Bad person or bad system? by Aubrey Samost M3, UMass

I am a system engineering graduate student, and I firmly believe that the vast majority of bad outcomes in health care are due to good people working in bad systems. However, today when watching the story of Michael Skolnik’s death after three years of complications from neurosurgery I felt like I had just seen one of the rare cases of a truly bad person in the health care system.

For those unfamiliar with the case here is the two-minute synopsis. A previously healthy 20 something year old male presented to the emergency room after having a syncopal episode. A head CT shows what may be a colloid cyst with no evidence of increased intracranial pressure. An MRI is done and may show the same colloid cyst. Michael and his parents go to see a neurosurgeon who immediately admits him to the neuro ICU. He gets the family to sign a consent form that they barely understand and places a bedside VP shunt to drain the possible excess CSF.  Next the neurosurgeon told the family that Michael needed to have the cyst removed. He said the  procedure was small and glossed over any possible complications.  The parents felt they needed more time before signing the consent form for the procedure, especially after feeling like they had been deceived with the last procedure. Later that day the surgeon returned, and, finding Michael alone, had Michael sign the consent form despite the heavy doses of opioids that he was on. The next day the surgery goes ahead with terrible results. Michael suffered severe brain damage and had nearly every possible complication, none of which the family was prepared for because of the terrible informed consent process. After three years, Michael finally died of these complications from a surgery that it turns out he may never have needed.

As the story unfolded it felt like the neurosurgeon constantly placed his own needs ahead of that of the patient. I was so angry that he seemed to force the procedure on the family and patient never mentioning alternatives. Maybe his motivations were financial or maybe he just felt he needed the practice with this procedure, but it always seemed to me that he prioritized doing this procedure despite it not being in the best interests of the patient. On the other hand, perhaps he wasn’t truly evil in intention but just had terrible clinical judgement and truly believed that he was helping the patient by performing this unnecessary procedure. Regardless of which of the above might have been the truth – evil intentions or incompetent medicine – my blood pressure was surely elevated by the end of this film because I was so angry.

As we discussed this, I realized I wasn’t alone in my anger. One of my colleagues pointed out that it practically felt like murder what had happened to poor Michael. As I was listening to these comments and reflecting on my own, my blood pressure slowly lowered and the systems engineer in my started to speak up. The documentary we watched was meant to highlight the importance of the informed consent process and show that it was poorly done in this case. However, none of us ever asked why the neurosurgeon performed such a poor informed consent. What other factors may have led him to mess up this process so badly? As with any complex system, the answer is multifactorial and more complicated than it initially seems. The following are some of the ideas that I considered. I haven’t got the facts in the case to support these; they are really just my own theories and possible explanations, but it forced me to think beyond my initial gut reaction of blaming the surgeon.

-Financial incentives are misaligned: insurance pays you to do a procedure, not to advise the family and patient to not undergo said procedure. The need to get paid could certainly have biased this surgeon into pushing strongly for the procedure.

-Time constraints: The surgeon was most likely in clinic or the OR during normal business hours when Michael’s family was visiting. After the surgeon was done in the OR he could come up to see Michael and get the consent form signed but that did not align with family visiting hours. Therefore, the system could have acted against him being able to give the family the opportunity to go through the informed consent process and instead forced him to get Michael to sign it alone.

-Culture: Many of my colleagues remarked after seeing this documentary that they rarely or never saw an informed consent properly done. What the neurosurgeon did here was just another example of normalized deviance. If everyone else in the hospital was signing consent forms this way, is it any surprise that he did?

-Administrative pressures: Perhaps this was the only full-time neurosurgeon in this hospital and he was under a lot of pressure from administration to not shunt business to their local competitors. This pressure could make him feel unable to turn away a case even if he did not feel totally comfortable doing the operation.

Overall, I have no idea if any of those above system ideas are correct or played any role in this accident. However, by the time I finished thinking through these theories, I felt that we as a class had been missing the most important question. If we want to prevent informed consent failures in the future, we need to ask why he failed to obtain a true informed consent. And when we answer this question, we need to consider the possibility that any neurosurgeon in the same position might have reacted that way because of the pressures the system exerted on him or her. Only then can we change the system to prevent a well-intentioned young surgeon from falling into the same trap and hurting a vulnerable patient and family.

I attached a picture of a basic diagram of this system as it impacts the neurosurgeon’s decision to operate in my fictional system.