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RANZCOG complications survey

I am an Obstetrician and Gynaecologist in a small country town in NSW.

When I set up my practice 2 years ago, I had trained with exceptional people and was introduced to a less emotional but more rational approach to surgical complications, which I have not been exposed to previously. While I applied these principles in my practice and work, I still found myself constantly worrying about surgical adverse events. I was wondering how many of my colleagues are worrying in silence, solitude and unlike me do not have access to professional friendship groups.

Together with Andreas Obermair, a colleague from QLD and the founder of SurgicalPerformance Audit we created an online survey. Initially we were concerned that only a small number of RANZCOG Fellows and trainees would respond. These days it is not very attractive to discuss complications and failure and put it out there in the open. We were concerned we could look stupid, dark and negative.

Nevertheless, we approached RANZCOG and they were very supportive of the project outline. The first email was sent to RANZCOG members on 13 FEB 2013. Andreas and I were overwhelmed because only a few of hours later we counted more than 200 responses. In total we received more than 600 responses, comments from 133 participants and 257 colleagues left their email addresses so that we could informe them about the outcomes of this research.

As a first step we inform you about the qualitative outcomes. In due course Andreas and I will put a proper manuscript together and submit it to our journal, the ANZJOG. We will notify you again when that paper gets published

In brief, the distribution of responses was consistent with the number of RANZCOG members in the Australian states and in New Zealand. Most responses (72%) were received from metropolitan areas. Forty per cent of respondents work in both, public and private practice and 62% practice both, Obstetrics and Gynaecology. Here are some excerpts from the comments that participants left to share with us.

 

Some comments outright triggered a WOW response

“Complications are the biggest issue for me, I am constantly thinking of an “exit” strategy so that when the day comes I have something to move on to...”

“I use a professional counselor to help manage my stress”

“Complications are THE most stressful challenges we face”

“Colleagues have a conflict of interest when they (mandatorily) report their local colleagues complications.”

“When complications occur I often feel like a criminal”

“I don’t want this survey to be a college bashing exercise”

 

Ten per cent of comments related to “audit” and participant’s interest to learn more about it

A number of respondents requested better audit tools and even more colleagues found the idea of comparing surgical skills and outcomes with their colleagues compelling.

“I'm always curious as to how my surgical skills compare with my colleagues - more so for a personal improvement point of view. I'm lucky to have a very supportive wife and family who are always there for debriefing, but it's also important to have fellow peers who understand the nature of our work to debrief to.”

Some people stressed the importance of confidentiality and anonymity.

“To clarify the question about interest in complications of colleagues, I would be interested in those as a group, with defined denominators of types of surgery and patient demographics but not those complications of individual colleagues.”

SurgicalPerformance Audit [1] and the Urogynaecological Society of Australasia Pelvic Floor Surgery Database [2] were mentioned specifically.

 

The most common theme mentioned from participants was around vulnerability, isolation and lack of training and support

The bulk of the support in case of complications comes from family, friends, social networks, MDOs and colleagues. In general, participants of the survey expressed their dissatisfaction with professional standard bodies, such as RANZCOG, AMA, and local hospital management quite clearly.

“Not only do I feel unsupported in dealing with complications, I am aware of hospital management eager to condemn or stab me in the back should any adverse event (or complaint) occur. In this toxic workplace I am planning to retire prematurely.”

“Because all complications have medico-legal implications, the only helpful organisations to us are the Medical Indemnity groups in particular AVANT and NASOG. Other administrative bodies such, as the RANZCOG, the AMA and the Government in particular are useless. Only other O&G's really understand what one goes through and so senior mentors who have been through a career can help younger graduates. The College (better still NASOG) may be useful in this regard by establishing a group of supportive mentors in each State that one may be referred for support. Lastly, 'hired guns' for the plaintiff should be shunned.”

“Because of lack of support over complications I became burnt out and left public work and Obstetrics altogether, and in private work ceased performing certain operations.”

“You can feel very alone when you have a complication in private practice. Partly due to the 'shame' of revealing this I usually write a note of sympathy when I hear of a colleague's misfortune but hardly ever receive a reply. In private practice there is no forum to examine an adverse outcome.”

“Support: what support?”

“In hospital peer review hospital administrators without clear guidelines and in an unprofessional manner have introduced meetings. These have been divisive in the extreme”

“The worst part is the examination of clinical privileges by Administrators with no understanding of clinical work.”

“Complications make me think of ceasing practice in Obstetrics and Gynaecology. Complications will always happen, yet you can be sued and potentially lose your career. There is not enough support from the government eg patients shouldn't be able to sue for recognised complications that could happen to anyone. You can’t guarantee against a complication, so why should they be able to sue? Also, AHPRA makes it too easy for patients to complain. It feels like they aren't on our side. We should feel protected by AHPRA, but it’s the opposite. I haven't had too terrible a complication yet, but I live in crippling fear of the day it happens.”

“I feel very poorly equipped to cope with my surgical complications.”

 

 

Andreas and I do thank all RANZCOG members who took the time and effort to take the survey. We will endeavour to honour your efforts by presenting the results to RANZCOG, our professional societies and the public.

We would also like to thank RANZCOG for supporting our endeavours to taking the first step to address this rather prickly issue. The first step is: Measure. You cannot improve outcomes that you don’t measure.

The survey has clearly shown that there are big unmet needs of support for O&Gs. Andreas and I are both very keen to advance existing support systems and lobby for new support that needs to be created.

We will keep you updated through this blog.  Subscribe here to receive weekly blog posts.

 

 

Yours truly,

 

Elizabeth Varughese

varughese.elizabeth@gmail.com

 

[1] SurgicalPerformance is online audit software for audit of general gynaecology, obstetrics and colposcopy (see article from last week). A LITE version is free and provides feedback on the users incidence rates of outcomes; a PREMIUM version compares the user’s outcomes with her/his peers and is $10/$25 per month for trainees and specialists.

[2] The Urogynaecological Society of Australasia Pelvic Floor Surgery Database is for urogynaecological procedures only. Membership of the Urogynaecological Society of Australasia including Database access is available from $320 per annum.

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Comments

  • Andreas Obermair 11/03/2013 7:56am (7 years ago)

    Hi Rog, I am sorry to hear and read that you had a rough time. I believe this kind of things happen regularly. One of my general surgical colleagues had to undergo review of all his cases. After the review it turned out his complication rates were within the limits that one would expect. His practice had to be closed down.
    Unfortunately, I have no quick recipe to offer but I am one of the 30% of people who believe that self-audit protects from these accusations to some extent. My colleague spent months wading through all his charts. I have them all entered at all times and everybody out there is well aware of it. You want to know what my visceral injury rate is - as per today - in the last 12 months - last 24 months??? I have at ready for you at the push of a button. We need to help ourself these days.

  • Roger McMaster-Fay 10/03/2013 4:06pm (7 years ago)

    "As per your letter dated 29th October 2010, I agree to voluntarily suspend the performance of laparoscopic surgery at ******* Private Hospital pending the outcome of the Medical Board’s
    Independent assessment."
    This process remains unresolved with no end in site despite no limitations being placed on my practice by APHRA / HCCC / MBNSW (ie. 28 months!!).
    I was never afforded the luxury of Peer Review by the hospital / local Department of O&G!.
    This rediculous delay has been financialy devistating while those'colleagues' who refused me due process have 'sponged up' my practice.
    Support? your joking, no one could give a bugger!

  • Rosie Jones 09/03/2013 4:01pm (7 years ago)

    Jules, you naughty man! Don't belittle the angst that some of us experience when we have a complication. Of all people I would have thought you would have more sensitivity. At the same time however, a death in a way is less traumatic; at least the woman is not limping back and being vocal about her disaster.
    When I started laparoscopic hysterectomy in 1991, I used to make a self deprecating joke about myself being the expert in complications of the new surgery since I was keeping good records and knew at the touch of a button what could go wrong and how it happened together with how to fix it. I stopped any attempt at leavening humour when I realised that no-one else found it at all funny.
    In fact I think the younger gynaes have lost their confidence and are simply ceasing surgery and that is both a good and a bad development. What it has meant is that the patient's options have become reduced and that may be good if the doctor successfully seeks a non invasive solution but that won't fix all the problems.
    I shall not be sad to leave surgery.
    Rosie Jones

  • Jules Black 08/03/2013 5:34pm (7 years ago)

    Gosh, all this talk of exit strategies, ceasing practice etc. What are those people on about? Are they equating a complication with a maternal or patient death?

  • Phil Watters 08/03/2013 4:24pm (7 years ago)

    These findings come as no surprise. I went to rural NSW in '85 mostly because I didn't have the capital to stay in Sydney and few connections. I spent 4+ years training in the UK and a year with the Gyn Onc team at Westmead before starting in Armidale (doing a 1 in 2 with no junior staff), so I wasn't afraid of getting deep into the pelvis. I was also well trained in vaginal surgery and not afraid of it. In a college website forum (which folded quickly) I would make statements like "to be in the country you have to be better trained than in the city because you are more on your own". This of course fell on deaf ears, especially those who had never stepped out of their cosy city comfort zones. Practice now is more and more compartmentalised. People are forced to limit their surgical practice to that which they do well, or have had adequate training for, and from what I see in public hospitals now, there's very little training to be had in major gyn surgery until you have an endoscopic or oncologic fellowship. Most of today's new fellows seem only capable of the French basic training style, ie Obs and Office Gynae only. If you want to do Gyn sugery you need more training.Given post grad degrees and 6-8 years training after that, there's less and less time to recoup your investments and try to have a family life too. Enough from me. Any others?

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