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 Humbled Physician

When I was in medical school, my mother, 53 and healthy, had a massive heart attack and ended up needing a heart transplant. By day I donned my white coat and learned the science and practice of medicine. By night I slept on a cot in my mother’s hospital room, observed her cycles of pain and relief, the comings and goings of doctors and nurses, translated and advocated for her. While my medical colleagues and I quizzed each other, and compared procedures, I agonized at the thought of my mother being the guinea pig as we fumbled through our first central line or NG tube insertion. While my attendings chided me for “caring too much”, my mother encouraged me to sit on my patient’s beds, ask them about themselves and how they were doing.

I became painfully aware of the chasm between physicians and patients, science and emotion, medicine and real life. The caring that was missing from health care disturbed me, and left me struggling to make peace with my profession. I considered leaving it, but the fact is, I simply love being a doctor too much, and am grateful for my skills and knowledge of scientific medicine.

I am hoping this blog will be a venue to articulate what is often lacking in the halls of medicine, and to explore ways to fill the void and transform it. To educate and empower patients, to honour our bodies and our journeys through illness. To heal the healers. Ideally this will be a collaborative effort – a tapestry of our stories and ideas – so that we can learn from each other, and, together, create change. Thank you for joining me!

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Queen Elizabeth Park, Vancouver, B.C.