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Editorial Comment: Integrated Care and Teamwork The Rashomon Effect in Cardiovascular Medicine

Gross, Wendy L. MD, MHCM

doi: 10.1213/XAA.0000000000000073
Case Reports: Case Report

Vice Chair, Anesthesia for Interventional Medicine, Division of Cardiac Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, Massachusetts,

In this issue, Wang et al.1 describe a case of tamponade in a nonsurgical candidate occurring after transcatheter aortic valve replacement, recognized late in the intensive care unit and requiring emergent sternotomy. The authors point out correctly that successful outcomes in such cases require heightened awareness of potential complications by each team member: anesthesiologists, cardiologists, surgeons, and intensivists alike. However, the authors neglect the deeply troubling underlying problem: an emerging Rashomon effect2 among the related but distinct participating medical disciplines.

The Rashomon effect, defined as simultaneous perception of a single or series of events in different ways by different observers, is ordinarily discussed in sociological and political contexts: medicine considers itself above such subjectivity. However, the emergence of hybrid techniques and integrated care processes increases the likelihood that failed interdisciplinary communication and understanding will become a new source of morbidity and mortality.

The concept that team training and collaborative practice are fundamental to integrated health care planning and practice is widely recognized. However, technological advancement and the concomitant growth of hybrid procedures exacerbate an already neglected problem: practitioners of closely related disciplines (cardiology, interventional cardiology, cardiac anesthesiology, and cardiac surgery) may think they understand each other when, in fact, they do not. Rather than enhancing communications and understanding, overlapping competencies can encourage unjustified assumptions and unwarranted conclusions. Important conditions and complications then go unrecognized.

Information learned and properly understood in one context may not apply in the same way to similar but nonidentical situations. A cardiologist in a coronary care unit might not consider hypotension after the administration of an anesthetic unusual or worrisome. But a cardiac anesthesiologist would find the same situation troubling in the extubated post–transcatheter aortic valve replacement patient with a correctly placed, nonleaking prosthesis, who had received short-acting anesthetics during the procedure and required no vasopressors postoperatively. To a surgeon or interventional cardiologist, prior classification of that patient as “inoperable” due to previous mediastinal radiation might warrant management with increasing inotropic support, but only in the context of a focused inquiry as to the need for pericardiocentesis or mediastinal exploration. Each discipline has unique thresholds for clinical action, acquired via culture, experience, and teaching.

Teams composed of cardiologists, cardiac surgeons, and cardiac anesthesiologists can achieve ideal outcomes only when each member understands the key features of the others’ reasoning. This broadens the scope of thinking and focuses appropriate action. Traditional medical education prepares us well to be self-sufficient experts, but interdisciplinary work demands that we learn how to efficiently incorporate the expertise of others.

Currently, better outcomes require broader technical cognizance on the part of medical providers as well. Points of care to consider include preprocedure evaluation and designations of inoperability. Plans for intraprocedural and postprocedural care, including anesthetic management as well as potential postprocedure problems arising from the patient’s comorbidities or the procedure itself, should be discussed among all collaborators (cardiologists, interventional cardiologists, surgeons, cardiac anesthesiologists, and intensive care providers) before each case. As in the operating room, intraprocedural concerns and expected postprocedural problems should be preemptively reviewed, preferably by checklist.

Cardiologists in coronary care units may not recognize indolent postprocedure complications. Interventional cardiologists do not have the same perspectives as surgeons. Cardiac anesthesiologists are used to transferring care and starting the next case. Our disciplines use common vocabulary, overlapping experience, and expertise, but each has a different set of priorities and sense of ownership. Each has a different sense of what constitutes an important departure from acceptable care. But we all need to consider the entire picture, and this is particularly critical when specialization and focus are encouraged and necessary. As in dialectal differences of languages, seemingly “mutual” vocabularies and expertise in medicine can misrepresent important differences and critical nuances of diagnosis and care. Unless the translation is accurate, misinterpretations occur and overtreatment or undertreatment becomes likely.

Others have signaled the danger of rote response in situations where teamwork is required.3 With interdisciplinary care and medical cross-training, we must minimize the extent to which perceived levels of urgency, diagnostic significance, and response to unforeseen circumstance are narrowed or fixed by specialized training. As technology evolves, hybrid procedures for structural heart disease will become increasingly sophisticated and common. Contributing disciplines are more subspecialized, and overlaps in practice highly detailed and increasingly difficult to master. Financial constraints require accurate judgment and appropriate, efficient care. Therefore, rather than chopping the puzzle into perfectly interdigitated parts, we need to soften the edges of each piece in order to provide a strong, unitary, and well-annealed service.

Hybrid cardiac procedures may well represent the evolving frontline of treatment for cardiac disease. The development of optimal collaborative thinking among participating specialists requires that we become less territorial and that we extend our responsibilities to include what we may have dismissed historically as unimportant or someone else’s responsibility. Collaboration and efficiency need not be mutually exclusive. Solid interdisciplinary relationships, and not new technology alone, are required to advance the cutting edge of medical practice.

Wendy L. Gross, MD, MHCM

Vice Chair, Anesthesia for Interventional Medicine

Division of Cardiac Anesthesia

Department of Anesthesiology, Perioperative and Pain Medicine

Brigham and Women’s Hospital

Boston, Massachusetts

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1. Wang C, Hamburger J, Bhatt H. Cardiac tamponade after transcatheter aortic valve replacement using a transaortic approach. A & A Case Reports. 2014;3:113–5
2. Davenport C. Rashomon effect, observation, and data generation. In: Media Bias, Perspective, and State Repression. 2010 Cambridge, UK: Cambridge University Press:55
3. Wahr JA, Prager RL, Abernathy JH 3rd, Martinez EA, Salas E, Seifert PC, Groom RC, Spiess BD, Searles BE, Sundt TM 3rd, Sanchez JA, Shappell SA, Culig MH, Lazzara EH, Fitzgerald DC, Thourani VH, Eghtesady P, Ikonomidis JS, England MR, Sellke FW, Nussmeier NAAmerican Heart Association Council on Cardiovascular Surgery and Anesthesia, Council on Cardiovascular and Stroke Nursing, and Council on Quality of Care and Outcomes Research. . Patient safety in the cardiac operating room: human factors and teamwork: a scientific statement from the American Heart Association. Circulation. 2013;128:1139–69
© 2014 International Anesthesia Research Society