Friday, February 02, 2007

It's Complicated: part two

Speaking only for myself (but guessing I'm not alone), I can say when a patient develops post-op problems, there's a strong tendency to deny it: not to deny there's something wrong; not to dismiss the patient's concerns or symptoms. Just to grasp first at the less dire set of possible explanations. Maybe it's just the flu, constipation, drug reaction. That sort of thing. It's not about blowing it off -- because I never did. It's about hoping against hope, both for the patient's sake, and mine. Rationalization is a powerful instinct. In reading various forums and blogs and seeing innumerable patient complaints that their doctors took a long time to take them seriously, I'd guess that in many instances the desire to believe you didn't screw up is at work. That doesn't excuse it: maybe it explains it to a degree. For better or worse, doctors are human. I know I am.

When I saw my patient in the Emergency Room, her abdomen was distended, she had a low-grade fever and a bit of a red incision, and her Xray was the usual hard-to-be-sure early post-op belly film: possible obstruction, possible ileus (a condition of bowel laziness often seen for a while after abdominal surgery.) I admitted her, of course. Intestinal leakage -- from where the bowel has been sewn together, or from an unrecognized surgical injury -- is always on the list of possibilities in such a situation, but I didn't think so here. How tender is tender? How red is too red for an early incision? She didn't, I told myself, look all that sick. Time and a stomach tube, antibiotics for a possible sub-clinical (meaning not obvious) leak or abscess at her anastomosis ought to do the trick. Indeed, she looked better the next day. Not that "looked better" is an objective criterion.

When intestinal content began to drain from her wound after a couple more days, it all became clear. Since the point of the post is not to discuss treatment of intestinal fistula (leakage of intestinal contents to somewhere -- in this case, to the skin), let me simply say I opted for the safest and most frustrating approach: high-calorie intravenous feeding, local wound care, and waiting. And waiting. With drainage, she stabilized and we both hunkered down for a long haul. At some point, while inspecting the wound daily, I noted the suture with which I'd hooked the bowel while closing up. And I told her about it straight away. I explained why, in my opinion, going back in at this stage could cause more harm than good, and that there was a reasonable chance it could heal with no need for surgery; and that if not, it would be much easier and safer to go in after time for the reactions to settle down.

So there she was: a living, breathing testament to my failure, for all to see, for a couple of months. Each time I approached her room on rounds, I felt a tug in my gut. I imagined that everyone was talking about it, probably questioning my competence. (Years later, I sort of doubt it. But it's how I felt, with every complication, big or small.) The lady was remarkably hardy and good-hearted. That made it a heck of a lot easier. With each visit, we talked about it, about how it was going, about our comfort levels with the current plan. Frustrated at times, stir crazy on occasion, she never evinced anger toward me. I was deeply grateful for that. She healed. I fixed her incisional hernia a couple of years later.

It's a terrible triangle: the patient, the injury, and me. The patient first and foremost is in need. Whatever the effect on me, their situation is way worse. Yet facing him or her can be tough: it may be unspoken, but there's the sense of permanent accusation. My shame, my guilt, my sadness all interfere with my connection. Magical thinking can keep me from facing the reality of whatever is wrong. At some level, I want the patient and his complication just to go away, because of what they say -- or seem to say -- about me. So, as I titled this series, it's complicated. I was lucky, I guess: in those rare cases where bad things happened due to what I felt was an actual error, my patients stuck with me, and we got the problems resolved. It's a key point, however complicated in its own right: impossibly difficult as these situations can be, hostility from the patient only makes it worse. If my reaction is "complicated," the patient's is -- understandably and necessarily -- complex to the power of ten.

It is, of course, unreasonable and probably impossible to expect patients to hang in there no matter what. It's like, oh, saying questioning a war emboldens an enemy. If there comes a point when you think your surgeon is simply a screw-up, it's time to pack up and go. Yet, I'm trying to say, early on it's at least a theoretically good idea to give him/her a little breathing room. Sometimes figuring things out takes time; sometimes problems can't be resolved as fast as the injured party would like. Hell, they never can. I think it's a truism that the attitude of both the doctor and the patient is crucial to how things end up when facing complications. If it's true that the patient's attitude is heavily influenced by their doctor's, so is the opposite. But, given that it's the patient who's the injured party no matter how upsetting (violins, here) it is to the doctor, the patient has first right of refusal to take the advice. Still: in the ideal world (remind me where that is again?), it's immeasurably better when each side keeps his powder dry for a while.

A commenter on the first post in this series raised an important point (and had he not veered into vile vituperation and personal pejorative, I'd have kept it in.) Why, he asked (in a manner of speaking) had I not canceled my bill or offered to pay her expenses? (In fact, he has no idea what I actually did, but it's a good question.) It is something about which I've ruminated a great deal -- maybe it should be another post sometime. I have generally, for example, (and despite suggestions from insurance companies to the contrary) not charged for a re-operation for bleeding -- a rare occurrence. That's a small thing. The larger question, I think, ought to be addressed in a larger way: something like flight insurance, as a top-of-the-head analogy. Patients deserve compensation when things go wrong, and it ought to be available outside of the adversarial court system. But if every surgeon -- every doctor -- were expected to pay out of his/her pocket for every adverse outcome, I daresay even fewer good people would choose the profession than are now doing so. I don't have an answer. I've wished I did...

In my view, there are three categories of bad outcomes: the ones I've already mentioned are those that clearly result from an error -- the most horrible to face because there's nowhere to hide. The second is imperfect results from proper and well-managed care; and the third is.... having to clean up another doctor's mess. That middle one can be the most frustrating of all, posing the greatest challenge on many levels. I'll see if I can explain it -- and figure it out myself -- in the final post(s?) in this series....


SeaSpray said...

Another good post - Thanks!

What does it mean when someone says a surgeon needs to be willing to commit?

Anonymous said...

Another great post.

I'm not a surgeon...don't even play one on TV. I am a primary care PA and have been for 27 years. About 10 years ago I saw a woman in an urgent care setting who had just had a hysterectomy with my local unfavorite, hostile to PAs, ob/gyn. She had come in because she noticed stool in her vagina; and yes, it was there, and the obvious culprit was the surgery of the week prior, and a fistula, of course.

These things happen, but when I called him, he said "impossible" and refused to see the patient back that day (well, not a good thing to say at the time). What did he think; after 20 years of doing pelvic exams I had the wrong hole? Imagine explaining to the patient that a) this likely was a surgical complication and b) her surgeon didn't want to see her back in the office any time soon? Well I didn't, just couldn't do that, no matter how I felt about him.

I didn't send her to another surgeon, but actually drove to his office (fortunately it was closing time) and asked him to rethink his position. He did, saw the patient in the am, and she had her re-procedure with him that day (I don't think she would have been okay with waiting, as you can imagine.)gwngcb

scalpel said...

To all the patients out there who don't want to give their surgeons a chance to fix their complications....please don't show up in the ER in the middle of the night and expect we can just admit you to another surgeon.

It doesn't work that way. Thanks.

Greg P said...

Also not a surgeon.
Yet I have primary responsibility for patients in the hospital on a continuous basis. Even for those of use not doing intestinal surgery, this takes quite a bit of intestinal fortitude.
When presented with the unexpected, the serious or intense symptoms that come up, I try to imagine the worst thing that could be going on, not to immediately go into emergency mode for that obvious catastrophic event, but to help frame the boundaries of what I need to do, what information I need, and what kind of timeframe is realistic to sort out the problem.
One of my personal aphorisms is that in many situations "the hardest thing to do is nothing." This doesn't mean literally nothing, but it means that as hard as it is, sometimes things just need more time to declare themselves so that it is then clear what needs to be done.
If you keep yourself aware of what the worst thing is, you know what to tell the patient, the family, the nursing staff what to expect in a broad sense, and all of these stakeholders need to know that you're not putting all of your chips on just one possibility, that you're hedging your bets and prepared for the worst if that's what it turns out to be.

Anonymous said...

I figure that students need to learn and I shouldn’t fault them for being in the transition of knowing, but in the case of my family it almost cost a life and it didn’t seem to matter. I don’t dwell on this occurance that happened 14 years ago because my family has had excellent medical care otherwise, but I think I still carry the psycological effects of having my first baby at a teaching hospital. My husband and I were young and we had no idea of what to expect from the various medical care available, and as I look back on it none of these people seemed to know what they were doing in a crisis situation. They jabbed monitors into my daughter’s head before she was born (which was probably normal because she was having trouble, but they kept getting it wrong and were extremely insensitive) so that she was born with several soars all over her head. Then, after the first time I nursed her, I told everyone that she was having trouble breathing and she sounded so gurgley. They all brushed off whatever I said, until an hour or so later a nurse noticed her breathing and she was taken for an x-ray. A student surgeon came to our room then; I had just gotten out of bed before he came in, and when he started talking about our daughter’s impending heart surgery I felt too weak to stand and had to sit on the bed with my husband. The surgeon chuckled and said, “Yeah, you might as well get comfortable,” then proceeded to tell us about the surgery. I felt it was callous that he thought I cared only for my own “comfort” when I thought my daughter was dying and I tried to forget it. A while later we were told that when she was on the operating table it was found that the x-ray had been backwards and she didn’t need heart surgery after all because she had situs inversus and all of her organs were reversed but still worked together, though the emotional effects of thinking my newborn daughter needed heart surgery was more than I could handle at the time. She was in the hospital for two weeks because she needed oxygen due to PCD/Kartagener’s Syndrome, and she got through that to be well and active ever since. It was good they caught the mistake of course, but he scared me to death and never came to my room again afterward. I now choose to remember the wonderful medical outcomes that my family has had rather than this terrifying one (though I’m careful now to avoid medical students - I hope no one reading this is offended because I understand that students need to learn somehow).

Sid Schwab said...

happyj: thanks for taking the time. We all need to hear stories like that, to be reminded how NOT to handle things (the doctors, not you!!) Stories like that make me cringe, less over the error (which was bad enough) but over how it was handled.

Anonymous said...

i like your idea about patients buying 'bad outcome' insurance, especially before surgery. i don't think i ever heard of that idea before. the proposed specialized health care courts seem to incorporate this idea that injured patients should be automatically and fairly compensated, without expensive, adversarial, and unfair trials led by manipulative lawyers and handsomely paid expert witnesses. i think these would be preferrable since the insurance scheme would be yet another expense for patients already drowning in health care bills, and anywhere a pot of money is created, the trial lawyers will find it and build their cottage industries to get it.

Anonymous said...

Bad Outcome Insurance?

I don't think any insurance company on earth would try that.

Can you imagine a surgical theater that has so much red tape the patient dies before a cut can be made?

Anonymous said...

As the commenter whom Sid the Cutter and Maimer has excised (again), I'm amused that you all LIKE the idea of patient-bought malpractice insurance. I'm an academic, and I actually wrote an article on it.

To really work (i.e., to use insurance to provide useful signalling information), we'd have to have individually set rates. I.e., good surgeons would have low rates for insurance/ bad ones high.

Are all you surgeons willing to have underwriters review your records to come up with rates? You wouldn't have to pay malpractice insurance but the world would see your mistakes and how you stack up against your peers.

Sid Schwab said...

See? I knew you could post without (much of a) personal attack. I assume you noticed I actually referred to the good part of the comment I maimed and excised.

I'm no insurance expert, but I don't see the "flight insurance" model in the way you do. I see it as a pool that would primarily be funded by malpractice carriers, because it would (I'd think) save them money in the long run. Government might chip in. Doctors and medical groups, too; the risk-adjustment might have more to do with field of practice than individual track record; although, were there such a model, my rates would be much lower than most. The hardest part, I'd think, would be establishing the payout parameters, rather than the premiums.

And surely you're aware that surgeons' and all doctors' track records are being reviewed and their rates adjusted already?


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