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....

Doctors, Working Together

One of my more naked screw-ups during training occurred when I was Chief Resident, and in the blink of an eye (quite literally) it took me from feeling like God's gift to surgery to certainty that I was the village idiot. (Turns out that form of rapid decompression continues more or less weekly throughout the career of any busy surgeon. Nevertheless, this was as deflating as hearing "That all you got?" from Scarlett Johansson.)

I'd seen a man in the clinic who'd had several operations for fistula-in-ano, recurring within a short time on every occasion. Brilliant surgeon that I was, I considered the possibility that he was one of the less common victims, having a connection from skin to colon, well above the anal area from which fistulas most commonly arise. So I ordered a barium enema. Sure enough, I got a call from the radiologist telling me there was a fistula between skin and sigmoid colon. Hot damn! Not only could I demonstrate my acumen to my attending, I'd be doing a very cool case: sigmoid colectomy was then and remains now one of my favorite operations. Got the man all worked up and prepped and a few days later, there I was in the OR, making a nice little lower midline incision. Figuring on finding some inflammatory process in the colon, I expected a possibly tough operation, but I felt up to it. So I was surprised to see that the man's colon was soft and pink and normal as the day he was born. No fistula, no how. Ooops.

My attending, having confidence in me, had had me start the case unattended, so I called him into the room to convey the news. "Where are the XRays?" he asked. Well, er, for some reason they weren't in the OR. "Did you look at them yourself?" he asked, voice a little tighter and higher than with the first question. Like a goddamn idiot, for no reason that would ever hold water, I hadn't. I'd been so excited to hear the confirmation of my brilliant diagnosis that I didn't bother to go down to the XRay department and have a look myself. The arrival of the films in the OR was met with steely silence by my attending, and horror by me, as even I could tell the so-called fistula was an artifact: spilled barium from the procedure, masquerading in at least one view as a tract from colon to skin. Idiot radiology resident had made the wrong call; idiot surgery resident hadn't gone to check it out.

Lesson: confer with the radiologist. Look at all your films yourself, most especially when the situation is unusual. Sit down side by side with the radiopod and go over the details. I can tell you I NEVER failed to do that again. (Incidentally, the man had a "horseshoe fistula," which had never been properly unroofed and cleaned out. My attending took over: propped the man's legs up and back and carved away most of the skin of the man's hindmost, until his sorry little anus looked like a tiny island in the seas of Hades. I was numb-struck at the carnage, but damned if it didn't eventually completely heal, and fixed the problem. (It was, however, I'd say in retrospect, a bit more than the poor man needed; maybe my attending was too pissed at me to slow down.)

Which brings me to the point of the post: as I've said previously, the best outcomes occur when docs work collaboratively. And that implies, among other things, that the people involved 1) know what they're doing, 2) like the idea of collaboration, and 3) can do it in a collegial fashion. For example, when I ordered a radiology study (except in the most routine and simple of situations), I talked to the radiologist in advance, explained exactly what I was looking for, solicited suggestions if another study might be better and, when the study was done I got together with the radiopod and went over it with him/her. Love and kisses, right? Well, not always. It was not rare that, despite my ministrations, the study didn't get done when scheduled, the wrong study was done, and the doc to whom I'd spoken neither ended up being the one to do the study nor took the time to pass the info to the one who was. And despite having made clear my concerns and the levels of urgency, I'd not get a call when the study was done. Or I couldn't find the radiologist who did the study, or even the available one, to sit down with. Not to mention being able to find the films.

That last little frustration, thankfully, is becoming rarer, as nearly all studies can be and are digitized into a server right when done. So as long as the names and numbers have been inputted correctly, they're instantly available. But the others, well, nothing's perfect. And between my occasional less-than-charitable attitude over such missteps, and some radiologists' less-than-delighted willingness to drop what they're doing to sit down with me, sometimes the atmosphere was a bit sullen. Nevertheless, the fact remains: that sort of working together is the ideal. Especially when it actually works.

Then there's this: sort of like actual humans, doctors vary in their level of skill and commitment. I think that's a huge part of the variation in costs and outcomes among doctors, and it's something about which it's hard to see what the solutions might be -- or even if there are solutions. You've got your great mechanics, honest and reliable plumbers; artists of varying talent; lawyers who get OJ off, and lawyers that wouldn't have. It's just the way it is. But with doctors -- and especially those in high acuity fields -- the impact of variation is enormous. I think the example of interactions between surgeons and radiologists, pathologists, anesthesiologists is a microcosm which provides some insights, and I plan to say more about it.

[Addendum: several months after posting this, I received an email from a person rightly upset about something I wrote, namely: "It was, however, I'd say in retrospect, a bit more than the poor man needed; maybe my attending was too pissed at me to slow down." He was outraged not only that I'd screwed up but that an attending might have, in anger, over-done the extent of the operation. Looking back, I think I was saying that nowadays one might have been able to do less extensive debridement, and I sort of threw in the "anger" proposition, because I still feel bad when I think of it, and of how angry he was at me. Anyhow, the fact is the man got what he needed from my attending and healed completely, and permanently. And although it in no way justifies it, I learned a valuable lesson than stuck with me and helped me provide better care for my patients throughout my career. I don't blame the reader for being ticked off.]