It’s Complicated (Medical complications and how to avoid them)

 

Someone dear to me is currently in hospital due to a serious complication of what was supposed to be a relatively straightforward elective procedure.

Too often, risk is a quick conversation as pen hovers over consent form. Even when given the time it deserves, studies show that both doctors and patients tend to underestimate the harm and overestimate the benefits, not just of procedures, but also of common tests, and drugs.

For the majority of people, hospital care is safe, but according to a 2016 study by the Canadian Patient Safety Institute, 1 out of every 18 hospitalizations in Canada in 2014–2015 involved at least 1 occurrence of harm. 1 in 8 hospitalizations with a harmful event ends in death (compared to 1/32 who would have died even without a medical complication/error).

Analyzing medical death rate data over an eight-year period, Johns Hopkins patient safety experts have calculated that more than 250,000 deaths per year are due to medical error in the United States. Their figure indicates that medical error is the third leading cause of death in the U.S..

At first glance, this statistic seems improbable. However, complications beget complications. A nick in an artery during a routine procedure may lead to a blood vessel dissection and clot, which, in order to prevent a pulmonary embolism, may require anticoagulation, which increases one’s risk of significant bleeding, and so on.

My cousin died in his early twenties, due to an uncontrollable hemorrhage during an elective tonsillectomy. Not only were his family and friends devastated, his surgeon was so affected that she had to take time off from practicing medicine.pexels-photo-263337

Professor Hoffman, from Bond’s Centre for Research in Evidence-Based Practice, says that doctors’ inaccurate expectations of benefit and risk may be driven by “therapeutic optimism”, underpinned by a desire to help. It can also come from losing touch with latest evidence, pressure from patients, or financial incentives.

The culture of blaming and shaming that persists in many hospitals makes it difficult to address this issue. When my friend’s husband had surgery for a complex ruptured appendix, he was, she said, the star of the ward. The surgeon loved bringing students around to see him. When, two weeks later, her husband was readmitted for a bad post-op infection, they noticed that the surgeon never brought students around anymore. “But wouldn’t that have been the great learning opportunity,” my friend asked, “seeing what could go wrong and how to manage that?”

The good news is that the death rate from complications of medical and surgical care in adults has been declining over the past decade. The tradition of blaming and shaming those involved in a safety incident is being replaced with a culture of openness and learning. Health care leaders have come to understand the importance of focusing of safety and quality improvement. But there is still a long way to go.

Here are some things patients and doctors can do to continue to minimize risk:

Patients:

  • Ask if your procedure is absolutely necessary, and if not, whether the hoped-for results will have an extraordinary enough impact on your life to assume the risks involved. If not, stop here.

If you must proceed…

  • Ask questions about the procedure and the potential risks.
  • Ask how your doctor will be communicating with or supervising any student learners involved in your care.
  • Determine what the follow up will be after the procedure.
  • Have a family member/friend with you as often as possible while in the hospital.

Doctors:

  • Communicate clearly and gain informed consent. This may mean taking extra time, or obtaining a translator. Ask the patient to repeat the risks back to you.
  • Stay up to date on standards of care. Procedures that used to be common practice may now be deemed unnecessary in many patients, such as cardiac stents or arthroscopy.
  • Remember that your trainees are often sleep deprived and overworked, and need your close supervision. In the end, if something goes wrong, it is you who will be considered at fault, so this is in both of your interests.
  • Share your medical errors/ complications with your students. We all make them, and there is no better learning opportunity.

 

“Do as much as possible for the patient, and as little as possible to the patient.”

– DR BERNARD LOWN

 

The Double-Edge of Diagnosis

A psychiatrist recently told me, “I have a gift for diagnosing people – I can do it from across the room.” Another psychiatrist, overhearing her, retorted, “Ha! Classic narcissist!”

Doctors are always diagnosing.

Making a diagnosis is central to medical practice. It sets off a chain of events, investigations, and therapeutic treatments, that, ideally, lead to appropriate management. Diagnostic labels help doctors communicate, help researchers keep track of diseases, study the causes of and identify treatments for them. They help patients to explain what they are experiencing to themselves and others.

Diagnosing is essentially pattern recognition – identifying and naming a constellation of symptoms/signs/test results. A study done at MIT showed that diagnosing involves the same brain systems in doctors that are required for recognizing and naming everyday objects.

Which hints at the limitations of diagnostic labels.

If only diseases were as clear cut as objects. As easily agreed upon as, say, a table. A table has pretty much been a table since four legs and a surface were invented. But diseases and their treatments are shaped by the science of the times, the culture we live in, and most importantly, by the people who experience them.

Our brain’s desire to match people to patterns can override our ability to be present and open to uncertainty. Patients with real, but medically unexplained symptoms (MUS) represent some of the most common conditions in medicine. Our lack of understanding of these illnesses has resulted in vague diagnoses of exclusion, such as fibromyalgia, irritable bowel disease, or chronic fatigue syndrome. Our inability to match their symptoms to a more definitive diagnosis leaves these patients in a type of medical pergatory, where they often end up seen as “difficult” patients.

Another problem with diagnostic labels is that, once diagnosed, doctors may see their patient’s disease before their personhood. “The appendicitis in room 3”, “the breast cancer in room 4.”

They can also direct our attention to the wrong symptoms. When my patients are diagnosed with drug dependence, they may get prescribed opioid maintenance therapy as treatment for their “disease”. But if this patient turned to drugs after a childhood where he was repeatedly raped by his father and uncle, is it fair to label him with a stigmatizing diagnosis of opioid dependence? Just because there does not exist a name for the long term effects of chronic abuse? By giving him a diagnosis that puts the onus of responsibility on him rather than on the failure of the system to protect him as a child, it also absolves us of having to pay for services/treatments that address his psychological trauma.

Diagnosing is an inherent part of practicing medicine, but it is important to keep in mind that our diagnostic palette remains incomplete, ever evolving as science advances. It behooves the medical community to take a step back and consider the impact and arbitrariness of our diagnoses.