Complications in medicine: who will ever know?

The article by Heller et al concerning “Complications of epilepsy surgery …” inspired me to write about this subject, which has long bothered me.

First of all, we are human, and we make mistakes. Physicians often forget that fact. Second, patients know that we are human and can make mistakes. However, fear of litigation, embarrassment from making mistakes, or hospital policy forcing doctors not to admit mistakes all influence doctors to avoid admitting their mistakes.

I compare the education of physicians to the development of a pure culture of any bacteria or cell. We are encouraged to pursue excellence in high school so that we can go to a good university. We compete in college or university for the top academic positions so that we can have a chance to go to a fine medical school. And we compete in medical school to obtain the best residency. This series of cultures we experience selects those who are obviously intelligent, but also obsessive-compulsive and perfectionistic. I have seen this course of events affecting neurosurgeons around the world. We learn not to make mistakes because these mistakes will compromise our future and our success. And as an extension of this super-selection process, some do not want to admit their mistakes. It is an understandable occurrence, but it is wrong. How many times have we been in mortality and morbidity conferences in which someone else is blamed for a patient error? Do surgeons blame the anesthesiologist, resident, nurse, or other doctors for the errors or problems that occur? Yes, we have all seen and heard it. Why does it happen? I have just explained the reasons. It is learned behavior resulting from the selection process to which we are subjected, to reach the goal of caring for a patient and his/her life. But it is the wrong behavior to have.

Heller et al write “there is a natural tendency for less experienced surgeons to underreport their complications, lest it be viewed as a negative reflection of their surgical prowess ….” I disagree. I have seen this behavior among all physicians at all stages of their careers. I just explained why this denial of errors happens.

In my experience, I tell patients precisely what happened if I made an error. First, it is the right thing to do. Second, I have great faith in our patients. They know that we are human and understand that we do not know everything. What they want to know is that we are doing the best we can with their loved one. What they really know is the doctor who is not telling them the truth. Our patients are human like we are, and sense when they are not being told the truth. They have much more respect for us if we show that we are human. If I try to shield the truth from them, they will know and then they are more likely to be angry and sue me. So that, to me, is not a good choice.

I have always said, “I am not that smart. I need all the help I can get.” (So does everyone else, but they do not always admit it.) So, in everything I do, I ask for anyone's advice. We make rounds with students, nurses, residents, other doctors, care providers, pharmacists, and others. I want their opinions on what they think about the patient. I do not know all the answers, and I am willing to listen to anyone's ideas to get the best answer. We provide better care with this approach. Our mortality and morbidity conferences were grounded in one fundamental principle: we told the truth, admitted our mistakes, and if we did not, others made sure that we were all held to that principle. That is how mortality and morbidity conferences should be run. To me, admitting your mistakes in front of everyone else is a positive reflection on your character.

Now, some other thoughts. Why do the complications cited by Heller et al and by the rest of us occur? What will happen in the future with complications in medicine? Heller et al state their list of complications, including “aseptic meningitis, subdural empyema, subdural hygroma, stroke, temporary ischemic neurologic deficit, deep venous thrombosis ….” The real questions for us as physicians are “Can we eliminate these complications? What can we do differently to reduce these problems?” In some complications, genetics is the answer, and there is a field of “perioperative genomics” that is developing in cardiology and cardiovascular surgery to predict complications, so that they can be avoided.

I recently had a case of a 62-year-old man who presented with a progressing neurologic deficit, a contralateral hemiparesis to a meningioma in the parietal region. At surgery when we inspected his scalp, the skin was very thin; upon incising it, there was little subcutaneous tissue. I did not know why his scalp was so thin but knew that this problem would cause a postoperative wound healing issue. We removed the meningioma that was superficial, put the bone back with sutures to avoid any metal that would erode the skin, and closed it in 2 layers as best we could using silk sutures and “steri-strips” to close the skin. Several weeks later, his wound dehisced, and he had to have 2 more surgeries to repair the scalp defect. What we found out later was that more than 50 years prior as a boy, he had radiation to his head. We did not know why, but at that time in Eastern Europe, where he was originally from, radiation was used to treat sinusitis. The fact that we did not learn from our history (which was our fault) probably was the cause of his meningioma and led to his scalp loss. We learned that he was bald as a child. He also appeared to have another meningioma on the opposite side, but it was very small, probably also from his radiation. So the question I always ask in the operating room at the close of every case is, “What could we have done differently to do this case better?” That is a good practice to adopt, by the way. So, were this patient's complications avoidable? Could I have done something better to avoid his complications? The answer, obviously, is yes. The result from what we did was not good. In retrospect, what could we have done differently? Leave the stitches in longer, see the patient more often to anticipate the problem, and perhaps some other ideas you may have.

In medicine and surgery, we list complications when discussing a treatment with the patients, and we write about them in articles in journals. Yet, what bothers me is that we begin to accept the idea that these complications are ones “that happen.” To me, that is a dangerous path to take. No complications are acceptable. We always need to reach for zero complications. That is the goal. “How can we do it better?” is always the question. The patient understands that. What is important is that we as physicians understand it also. We are human and make mistakes, but we need wisdom and experience to reduce those mistakes to zero, or we need to find a better way to do the surgery or to administer the treatment so that there are no mistakes. We cannot accept mistakes. We have to find a better way.