Managing complications and complaints
By Julie Kohls
Consultant Orthopaedic Surgeon, Royal Surrey County Hospital, Guildford
I hope I am asked to write this article because I have spoken about Managing Complications at the BOFAS New Consultants Course. My advice in the course is likely very much what others would give and certainly I built that talk on the talks of my predecessors. I tell new consultants: firstly, strive to prevent complications, secondly once a complication is recognised take responsibility and intervene early, thirdly learn any lessons that can be learned from complications, fourthly discuss complications with colleagues and finally learn to be able to pack away the worry and stress that comes from being part of a profession that entails being responsible when adverse outcomes occur.
I recently had a young A-level student enthusiastically tell me after sitting in my clinic, how inspired she was to be an orthopaedic surgeon. In the clinical encounters she witnessed, every patient was delighted with their treatment be it conservative or surgical. It was also a wonderful experience to have the chance to be a role model for an aspiring young surgeon but I felt she hadn’t really seen how challenging most days are.
The trouble with complications is that no matter how hard a surgeon strives to prevent complications, complications do still occur and if a surgeon does enough surgery, they will inevitably have patients who have suffered even the rarest, the 0.001% of complications. Patients of course need to be made aware of the risks of surgery when agreeing to surgery as part of the consent process but once a complication occurs for the patient the complication changes from being a theoretical small risk to an actual experience and the surgeon and patient must work through the complication to the best possible outcome.
Preventing and monitoring complications
Strive to develop a practice that is vigilant against complications. One way of preventing complications is not intervening with surgery before exploring conservative treatment options and optimising patient risk factors before any surgery. Patients need to know that not having surgery is one of the options that should be offered to them. As part of the consent process they need to know what not intervening will mean for them. In patients who are more likely to suffer complications it needs to be made clear to them that not starting or not starting until they have become more fit for surgery will help them in the long run (Examples include correcting vitamin D levels or giving smoking cessation advice or explaining how weight loss will improve their chance of operative success.) In a surgeon’s yearly appraisal, it is important to look back at individual surgical results and take action when trends emerge. As more surgery goes into National Registries, surgeons will have more and more data to look at and analyse. We also are operating in a world where individuals do not all do all surgeries, and it is our collective responsibility to know who in our area has regional expertise and to work together with them to create referral pathways and MDTs. It is also important to make certain that the load is shared by developing expertise in other areas. When a patient has a particularly difficult problem seek to discuss the case in regional MDTs and/or to have a formal second opinion ahead of any surgery.
Taking responsibility and acting early
Taking responsibility and acting early may simply mean spending time with the patient who has had a complication and answering questions but it can also mean that more investigations and follow-ups are needed or even that further intervention is required. To a patient the most important thing is a successful outcome despite the complication, but feeling as though their experience maters to their surgeon is also of great significance. Demonstrating that you as a surgeon care about the patient’s experience of suffering a complication can be done in several ways. It is important to take some time in the consultation, to listen to the patient and to be empathetic about the more difficult recovery they now face. I believe that saying to the patient “I am sorry that you are experiencing this complication” is very helpful for them. It shows empathy and an understanding of how difficult it is for the patient. It is just as important to also clearly communicate what can be done and to answer any questions the patient has. As important as it is to communicate it is just as important to make sure that the plan is executed, and the patient doesn’t fail to be booked in for tests and clinics particularly in the NHS where the system can be unwieldy. (These are the patients to email the plan to your clinic coordinator, your secretary, specialist physio and registrar to make sure the entire team is helping to ensure a good outcome but these are also the patients to see yourself in clinic wherever possible). The final part of helping a patient through a complication is to make sure the patient understands that there is a strong desire to learn from what has happened to them. The extent to which learning from the event will mater to the patient will depend on the severity of the complication, but many complaints come from the patient not wanting anyone else to experience what they have experienced.
Learning from complications
Learning from a complication, a complaint or a serious incident investigation takes considerable time. It means a very complete investigation is needed involving reading everything in the notes, speaking with juniors and having a very thorough understanding of the timeline around the patients care. Often there is evidence of the ‘Swiss Cheese model’1 whereby a series of events lined up to create a ‘hole’ through which that patient fell. It will be important to that patient to again have the chance to speak clearly and thoroughly with their consultant but as emphasised they will want to know what processes can be changed so that future patients don’t have a similar experience. It is important that the entire team of other junior doctors and wider clinical staff also have learning and support as part of the process.
Second opinions and MDTs
The importance of having MDTs can’t be over emphasised. Regional MDTs of consultants practising within your subspecialty carry the offer of gaining a consensus opinion and often someone within the MDT will have some expertise and may be a good pair of eyes for a second opinion. Ideally, it is best to obtain the second opinion ahead of starting a difficult surgery, but I also have started to move to a second opinion when a patient has an unexpected complication and I find myself wanting to list the patient for a second procedure; I discuss the case with a colleague and where needed refer the patient on for a formal second opinion. Often a fresh pair of eyes offer a more dispassionate opinion, and patients appreciate a measured approach to further surgical interventions. The MDT often helps me to explore all the possible other intervention but certainly in the MDTs I am part of there is also often wise counsel to hold course and explore conservative treatment and often when we present to a group of peers, we realise other investigations are need such as a bone biopsy for infection, or vitamin D levels before making a new surgical plan. I would also raise the point that if in seeking advice in a MDT you are told to do a procedure that you are not fully familiar with, that it becomes a good time to have a formal second opinion.
Coping with the burden
The final piece of advice is to learn to live alongside the demands and pressures of the job. Looking after anxious, emotional or angry patients is draining. The patients helped are forgotten and the patients who have suffered are remembered. There will be cases where we reflect and worry that we have unintentionally harmed a patient who has suffered a complication.
Eventually, knowing that on a daily basis you will do your best to help and that when a surgery does not go as planned that you will again do your best (in all the ways listed above) becomes a method of living alongside the demands of a surgical career. We as surgeons can never be complacent, but we can trust in our processes to prevent, treat and learn from complications.
A final thought on complications is the well-being of the surgeon; In serious complications and events the surgeon often is also an unseen victim. The burden of feeling that one’s best fell short and led to unintended harm can led to depression, alienation from friends and family, divorce and even suicide. Adam Kay’s brilliant memoir “This is Going to Hurt” provided a visceral account of how altered a surgeon can be by a serious complication. It is essential to be able to talk of our burden with colleagues, mentors and friends and families and to be able to have outside interests and hobbies.
It is essential that we also teach our juniors to cope too. Perhaps the young A-level student who sat in clinic with me didn’t need to see all of the burdens of a career in surgery, but our registrars and fellows need to be prepared to cope with the sleepless nights that befall a young consultant. The New Consultants Course run by BOFAS is a forward step in preparing new Foot and Ankle Surgeons for the trials and tribulations of managing complications and I would encourage all surgical societies to provide similar support.
Regional and national problems
There is of course the problem of what we do in a region when we start to be aware of a recurrent complication arriving at our door as a second opinion. Personally, if one of my patients has sought a second opinion, I do want to be copied into the correspondence as it is important to know when a patient is unhappy with the care I have provided but of course the patient should be involved in the decision of whether to copy in the first consultant. In Foot and Ankle surgery second opinions can arise from patients having had poorly executed surgery by a Podiatric Surgeon. These aspects are best dealt with by our professional societies, and it may be appropriate to let your society know of the complications you are seeing. When a patient talks to me about whether to complain, I feel that my job is to be professional as every surgeon has some poor outcomes and so I try to give the patient a wider and balanced perspective and help them to focus on treating the problems they now have rather than apportioning blame.
Summary
Complications are one of the least enjoyable aspects of a career in surgery and managing complications is often a poorly taught aspect of surgery; however looking after patients’ complications is also part of the role we have committed to undertaking. Our first job is to prevent complications, but we can also communicate effectively with patients before, during and after the process. It is essential we monitor our results and learn from mistakes. We should seek second opinions and engage with MDT networks. We must also learn to accept that our best will not prevent every complication and that we must then rely on our skills and dedication to help our patients navigate a recovery after a complication and to allow ourselves to cope with the stress that complications add to our burden of responsibilities. We spend years training to be skilled and we have chosen a profession which occupies much of our time so it is important that we enjoy what we do.
References
- Reason J. Human error: models and management. BMJ. 2000;320:768-70.