Issues surrounding videotaping surgeries in the operating room

The rapid advance in digital video and still camera technology has found its way into the operating room.

There is the potential to capture and record just about every minute of every surgical procedure in some way. The newest endoscopic camera systems and operating microscopes have integrated systems to record video footage. Storing all that data is just the press of a button away.

The advantages for surgeons are obvious, like the ability to record interesting pathology, new techniques, to document surgical process, to teach, and, last of all, to see with hindsight where mistakes might have been made.

But it is that last potential that opens up some serious, and unanswered, questions:

* Given that a whole procedure may be recorded in some way, where should the recording start and end? As the patient is wheeled in, and then wheeled out?
* Who “owns” the recording? The hospital, on whose equipment the recording is invariably made, the doctor, or the patient? Who controls the recording – the owner?
* Can, or should, the recording be edited, cut or deleted in any way, particularly when things go wrong?
* Does a surgeon have the right to refuse being recorded, or to turn it off when the surgery does not go to plan?
* Consent to record must be taken, but does a patient have the right to refuse?
* What about procedures on intimate areas of the body? What controls on recorded data should be in place to protect patient dignity?
* Does the doctor have a right to refuse his patient’s access to the recorded data?
* Does the presence of a procedure recording enhance or suppress potential litigation?
* How do the malpractice insurers feel about this technology? Do they embrace it, or warn against it?

I have found my recording of procedures extremely useful in showing pathology to my patients, and in demonstrating what was done during their procedures. The consent I take is as “bullet-proof” as I can make it.

I don’t know how comfortable I would be showing my patient the exact moment of a mistake or complication. Currently, I am selective as to what I record, and never attach an associated audio recording.

I would have an uncomfortable sense of “Big Brother” in the operating room if such technology was made mandatory. On the other hand, airline pilots have had to cope with every word and decision being recorded on flight recorders in the interests of safety, and it may be argued the same should apply to the operating room. In an era of a drive towards greater transparency, recording seems to be an appropriate control. We surgeons at least have the ability to turn off the recorder when it is to our advantage to do so, something airline pilots cannot do.

The technology is here, in use, and growing. There may be a demand for it, and we would be wise to deliberate and define answers to the questions posed above before a mandatory “record everything” policy is one day thrust upon us.

Martin Young is founder and CEO of ConsentCare.

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  • ninguem

    Somebody called, asking me to consult on a patient, where the patient’s lawyer would videotape the entire interaction.

    “no”

    “but we’ll pay……….”

    “I don’t care how much you pay, no, and goodbye.”

  • alex

    You’re conflating two totally different types of recording in this post. There is “key element” recording, where you record the sight of the patient’s pathology or something important in the case. This can be useful to go over with the patient, to beat insurance companies into compliance (blech), or for your own personal reference. This is increasingly common and offers few downsides for anyone, except for the fact that it’s becoming increasingly mandatory when insurance companies make it yet another hoop to jump through to get paid.

    External recording of what’s going on in the OR is far less common. The benefits are questionable and it’s mostly done for educational purposes. I believe patients should always be able to refuse this with no questions asked. Haven’t heard anybody suggesting it be mandatory and quite frankly I would consider it a total dealbreaker for any patient or hospital who demanded recording. Pilots don’t have their tapes regularly pulled for lawsuits where their comments are held against them. “So, Dr. X, you felt it was appropriate to MAKE JOKES while doing cancer surgery? Perhaps that played into her bad outcome?” Nuh uh.

  • jenga

    I know if it was mandatory, I wouldn’t operate. Find another physician

  • http://www.consentcare.com Martin Young

    I agree with all these points. There are however institutions and disciplines where all residents operate under video surveilance so that mistakes can be analysed. This protocol is already in place. The three comments so far have in common a hope of avoiding this issue rather than addressing. I share their concerns, and this is my reason for writing the post!

  • D

    The patient should always be able to give informed consent and shouldn’t be refused treatment if they refuse. It may be beneficial in some ways (keeping the nurses from doing anything unethical) but realize that the patient will most likely be exposed for some or all of the surgery. Pilots don’t ever have to worry about anything like that. Patients rights should always come first.

  • alex

    Can you cite a reference to an institution where residents are always recorded? I have never heard of any such thing. In fact, I know of a program director who wanted to do something like this and got shot down hard.

  • Jenga

    With the continued intrusion into physicians lives, I could easily see this as a line in the sand moment for most surgeons.
    On a side note, thanks Kevin for the mobile format on your weblog. It makes it on of the easiest to use sites around.

  • http://www.taskforce.org/justinhope.asp Dale Ann Micalizzi

    I have to chime in here as I would like to address the issue. A hope for avoiding the issue has long passed.

    My 11 year old son died following a “simple” ankle drainage. The answers were not, and are not, forthcoming as to what complications did occur. Deny and defend took the place of healing a family or learning from an adverse event. I’ve spent the past 9 years becoming nationally involved in quality, transparency and patient centered care as a result of my experience.

    I believe in real time recorded surgical procedures for educational and ethical reasons and I think they will fix some of the wrong site surgeries that are continuing to occur. Staff will think…or check… twice and hopefully an open dialogue will result. The patient and family deserves to see the recording-all recordings and become actively involved in the root cause analysis when things go wrong. No, the recordings should not be edited just as medical records are not supposed to be edited. There are still bugs to work out to make this system idea work efficiently. This is not big brother watching you. It is a safety monitor. In the future world of IT, the recording and records would belong to the patient.

    I’ve received hundreds of possible explanations from caring physicians across the world who wanted to take a shot at what went wrong in my son’s care but only those in the OR would really know but have refused to talk. Or perhaps, they wouldn’t know either but the recording would verify their competence and ability in completing the procedure to the family, administrators and themselves. Don’t be afraid of technology. Yes, we need to fix the fear of litigation that some of you still possess in order to make this step acceptable and fair to everyone.

    So, if your child has minor surgery and your child dies as a result, this recording may help someone else, as well as your family. Someone may learn from an error and another child would be saved. Students could see more real time surgeries before practicing.

    Yes, I have met physicians who have traveled my same journey when their child died during surgery. Don’t think that you are treated differently just because you are a physician. You are “just” a Mom or Dad when your child dies in surgery and the walls still go up in most facilities. Believe me, you will feel disappointed by your profession beyond comprehension when this occurs. We need more physicians and caregivers involved in our culture change efforts. Please help us make patient safety the only priority. Take down the fences that divide us.

  • William

    I thought the tort reform issue was that there were too many false claims of error. If this were true then video would demonstrate that no mistakes were made. Now I read here that the fear is that actual mistakes, presumably those that would otherwise not be revealed, would be recorded. Which is it, are there too many requests for compensation, or too few? Or does tort reform mean yes errors were made but no, you don’t get compensation, but yes you do get to pay for correcting the mistakes.

    And as for editing the tape to hide the mistakes, please!

  • Andrea

    The doctor raises some interesting questions, but my feeling is that they are self-serving.

    There should be both videotaping and audiotaping of all sugeries. It should be illegal to tamper with them, i.e., edit parts out. If an error is made the patient has the right to know.

    I am a nurse who became disabled after a spinal fusion. I suffered innury to the S1 nerve and have cauda equina syndrome as a RESULT of the surgery. My surgeon steadfastly maintiained that I would be fine, minimized the excruciating pain I was in and that was documented by the pain service in his hospital, and sidestepped my blunt questions about what went wrong.

    No attorney would take my case. Patients are already behind the 8 ball when the have to sign a consent form that lists death as a possible outcome.

    There is no question in my mind, based upon my experience as both a patient and briefly as an OR nurse, that had my surgery been video and audiotaped some comment or “oops” would have been recorded and I would have had legal redress.

    The doctor wants to put a plethora of restrictions on the use of this technology. He can’t have it both ways.

  • Andrea

    I have heard that one half of all medical malpractice claims are directed towards 5% of all physicians. It makes far more sense to root out the bad apples and pull their licenses. However, the good old boy network is firmly entrenched in medicine; if you can bring a suit just try to find another MD who will testify on your behalf. You will be hard pressed to do so and if you do find someone you will have to fly them in from another part of the country.

    Torte reform is a very nice phrase that. politicians like to (sometimes) throw around; physicians would love it if they could never be sued. It is next to impossible to bring a malpractice suit because the lawyers are not dopes and they know which cases have a chance of making them money and which ones do not. If you don’t believe me just try calling a dozen and tell them you had a bad outcome from a surgery. As one of them said to me sh** happens, but you signed a consent that said you could have nerve damage and indeeed that you could die.

    Unless the action is so egregious, like the doctor in Boston who left his patient on the operating table while he went to the auto teller maching, virtually no one has a case.

  • Martin Young

    The comments so far indicate how polarized we the medical profession are from our patients. Doctors’ comments here say “No way!” and patients, most of whom appear to have suffered badly, say “Please use this layer of protection!”

    The technology is here. The medical profession has to find an ethical and fair happy medium acceptable to our patients.

  • Andrea

    Having gotten out my personal frustration in a previous comment, I think this is a good time to address Martin Young’s comment that the medical profession is polarized from patients.

    I have worked in QI (quality improvement) in the past and have spent time in the OR observing the team to see if they were in compliance. The public does not realize that patients under anesthesia are sometimes left by the anesthesiologist for periods of time, and I am not talking about instances where a CNA is monitoring the patient. I have seen post-op notes completed before the surgery was done. Ditto for anesthesia notes. This is called fraud. I have observed, or better yet, not observed, compliance with “time outs” to make sure procedures were being followed as put forth by JAHCO. I have had expletives thrown my way by MD’s who did not appreciate the fact that I was there to observe and later comment to the administration deficiencies that existed. Nurses aren’t always doing things by the book either. We are talking about people’s lives here. If doctors are doing their best and there is an adverse outcome but the videotaping is impeccable they have little to worry about.

    Patients have a lot more to be polarized about than they can imagine.

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