August 6, 2015

In the United States, some patient advocates and lawmakers are pushing for legislation to install cameras and audio recorders in operating rooms. Most doctors oppose the idea of being monitored while they operate. In Germany, trial runs with recording equipment are underway.

By Katja Ridderbusch, Atlanta

For Dr. Andris Golde, the time he spends in the operating room usually is the highlight of his workweek. “When I operate, I’m at my most relaxed and focused,” he says. “Surgery to me is the epitome of what I’m trained to do. I find it truly enjoyable.”

Those moments of happiness in the professional life of Andris Golde, otolaryngologist-head and neck surgeon at Advanced Ear Nose and Throat Associates in Atlanta, Ga., may be numbered. In the U.S., more and more patient advocates, attorneys, and lawmakers are pushing for legislation to make video cameras and audio recorders mandatory in operating rooms.

A recent case in Virginia fueled the debate that has been going on for a few years. A patient who was about to have a colonoscopy wanted to record the post-operative instructions on his smartphone, but ended up recording the entire procedure. When he pressed play on his way home, he found that the OR team had trashed him while he was sedated. The anesthesiologist called the man, who had previously gotten queasy when the IV was placed in his arm, a “wimp” and a “retard”, mocked a rash on the man’s penis and announced she would write a false diagnosis – hemorrhoids - on the patient’s chart. The recording was legal, since in the state of Virginia, as in most of the U.S., only one person involved in a conversation needs to consent to a recording; in this case: the patient. The man went to court, and the anesthesiologist was ordered to pay $500,000.

Defamation, however, is only a side aspect of the debate about installing surgical black boxes in the OR. The move is primarily supposed to make it easier for aggrieved patients and their attorneys to gather evidence for alleged malpractice. In June, four state representatives in Wisconsin introduced legislation that would require hospitals or outpatient surgery centers to offer patients the option to have their procedure recorded.  If the bill becomes law, it would be the first of its kind in the United States and could set a precedent.

“In a lot of other professions that deal with life and death situations, peoples’ work is monitored by cameras and voice recorders,” says Wade Ayer, who has founded the National Organization for Medical Malpractice Victims and who is a driving force behind the proposed legislation is Wisconsin. “Pilots have black boxes in the cockpit; many police officers are wearing body cams. Why should doctors be an exception?”

Ayer’s motivation is deeply personal. His sister Julie Ayer Rubenzer, died in 2003, after she was given excessive amounts of the anesthetic Propofol during breast augmentation surgery. In the investigation following the incident, there were conflicting testimonies, and it remained unclear who administered the drug. “Cameras can provide definitive answers,” says Ayer, “who was in the room and who wasn’t, and who did what and when.”

Andris Golde doesn’t see cameras and audio recorders as an effective way of controlling the environment in the operating room. “Usually, there is not one move or blink that makes malpractice happen,” he says. “It takes an entire series of decisions, a suspended course of things, not one isolated event.”

Golde, tall, athletic, with a relaxed smile, is Canadian with family roots in Latvia. He’s been a surgeon for 20 years and has done thousands of procedures, from complex tumor removals to straightforward tonsillectomies. A lot of operations today are being recorded on digital cameras, anyway, he says, “because they are performed endoscopically, or laparoscopically, so the recording of the procedure itself is very standard.”  He adds that most of the modern anesthesia machines are digital. The data is recorded in a digital format, and any trends and abnormalities are well documented. “I just don’t see where a camera, or an audio recorder, would make any difference,” he says. 

Patient lobbyist Ayer strongly disagrees. Room cameras could capture the surgeons’ body language, and voice recorders may indicate whether or not the OR staff was distracted during the procedure. It’s an argument that doctors find problematic, since body language is subject to interpretation. They worry that at some point, every move a surgeon makes, every habit he follows, and every word he utters would be analyzed and judged. How does he hold his instruments? How often does he and his staff laugh, and about what? Which genre of music is played in the background, and at what volume?

Such a “big brother” scenario would disrupt the cautiously balanced culture in the OR, the communication and workflow, says Golde. “A black box would create an environment that would be very artificial and strange, and create unnecessary stress and regulation on the staff, which would not be beneficial for the patients, quite the contrary,” he says.

Scott Wolf, an attorney with Blanchard, Walker, O’Quin and Roberts, a law firm in Shreveport, La., takes it a step further. He says that especially during critical surgeries, constant electronic monitoring of the OR team may become downright dangerous. “If doctors feel like they’re controlled and second-guessed non-stop, they may inadvertently slow down, “ says Wolf, who represents physicians, hospitals and insurance companies. “Their performance may become more hesitant und self-conscious, and the entire team may lose valuable time during surgery.”

ENT surgeon Golde always makes sure to take the stress out of his OR, so that the mood is light, yet serious. He has music playing, mostly jazz and classic rock, there’s laughing among the staff at times, as well as conversations about personal matters, the kids, last night’s baseball game, or upcoming weekend plans, just like in every other line of work. “It’s a very carefully choreographed environment, where I make sure everyone knows exactly what to expect at any given time, so that the operations go smoothly and efficiently,” he says.

Of course, Golde adds, patients can be subjects of conversations in the OR, too. “If a patient has been very rude and obnoxious before he goes asleep, we say something about him being rude and obnoxious,” he adds with a little smile. “If they’ve been extremely polite, we say, what a nice guy, or what a wonderful lady. That’s just human.”

In Germany, the debate is still in its early stages. “Also, unlike in the United States, it’s not primarily patient and consumer protection advocates who are pushing for the idea to install cameras and audio recorders in operating rooms,” says Irem Scholz, a medical malpractice attorney for the law firm Quirmbach und Partner in Montabaur in Southern Germany. It’s rather coming from doctors and hospitals. Recording technology would serve as a tool to analyze and avoid mistakes, and to assure and control quality and patient safety, she adds.

A small number of German hospitals have already started trial runs. One is the Acqua Klinik in Leipzig, a private hospital specializing in ear, nose, and throat procedures. Its state-of-the-art operating rooms have been, since January, equipped with high-tech recording technology called a surgical recorder. With the patient’s consent, the surgical recorder tapes the surgical navigation, the endoscopic images, and on a separate audio track, the voices of the surgeon and the entire OR team. According to hospital officials, transparency was the main reason why they decided to install the recorder, but also the competitive edge.

For patient attorney Scholz, preservation of evidence is the main argument. “When we have a suspected case of medical malpractice, and I know the procedure has been videotaped or otherwise recorded, I request the tape in order to check if there’s probably cause,” she says.

Scholz doesn’t expect to see black boxes installed on a larger scale in German ORs anytime soon. But the debate will continue. “Most likely, individual hospitals will start installing recording devices on a voluntary basis,” she says.

There are some trials runs in the United States we well, but very few can be called voluntary. Take, for example, the Rhode Island Hospital, in Providence, R.I. In 2009, the Rhode Island Department of Health ordered the hospital to install audio and video monitoring equipment in each of its operating rooms because there had been five wrong-site surgeries since 2007.

Even though there aren’t any cameras in the OR looking over his shoulders, Andris Golde, in his daily clinic routine, sometimes gets a flavor of what the future may bring. “More and more people these days shove a smartphone literally a foot away from my face,” he says. And when he asks why, they answer, “I just want to record what you’re telling me.” He wearily shrugs his shoulders. “I’m trying to stay polite, but honestly, I find that offensive.” He says that such behavior alienates the doctor patient-relationship, as it plants the seeds for mistrust, and makes doctors put up their guards.

It is in moments like these that he really looks forward to the hours in the operating room, where he and his team can be relaxed and focused, and simply do the work that they are trained to do.   


This is the translation of an article originally published in German in the daily national "Die Welt" on August 6, 2015. - © Die Welt / Katja Ridderbusch