Complications and poor outcomes are an inevitable part of sports medicine surgery. When building a practice, dealing with complications can be overwhelming and difficult to overcome. Establishing strong and transparent surgeon-patient relationships built on open communication and realistic expectations is fundamental to preemptive management of poor outcomes. When a complication occurs, careful action and appropriate treatment are imperative to ensure the best possible outcome. Patients who trust their surgeons are less likely to pursue medicolegal action. A complication can lead to self-doubt, anxiety, and depression. Surgeons should seek counsel from colleagues when dealing with complications and learn from their mistakes.
Key points
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Complications and poor outcomes are inevitable in a surgical practice.
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Effective communication and a transparent patient-surgeon relationship are essential to navigating potential complications.
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Early recognition and judicious action help to minimize the amplification of a surgical eror.
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Patients expect full disclosure regarding adverse events.
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Surgeons should seek counsel and support from colleagues and mentors to help mitigate the mental and psychological impact from a surgical complication.
Dr Atul Gawande writes in Complications: A Surgeon’s Notes on an Imperfect Science , “We look for medicine to be an orderly field of knowledge and procedure. But it is not. It is an imperfect science, an enterprise of constantly changing knowledge, uncertain information, fallible individuals, and at the same time lives on the line. There is science in what we do, yes, but also habit, intuition, and sometimes plain old guessing. The gap between what we know and what we aim for persists. And this gap complicates everything we do.”
One of the hardest lessons a young surgeon must experience is how to manage complications and poor outcomes. A surgical complication has been defined by Dindo and Clavien as “any deviation from the ideal postoperative course that is not inherent in the procedure and does not comprise a failure to cure.” While this is hard to comprehend, the reality is that complications are inherent to all medicine and surgeries. A recent article demonstrated high failure rates after common arthroscopic and sports procedures and complication rates exceeding 18% in some cases. In a study of over 27,000 arthroscopic shoulder procedures submitted as part of board collections to the American Board of Orthopaedic Surgery, Shin and colleagues found a complication rate of 11.1%. Complications listed included persistent pain, infection, arthrofibrosis, and nerve palsy. To put that into perspective, out of 100 patients who underwent rotator cuff surgery, 11 experienced a complication. When reading the article, 11 is just a number. However, when you are speaking to one of your patients who is dealing with a complication from a surgery that you performed, that number means a lot more. To the patient, the only number that matters is one: him or her.
Graduating from busy surgical training programs, new orthopedic surgeons are well versed in informed consent. After the elective procedure is described, the potential complications are itemized like unwanted side courses on a menu without much additional explanation or consideration. The patient, eager to get out of pain, signs the consent anticipating a favorable outcome while dismissing the rare potential complications. To be fair, the surgeon may have calculated a 90% success rate with the operation—great odds it would seem to that patient. With the growth of practice and the increase in surgical volumes, those one in 10 failures occur and start to accumulate. In addition, those rare significant complications are bound to happen. The additive weight of the poor outcomes and complications can become a burden on a young surgeon trying to gain confidence and build a practice. It is helpful for a surgeon to adopt a strategy to address and handle bad outcomes and complications to avoid fatigue from the excess burden.
After realizing that bad outcomes are inevitable in a busy surgical practice, the first step in the management of potential complications starts with preoperative communication and the establishment of a positive and transparent surgeon-patient relationship. According to the American Academy of Orthopaedic Surgeons, the informed consent process is actually an integral part of establishing that relationship. Patients should be fully informed about their care, including the risks, alternative treatments, and benefits of the proposed procedure. The expected outcome should be described, but also less than optimal outcomes and potential complications should be reviewed. Elective surgery is just as it is described—elective. The expected benefits should clearly outweigh the risks, and the patient should be an integral part of the decision-making process.
It is helpful to include in the preoperative discussion any family members who may be participating in the perioperative care as well as any clinical support staff with whom the patient may interact with after surgery. This establishes the concept of a team approach. While the documentation of this conversation is important from a medicolegal standpoint, the discussion establishes rapport and helps patients understand that the surgeon is invested in the outcome and the mitigation of risk. Patients want to know that the surgeon and his or her team care about their well-being and outcome, and that relationship is best established in the clinic. The surgeon should again review the goals and potential risks of the surgery in the preoperative holding area to ensure that all questions are answered.
In the event of an intraoperative surgical complication, early recognition and judicious action help to minimize amplification of the error and to minimize collateral damage. The earlier an error is detected, the sooner it can be corrected. Upon identifying a surgical error intraoperatively, the surgeon should immediately pause the procedure and fully characterize the error before proceeding with additional surgical steps. As the old saying goes, “when you find yourself in a hole, the first thing to do is to stop digging.” The error may elicit an emotional response ranging from shock to anger to fear. Collecting oneself and regrouping with the operative team may be required to formulate the appropriate path forward. It may be helpful to return to a previous step in the operation to correct the error and allow the remainder of the case to proceed. Consultation with another provider may be required to ensure that the error is adequately addressed, and no further injury occurs. When a surgeon tries to control an intraoperative situation that exceeds his or her skills, the error may be magnified, and a larger problem may be created. The Hippocratic Oath mandates, “first, do no harm.” Ultimately, the only thing that matters is the safety of the patient. Completing the surgery in a safe manner is the supreme priority.
When a patient experiences a complication after surgery or less than optimal outcome, the situation may not carry the same sense of immediacy and urgency as an intraoperative complication. The consequences, however, may be just as dire. The surgeon must recognize the complication as early as possible and not ignore warning signs. When in doubt, listen to the patient and do not minimize complaints. If the patient’s postoperative course deviates from the norm, or a concerning symptom emerges, appropriate investigation is warranted. If evidence of a postoperative complication materializes, the surgeon should pursue a judicious course of corrective action to minimize additional damage. An example would be loss of motion after knee surgery. Early intervention with manipulation and lysis of adhesions may circumvent permanent knee motion loss. Consultation with colleagues or the recommendation to seek a second opinion will ensure that all avenues for rectification are explored.
How a surgeon responds in the immediate aftermath of a surgical complication or poor outcome will determine the patient’s perception of the surgeon and define the patient-surgeon relationship. Patients want full disclosure regarding adverse events as soon as possible, beginning with an explicit statement that an error has occurred. Surgeons frequently avoid the use of the word “error” or “mistake” when disclosing an adverse event to a patient. The exposure to malpractice liability and potential litigation may influence word choice, but research indicates that patients appreciate and expect honesty and are less likely to sue if they trust their physician. Delay in disclosure may lead a patient to believe that the surgeon is hiding the truth. Misleading a patient or misrepresentation of a surgical error erodes trust and compromises the surgeon-patient relationship. When delivering bad news, the surgeon should try to take the patient’s perspective. Patients want surgeons who care. Expressing remorse and offering an apology if appropriate for a surgical complication demonstrates empathy and helps to establish the surgeon’s investment in the patient and ultimate outcome.
After disclosure, the next step is setting expectations and defining a path forward. Patients dealing with an adverse event need reassurance that a remedy or reasonable outcome is possible. The surgeon must navigate a fine line between the perpetuating hope and controlling expectations. Patients expect an accurate and realistic prognosis. If a patient fails to achieve the amended predicted outcome, it in effect magnifies the negative perception from the first complication. Continued conversation is critical during this phase, as the path forward may not be clear initially, and the path may evolve based on patient factors. An open line of communication and frequent follow-up are mandatory with a patient experiencing a complication. The enhanced clinical support promotes further restoration of the surgeon-patient relationship and prevents that patient from feeling abandoned. The definitive goal after a complication is the best possible outcome despite the setback. The surgeon should work diligently toward achieving that goal.
Outside of the surgeon-patient relationship, a surgeon should notify the hospital risk management team and liability provider of a surgical error so that appropriate steps are taken to mitigate exacerbation of the situation. The hospital may be able to control billing to avoid unnecessary costs to the patient for tests or procedures related to the diagnosis and treatment of a surgical complication. A surprise bill will lead to further souring of the situation and may prompt the patient to pursue legal action. The liability provider can help the surgeon limit exposure and formulate a strategy to defend against potential litigation. The hospital human resources department can help a surgeon identify programs to help manage stress and well-being.
The emotional impact of a complication on the surgeon should not be underestimated. Surgeons may develop guilt, self-doubt, and anxiety related to a complication. Describing this deleterious impact on physicians, Dr Albert Wu coined the term “second victim” in an editorial. While the patient is clearly the victim of the complication, the physician is also victimized by feeling personally responsible and starting to second guess his or her skills and knowledge base. Dealing with the aftermath of a complication can lead to significant stress, lower quality of life, depression, and burn-out. Complications may also have an impact on a physician’s clinical practice with decreased productivity and the tendency to become more conservative and risk-adverse.
Complications and poor outcomes may lead to a feeling of isolation or embarrassment. A recent study demonstrated that up to 25% of surgeons face their complications alone. However, most physicians agree that openly discussing the case with peers is the most effective strategy to cope with complications and to move on. Not only does an open discussion facilitate learning but also the shared experiences of others help the physician to realize that he or she is not alone. Seeking out counsel from a senior colleague or mentor is an appropriate action. Departmental quality assurance or an “Morbidity and Mortality” conference is a good venue to openly discuss adverse events. In a recent article in Orthopaedics Today , Drs Rachael Frank and Anthony Romeo recommend that a surgeon perform a root-cause analysis in which the problem is defined and the preoperative assessment and intraoperative execution are reexamined. The surgeon’s response in the face of adversity demonstrates key insight into his or her character.
In his book, Dr Gawande describes “the gap between what we know and what we aim for” and states, “this gap complicates everything we do.” My first five years in practice, I had a hard time narrowing the gap between what I knew and what I aimed for, and I often found myself guessing. When I had a complication, I was crushed. When a postoperative patient was not performing as well as I anticipated, I started to doubt myself. Where did I go wrong? Did I improperly indicate the patient for surgery? Did I perform the wrong surgery? Did I not execute the surgery well? Was the postoperative rehabilitation protocol incorrect or inadequate? I found myself dwelling on the complications and bad outcomes rather than appreciating the good outcomes and happy patients. Ten years into my orthopedic sports medicine career, complications and bad outcomes still occur, but I have accepted them as necessary lessons in the practice of medicine. The key is that we learn from each complication and adverse event to improve our skill set and help future patients. My fellowship mentor Dr Thomas Byrd often told me that experience is just the name we give our mistakes. Gaining experience is not necessarily pleasant, but the best surgeons are the ones who learn from mistakes and become better surgeons because of them.
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