases, his trial techniques have become standards.

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