Issue: March 2022
Disclosures: Frank reports being on the speakers bureau and a consultant for Allosource, Arthrex, JRF, Ossur; receiving research support from Arthrex and Smith & Nephew; and receiving publishing royalties from Elsevier. Romeo reports receiving royalties from, being on the speakers bureau and a consultant for, and doing contracted research for Arthrex.
March 17, 2022
4 min read
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Surgical complications have implications for patients, physicians

Issue: March 2022
Disclosures: Frank reports being on the speakers bureau and a consultant for Allosource, Arthrex, JRF, Ossur; receiving research support from Arthrex and Smith & Nephew; and receiving publishing royalties from Elsevier. Romeo reports receiving royalties from, being on the speakers bureau and a consultant for, and doing contracted research for Arthrex.
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Complications occur in patients even when we perform surgical tasks with the highest level of skill. As orthopedic surgeons, the only way to avoid surgical complications is not to operate.

Anthony A. Romeo
Anthony A. Romeo
Rachel M. Frank
Rachel M. Frank

We need to be able to inform patients of potential complications of the recommended procedure before the final decision to proceed with surgery as part of the informed consent. Unfortunately, the literature on complications can be difficult to interpret due to variable definitions, incomplete data and the impact of comorbidities and social determinants of health. In preoperative discussions with patients, we do our best to provide a summary and individualized risk analysis. However, we may be left with a sense that a shared decision-making process was not entirely possible. When complications occur, we need to be able to provide an open and honest explanation to the patient, which the United Kingdom General Medical Council refers to as the “duty of candor.”

When complications occur

Complications may impact the patient's life in ways that are unappreciated. They affect the patient’s ability to resume pre-surgical behavior, which can affect the patient’s ability to work, participate in sport, interact with family and friends or manage their mental and emotional health.

When complications occur, it is human nature to try to identify the cause of the problem. Commonly, the question arises regarding competency of the surgeon, including the ability to not only avoid complications, but also to be able to incorporate practices that work toward eliminating complications. With the concept of “fault” or responsibility, comes a myriad of potential responses, including the desire for accountability, perceived justice and, at times, revenge.

There is another side to complications that are less appreciated by patients and families. The impact on the surgeon can be devastating. Without question, the patient is the one who suffers the most. However, surgeons, especially early in their career, can be severely traumatized by complications that may or may not be related to mistakes they made. They may develop overwhelming guilt, self-doubt, depression, anxiety and even post-traumatic stress disorder. In the past, this was referred to as “second victim syndrome,” but the term is avoided today as patient advocates argue it dismisses a level of accountability for the surgeon.

The very word “complication” brings up a visceral response, making one cringe at the thought of any complication in our patients. Complications range from minor — such as a wound infection that can be effectively treated with antibiotics without impacting the ultimate outcome — to major — such as a nerve or blood vessel injury that causes permanent impairment, dysfunction or death. Surgeon and public health researcher Atul Gawande, MD, MPH, elegantly discusses the power and imperfection of surgery in Complications: A Surgeon’s Notes on an Imperfect Science. No matter how gifted and prepared you are with surgical indications and with the techniques themselves, or how thorough you define the preoperative and postoperative care pathway, complications are inevitable. Managing complications is among the most difficult behaviors we have to learn during our careers.

Honesty is key

Common themes exist when developing effective methods to deal with complications. Honesty is the key. Remember the duty of candor. Tell the patient exactly what has happened and what went wrong. If appropriate, apologize to the patient. Apologizing is not an admittance of guilt. In most cases, a sincere apology is a sign of respect and empathy for the patient. They want to know you care for them as a person. Apologizing often has healing effects for both the patient and surgeon.

Be sure to offer hope that a remedy or reasonable outcome is possible, if not in your hands, then in the hands of someone with added expertise to manage the complication. Do not abandon the patient. In fact, if possible, become more involved in their care. If you are not the best person to manage the complication, refer the patient and speak directly to the surgeon who is accepting providing the care, so the patient knows you remain involved in the outcome.

At some point in the process, assess your role in the complication. In essence, perform a root cause analysis. Clearly define the problem, re-examine your preoperative assessment and intraoperative behavior, identify the most likely causal factors and set a course to prevent the problem from occurring again. Actions to help avoid surgical complications may include better indications, time in the cadaver lab practicing surgical technique or even inviting a co-surgeon to participate in a future case with similar surgical requirements.

Speak to colleagues and mentors to learn from their experiences and insights on strategies they may have developed to avoid the complication. Often, honest mentors will be able to provide great advice because they have experienced a similar problem or complication during their career. Knowing that those you admire have had similar issues helps in the care of your personal wellness and mental health.

Duty of candor

Managing complications is an integral part of what we do as surgeons. We can and should do everything in our power to avoid complications, but if we have a typical orthopedic surgery practice, complications are inevitable.

When complications occur, employ the duty of candor. Sit down with your patient and, if possible, their family, and honestly discuss the problem and your recommended solution. Throughout the process of resolution, support your patient and make sure you have the support to maintain good mental health while you identify the cause of the problem and establish a plan to minimize or avoid the risk of it happening again.