Surgeons, Intensivists Often Disagree on Postoperative Goals

Laurie Barclay, MD

January 16, 2013

Surgeons and other intensivists are often at odds regarding postoperative goals of care, according to findings of a cross-sectional study published in the January issue of JAMA Surgery (formerly Archives of Surgery). Among 912 surgeons surveyed, 43% reported conflict with other intensive care unit (ICU) clinicians regarding postoperative goals of care, and 43% reported similar conflict with ICU nurses.

"Conflict in the [ICU] is a significant public health problem, as more than 70% of ICU clinicians report experiencing conflict weekly," write Terrah J. Paul Olson, MD, from the Department of Surgery, University of Wisconsin Hospital and Clinics in Madison, and colleagues. "The combination of caring for acutely ill patients, end-of-life decision making, and coordination of large multidisciplinary teams can lead to frustration, communication breakdown, and discord among members of a health care team.... This conflict has been associated with lower-quality patient care, higher rates of medical error, higher levels of staff burnout, and greater direct and indirect costs of care."

Dr. Olsen and colleagues used this incentivized, US mail–based survey to assess surgeons' perceptions of conflict with intensivists and nurses about goals of care for their postoperative patients. The team sent the survey to 2100 vascular, neurologic, and cardiothoracic surgeons at various private and academic surgical practices; the adjusted response rate was 55.6%.

A substantial percentage (43%) of surgeons reported sometimes or always having conflicts with intensivists about postoperative goals of care. The same percentage of surgeons reported having such conflicts with nurses.

Compared with surgeons who had more than 30 years of experience, surgeons with less than 10 years of experience reported higher rates of conflict with intensivists (57% vs 32% on bivariate analysis; P = .001) and with nurses (48% vs 33%; P = .001). Surgeons practicing in closed ICUs were also more likely to report conflict than those practicing in open ICUs (60% vs 41%; P = .005).

In a multivariate analysis, adjusted for sex and surgical subspecialty, surgeons with fewer than 10 years of experience had 2.5-fold higher odds of reporting conflict with intensivists than did surgeons with more than 30 years of experience (odds ratio [OR], 2.5; 95% confidence interval [CI], 1.6 - 3.8), and 70% higher odds of reporting conflict with nurses (OR, 1.7; 95% CI, 1.1 - 2.6).

Compared with surgeons practicing in a closed unit, those who primarily managed their ICU patients in an open or mixed unit had 40% lower odds of reporting conflict with intensivists about postoperative care goals (OR, 0.60; 95% CI, 0.40 - 0.96). However, the type of ICU was not associated with surgeon-reported conflict with nurses, based on multivariate analysis.

Managing Personal Discomfort

"Surgeons regularly experience conflict with critical care clinicians about goals of care for patients with poor postoperative outcomes," the study authors write. "Higher rates of conflict are associated with less experience and working in a closed [ICU]."

The investigators suggest that surgeons may need time and experience to learn how to manage personal discomfort when faced with poor postoperative outcomes. They also suggest that the structure of a closed ICU may impede the continuity of the surgeon–patient relationship and that conflict may ensue when an intensivist replaces the surgeon as the primary decision maker for the patient.

Limitations of this study include the nonresponse bias associated with surveys, a social desirability bias, and a potential lack of generalizability to surgical subspecialties other than vascular, cardiothoracic, and neurologic surgery. Because the survey did not specifically define a poor postoperative outcome, the investigators are unable to specify a clinical threshold that may trigger conflict. In addition, the study did not distinguish closed ICUs run by surgeons from closed ICUs managed by nonsurgeons.

"Given the myriad challenges inherent in delivering the highest quality of care in these settings, clinicians from all backgrounds should focus on eliminating these interteam conflicts to allow energies to be spent more productively on other clinical issues affecting safety and quality," the study authors conclude. "Interventions directed at the individual level as well as the system level will be important to mitigate conflict to provide better care for our critically ill postoperative patients."

In an accompanying editorial, Susan Galandiuk, MD, from the Department of Surgery at the University of Louisville in Kentucky, addresses the issue of "patient ownership" as it relates to conflict of surgeons with intensivists and nurses.

She notes that the operating surgeon, perhaps motivated in part by guilt, is less prompt to move toward palliative care for the patient with a poor postoperative outcome than intensive care clinicians are.

"Just who is the more consistent and ethical conservator of resources varies widely in the hospitals in our university medical center," Dr. Galandiuk writes. "I do not believe intensivists are more protective of those resources; more likely, the opposite is true. The reader must also be wondering how [ICU] nurses view these complex and intense interactions. These kinds of questions are hard to pose meaningfully and even more difficult to answer."

The National Institutes of Health, the University of Wisconsin School of Medicine and Public Health, the Agency for Healthcare Research and Quality, and the University of Wisconsin support research by some of the study authors. The authors and Dr. Galandiuk have disclosed no other relevant financial relationships.

JAMA Surg. 2013;148:29-35. Abstract