Show and tell: Letting outsiders see into the OR

Forget going out to the waiting room to talk to patients' families after the operation; one Cincinnati orthopedic surgeon lets them watch.

By Tanya Albert amednews correspondent — Posted July 26, 2004

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"Look at the size of that vein," orthopedic surgeon Timothy E. Kremchek, MD, tells the parents and 13-year-old brother of 16-year-old Caleb Deeds after he opens up Caleb's elbow for ulnar collateral ligament reconstruction.

Caleb's family is on the other side of a glass that separates a viewing area from the operating room where Dr. Kremchek is working.

Some might say Dr. Kremchek is taking an unnecessary risk in an out-of-control liability climate. Dr. Kremchek believes he is taking the ultimate step in patient communication.

The Deeds family welcomed the openness.

Marilyn and Galen Deeds each crack a small smile from the edge of their cushy black leather chairs and look at the television screen as physician assistant Megan Chojnacki, who is in the room with them, points to the thick, dark healthy vein Dr. Kremchek is talking about.

The Deeds stand up and get closer to the screen to see the inside of their son's elbow. On the video screen, Dr. Kremchek points out the torn ligament. The Deeds turn their heads to the right to look out the glass. They see Dr. Kremchek and two others hunched over Caleb's arm.

Through an open intercom system that allows patients' families to hear the operating room staff's conversation, the sound of the instruments whirring and beeping, and the '70s music the staff is listening to, Dr. Kremchek tells the Deeds family that they'll take a tendon out of Caleb's arm to repair his elbow.

Several minutes later, a physician working with Dr. Kremchek steps away from the operating table, holding the long white tendon. He turns and shows it to the Deeds. If not for the glass, they could touch it.

The physician prepares the tendon and brings it back to Dr. Kremchek.

"Isn't that cool?" Dr. Kremchek asks after he pulls the tendon through a hole he's created.

The Deeds look eye-to-eye with Dr. Kremchek, who is sporting a Cincinnati Reds surgical cap, and nod.

In today's litigious climate, most physicians couldn't imagine opening up their OR.

But Dr. Kremchek -- who jokes that he sometimes feels like an animal on display in a zoo -- believes that opening the lines of communication in this way could minimize lawsuits.

The chief orthopedic surgeon and medical director for the Cincinnati Reds, Cincinnati Cyclones, and some local high school and college teams, Dr. Kremchek, along with 10 other physicians, participated in designing and building the now 1-year-old Beacon Orthopedics & Sports Medicine in Cincinnati's northern suburbs. It's not your traditional office.

There is a physical therapy center, chiropractor offices, batting cages and a sports field, all under one roof. An athlete can be diagnosed, operated on and rehabilitated at one facility.

But the surgery observation rooms make the practice even more unique.

They provide an opportunity to demystify what goes on behind traditionally closed doors and educate patients' families about the operation firsthand. It gives families the opportunity to ask questions. It lets them see how much care and concern is being given to their family member.

"I've been sued before," Dr. Kremchek said. "The people who sue you are the people who for some reason didn't realize you were going to do something. It was a communication issue."

By having a family member watching the surgery, Dr. Kremchek can, for example, show them the soft bone that might make it more complicated to use a screw. He can also get instant verbal consent if he needs to change course.

"There is nothing worse then being a family sitting in the waiting room wondering who is doing the surgery or whether the doctor is taking time to eat lunch before they come out to talk to them," Dr. Kremchek said. "This takes away some of that fear and anxiety."

Wave of the future or risky idea?

Observation rooms -- one off each of two ORs -- were a tough sell to his colleagues, and most don't use them to the extent that Dr. Kremchek does.

"Physicians were concerned that it would cause a distraction," said Steven Scheffel, Beacon's administrator. "But even those who were reluctant are now using them sometimes."

Dr. Kremchek offers the opportunity to all of his patients, and about 95% take him up it. Other physicians might have people in the observation room about 5% of the time.

It is a controlled situation, and patients and families sign a variety of consent forms. Family members and sometimes agents or team trainers enter the room after the anesthesia is administered and only the body part about to be operated on is exposed. Observers leave when the surgeon leading the operation is finished.

Although doctors can communicate with the people in the observation area, a physician assistant or nurse is in the room with them the whole time to provide extra explanation and answer questions.

And to keep the mood light, Dr. Kremchek often reminds those watching that he's "a trained professional and that they shouldn't try this at home."

His theory: "I'm not going to hold anything back when I come out of the OR to talk to the family, so why not let them observe? If something happens, they got to see it, and they are able to see we acted appropriately. ... Patients and their families are not left saying, 'He didn't try.' "

Some experts question that logic.

"It could severely backfire," said health lawyer Kirk Willis, chair of the Personal Injury Law Section at Godwin Gruber in Dallas. "If something goes wrong [and the family isn't in the room], the family only testifies about what they saw before and after surgery. ... I don't want the testimony of a family member about what they saw go wrong in the operating room."

Willis, who represents physicians, said he would rather see doctors spend more time with patients and their families in other ways.

"The open line of communication should be total dedication of time before the operation," he said.

He said physicians should talk about the diagnosis and every treatment available as well as the risks of each one. He also advises doctors to walk patients and their families though the procedure, convalescence period and recovery period.

Dr. Kremchek said if something is not going right during the procedure, they can have the staff take the family out of the observation room. They have had a few situations in which the anesthesiologist wasn't comfortable with the patient's status. The family was told what was going on, escorted out and brought back once the situation was addressed.

Wendy Menzel, a claims supervisor with American Physicians Assurance in Louisville, Ky., which once insured Dr. Kremchek, said the insurer hadn't taken a position on whether letting family members watch is a favorable or unfavorable thing.

"Like videotaping, it could be extra evidence that could be helpful or not helpful," she said.

Anecdotal evidence shows that an increasing number of hospitals and obstetricians are no longer allowing parents to videotape childbirths because of a fear that it could be used as evidence in a trial. And a 2000 University of Iowa study found that legal concerns stopped about 40% of the 610 Iowa obstetricians interviewed from filming medical procedures such as births.

But with most lawsuits resulting from a patient's lack of understanding about a procedure, observation rooms for families are a chance to better understand, Menzel said. "There is less fear, and it promotes discussion and interaction," she said. "That is a good thing. But I don't see this as the wave of the future. It needs to be evaluated on a case-by-case basis."

Dr. Kremchek said he realizes that observation rooms might not be for every physician or every type of medical procedure. For example, he said, the physician has to be comfortable with doing his or her job in front of the family. Procedures that are more controlled also might be more suitable for observations.

Obstetricians have allowed fathers or other family members or friends in the room for years. And Dr. Kremchek said he could see observation rooms working for some procedures that otolaryngologists, ophthalmologists and general surgeons perform.

"It takes doctors off the white coat pedestal," Dr. Kremchek said, noting that medicine has changed since the days his father was an orthopedic surgeon, when white coats and titles brought a certain prestige. "It takes away the inner sanctum and personalizes the whole thing."

Patient perceptions?

Most patients and families love the idea and are spreading the word to friends about the experience.

"I just feel a little more educated on what the damages are," Margaret Osborne, a nurse, said after she watched Dr. Kremchek operate on her husband's rotator cuff.

Doug Painter, a Blue Ash, Ohio, resident who watched his wife's knee surgery, said it was less stressful to be observing than it would have been if he were in the waiting room waiting for a doctor to come out. He, like Osborne, was surprised that he was allowed to watch the surgery firsthand.

"This would probably help out in cutting down on lawsuits, because you have the patient's family seeing what is going on and not in the dark wondering what could have possibly happened," Painter said.

Cincinnati Reds head athletic trainer Mark Mann said watching surgeries on players allows him and his staff to better rehabilitate them. "It takes the guesswork out of how or why the procedure was done."

Galen Deeds said being allowed to watch his son's surgery helped build trust with Dr. Kremchek. "He says, 'Here I am, and here is what I'm doing,' " Deeds said. "It made me feel at ease."

And that is Dr. Kremchek's goal. "You never hide anything from people. If you are competent at what you do and honest with people, there's no reason why you shouldn't let them see it."

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