Friday, June 29, 2012

Patient Complications & Surgeon Collateral Damage

"Collateral damage: the effect of patient complications on the surgeon's psyche" was a brief but interesting paper that probably went unnoticed by many. Using the results of a survey completed by only 123 of the 403 surgeons who received it, the paper studied the effect of complications on the emotional well-being of surgeons. You could argue that the response rate of 30.5% renders the conclusions suspect. But that’s not the point.

The subject matter hits close to home for any surgeon who cares about his patients and what he does to them.

There are two types of complications—those that happen despite your best efforts, such as a postoperative MI in a seemingly healthy patient or an infection that develops after proper surgical technique and appropriate antibiotic prophylaxis were used.

Then there are the complications that occur because you made a mistake. Examples of this are sepsis due to an anastomotic leak due to your well-intended but erroneous judgment that the patient’s bowel wall would hold the staples or your failure to operate soon enough on a patient with a bowel obstruction.

Of course when any complication occurs, we feel bad for the patient and the family. But the latter type of complication can keep you awake at night, undermine your confidence and your ability to function and even effect your enjoyment of life in general. Eventually, you get over it and move on, but the next time is no easier. According to the survey, about two-thirds of the surgeons felt it was difficult to deal with the emotional aspect of  complications throughout their careers and experience did not seem to lessen the impact.

Not everyone is affected in the same way or to the same degree. I once had a surgeon tell me, “I’ve been in practice for 22 years, and I’ve never made a mistake.”

But for us mere mortals, mistakes happen and leave scars. A South African blogger named Bongi said it much better than I in a post he called “The Graveyard.” In it, he describes a case of his with a delayed diagnosis that resulted in a patient’s death. He said every surgeon has a graveyard in the “dark recesses of his mind” where “names engraved on the tombstones” can be recalled.

I have a graveyard. I think most doctors do.

Note: This post appeared on Sermo yesterday and generated some thoughtful comments.


Andrew Frederickson said...

This reminded me of Malcolm Gladwell's New Yorker article about Charlie Wilson, the legendary UCSF neurosurgeon. In the article Gladwell cites a quotes a sociologist (Charles Bosk) who was studying what makes someone a "good" surgeon:

"In my interviewing, I began to develop what I thought was an indicator of whether someone was going to be a good surgeon or not. It was a couple of simple questions: Have you ever made a mistake? And, if so, what was your worst mistake? The people who said, 'Gee, I haven't really had one,' or, 'I've had a couple of bad outcomes but they were due to things outside my control'—invariably those were the worst candidates. And the residents who said, 'I make mistakes all the time. There was this horrible thing that happened just yesterday and here's what it was.' They were the best. They had the ability to rethink everything that they'd done and imagine how they might have done it differently."

I have no idea how this sociologist measured who was a "good" surgeon, but the sentiment is kind of nice. Was your college who never made a mistake a good surgeon?


Skeptical Scalpel said...

Andrew, thanks for the comment and the link. Bosk wrote a book in the 1970s about his observations while spending a year with surgeons. It's called "Forgive and Remember" and is still available in paperback. It's worth reading.

As you probably guessed, the guy who never made a mistake was not a grat surgeon.

RobertL39 said...

This is definitely part of what made me retire. I just couldn't deal with the circuitously self-inflicted [I made the cut; they got the complication; I got the anguish] mental distress. On top of which I didn't think I was improving and learning from those complications. So, much like a musician, I stopped practicing and quit performing. Even though you can tell yourself that at least you're doing it better than some other people it doesn't make the collateral damage easier on you.

Skeptical Scalpel said...

Robert, I appreciate your comment and I understand completely. I think only people who do what we do can really "get it."

John C. Key MD said...

I remember my worst was on an aortic aneurysmectomy about 30 years ago. Patient died. It didn't drive me out of surgery but I still remember every detail...and never made those mistakes again.

I think most non-sociopathic doctors are harder on themselves than others are on them. I read an article on malpractice cases many years ago that stated that being a physician is so integral to a doctor's being that you can get away with accusing them of almost anything other than "being a bad doctor". That sentiment remains true for me.

Dr Skeptic said...

A related question: do you think that complications that are our fault arise more from over-intervening or under-intervening? Or does it matter?
We feel terrible when we decide to leave something alone and it turns out bad, but I find that more mistakes occur when we intervene and later realise that the patient would have been better off if we had left them alone. The problem is, we can justify the latter situation by saying "At least I tried".
Maybe this reflects orthopaedics more than general surgery, but personally I find younger surgeons to be aggressive, then they become more conservative when they become aware of their potential to do harm, and the ability for many patients to improve without their intervention.

Skeptical Scalpel said...

John, thanks for your thoughts. I remember my really bad ones and learned from them too.

Dr Skeptic, I think we are programmed during residency to believe that errors of omission are worse than errors of commission. That plus the fact that we become surgeons so we can do something about disease tends to push us to act. Thanks for the comment.

Shahzad Shamim said...

Reminds me of a quote: "young surgeons kill their patients, old surgeons let them die."it is an interesting debate whether the errors of commission are graver than the errors of omission, but I would agree with skeptic, sometimes it is a consolation to know that we tried.

Skeptical Scalpel said...

Shahzad, thanks for the comment. I had never heard that quote before. It's thought provoking.

Anonymous said...

Two sayings from our country, comes to my mind:

1. "The surgeon takes the chance, but the patient takes the risk".

Sometimes we just have to acknowledge that we have to be more careful and put ourselves in the same position as our patients.

2. "The art of Surgery is not to perform surgery, but to abstain from surgery"

This doesn´t mean that we should avoid performing surgery, but rather that we should focus on patient selection. This is especially important in oncologic surgery and in surgery of the elderly.

Best regards from Dr Anonymous

Skeptical Scalpel said...

Nice comments. I agree. Thanks.

Robert said...

Nice post which The people who said, 'Gee, I haven't really had one,' or, 'I've had a couple of bad outcomes but they were due to things outside my control'—invariably those were the worst candidates. And the residents who said, 'I make mistakes all the time. There was this horrible thing that happened just yesterday and here's what it was

Anonymous said...

Personally I prefer to under-intervene. If the surgeon ain't sure about operating, what about the patient? Maybe the patient don't want surgery, which may count in borderline cases. Take the patient to the OR and cut him is easy, the tough decision is to know if it will do good.

Another metaphor for the graveyard is albatross -

Skeptical Scalpel said...

Yes, a lot what a surgeon does is knowing who NOT to operate on.

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