When to refer to another surgeon

Abstract

You are a busy vascular surgeon located in a large community hospital 2 miles from a world-renowned cardiovascular center specializing in complex aortic surgery. A patient whom you have previously treated just presented in your emergency department with a tender but hemodynamically stable 10-cm thoracoabdominal aortic aneurysm. A computed tomography scan shows extravascular blood. The patient and his family trust you and insist that they want the patient to remain under your care. You are an excellent technical surgeon, but you haven 't repaired a thoracoabdominal aneurysm since residency. What is the most ethical course of action? 1.Send the patient directly to the specialty center.2.If you believe that the outcome will be satisfactory, take the patient to the operating room.3.Explain the situation to the patient, and let him choose where he wishes to have his surgery.4.You must understand your limits, and you base your decision accordingly.5.Recommend that a more qualified surgeon perform the operation and, with the patient's consent, arrange transfer to the specialty center. The best answer is E. The least appropriate response is C. Choice A, immediate direct transfer, would not be appropriate without careful clinical evaluation to ensure that transportation to another center would not aggravate the patient's condition. The patient's consent to transfer must be sought and obtained, and the referring surgeon should personally ensure that a duly qualified surgeon is available and willing to treat the emergent condition before the patient leaves your center. Choice B places the patient at undue risk when the surgeon is not current in the skills required to perform a highly difficult operation. Choice C places an unfair burden upon the patient. Clinical studies have shown that patients are excessively trusting of the surgeon's skills, particularly in life-threatening situations.1McKneally MF Martin DK An entrustment model of consent for surgical treatment of life-threatening illness: perspective of patients requiring esophagectomy.J Thorac Cardiovasc Surg. 2000; 120: 264-269Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar This patient has been treated successfully by you in the past and is likely to believe that you will be equally capable of treating any surgical situation. Although you have done your best to fully explain all elements of the current situation to him, his judgment may be adversely affected by the anxiety and duress of acute illness. Most patients cannot appreciate the subtleties of treating a complex condition enough to make an informed distinction between variously capable surgeons. Recommending, rather than simply offering, transfer is a more appropriate approach to the management of this problem. Evaluation of one's limitations, Choice D, should not be performed at the expense of patients requiring urgent care. When outcomes cannot be reasonably predicted, the independent surgeon's efforts to expand his armamentarium can be rightly considered reckless experimentation.2Jones JW Ethics of rapid surgical technological advancement [editorial].Ann Thorac Surg. 2000; 69: 676-677Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar Furthermore, the emergent nature of the patient's condition does not permit the quiet reflection on alternatives typically available before elective operations. Choice E, recommending referral, obtaining the patient's consent, and arranging transfer to a surgeon with the current skills and knowledge to treat the condition, meets the ethical and clinical needs of this situation. When a dangerous condition requiring special skills presents, and a better qualified surgeon is readily available, a referral should be strongly urged if transfer will not increase the patient's risk. This reflects the physician's obligation in the process of informed consent: when evidence supports one alternative as clearly superior, it should be recommended.3McCullough LB Jones JW Brody BA Informed consent: autonomous decision making of the surgical patient.in: Surgical ethics. : Oxford University Press, New York1998: 15-37Google Scholar In 1996, the Wisconsin Supreme Court (in Johnson v. Kokemoor) ruled that information about the informed consent process includes disclosure to patients of information about the availability of other physicians with better outcomes.4Icenogle DL Update on informed consent law: the Johnson V.Kokemoor decision. Wis Med J. 1997; 96: 58-61PubMed Google Scholar The transfer of care must be surgeon to surgeon to ensure that the exchange of pertinent information is complete, the specialized care required is available, and another surgeon accepts responsibility for the patient.