Surgeons feel responsible for patient outcomes after surgery. As a result, they may disagree with decisions made by critical-care clinicians called intensivists when their patient is in the intensive care unit (ICU). Conflict may arise from any number of situations, particularly when it comes to discussing end-of-life care.
A new study reveals that conflict arises regularly between these two types of clinicians when it comes to care goals of patients doing poorly after surgery. Less-experienced younger surgeons tended to have more conflict with intensivists than older surgeons. The ICU administrative model also affects conflict, with more conflict reported in closed ICUs where intensivists, rather than the operating surgeon, primarily manage patients.
A total of 2,100 vascular, neurologic, and cardiothoracic surgeons received a mailed survey (700 to each specialty). Surgeons were asked fixed-choice questions about which clinicians they experienced conflict with and how frequently conflict occurred. Other questions asked about how challenging they found certain aspects of their practice, such as communicating about poor outcomes, addressing patient fears about dying, their own discomfort about poor outcomes, and managing the clinical aspects of poor outcomes. The survey also collected other information on the surgeon’s gender, practice type, years in practice, high-risk procedures conducted per month, and the type of ICU they worked in. A total of 912 completed surveys were returned.
Among the respondents, 43 percent admitted to sometimes or always experiencing conflict with intensivists and nurses about the goals of postoperative care. Nearly three-fourths of surgeons (73 percent) reported managing their own discomfort about poor outcomes as a significant challenge. More than half (62 percent) also said they found managing the clinical aspects of poor outcomes to be challenging. A strong association was found between surgeon experience and conflict with intensivists. Reported conflict was 2.5 times higher for surgeons with less than 10 years of experience than for those with more than 30 years of experience. The odds of conflict were 40 percent lower for surgeons practicing in an open ICU model (where the surgeon is primarily responsible for patients) compared to a closed ICU (where the intensivist is responsible for all patients).
The researchers call for more interventions at the individual and system levels to eliminate inter- team conflicts in the ICU. The study was supported in part by AHRQ (HS15699).
See "Surgeon-reported conflict with intensivists about postoperative goals of care," by Terrah J. Paul Olson, M.D., Karen J. Brasel, M.D., M.P.H., Andrew J. Redmann, B.A., B.S., and others in the January 2013 Journal of the American Medical Association Surgery 148(1), pp. 29-35.