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Honesty Is Always the Best Policy

By Peter R. Thomas, MD, MSc

Honesty is always the best policy. When I think of difficult conversations I have had with patients, this sentence is always foremost in my mind.  I believe one of the most difficult conversations that can be had with a patient occurs in the immediate postoperative period at the first follow-up visit. The conversation is that which centers around the presentation of a poor outcome after surgery.  Whether it’s a radiograph that demonstrates a loss of reduction and fixation, a wound that clearly shows infection, or a tendon that has ruptured after repair, having the conversation that centers around a poor outcome challenges me each time. There is always a feeling of failure, a feeling of “I could have done more” or “my judgement was off.”  This can also be followed by “it’s the biology of the patient” or “the patient did something to alter my results.” It is difficult to suppress these thoughts and refocus.

What I have learned through experience is not to sugarcoat it: be direct and discuss the poor outcome in straightforward terms. I learned this by example in residency and fellowship, but it took several years to come to grips with it and use this approach in the aforementioned situations.  I best learned this from a senior surgeon during fellowship who was revered by patients and practitioners. While performing a tendon transfer, we mistakenly cut the profundus tendon rather than the superficialis tendon of the ring finger for transfer. He delivered the flexor digitorum superficialis out of the wound, which then slipped back into the wound, and then he inadvertently delivered the profundus tendon.  He encouraged me to cut it and I hesitated, unsure of myself. He insisted and I cut it. He then realized his mistake. He didn’t blame me and we immediately went to work fixing the profundus tendon and transferring the correct superficialis tendon.  His actions at the end of the surgery were the example I return to time and again.  He immediately went to the family and disclosed what had happened.  He then waited until the patient was fully awake and told him directly what had happened. At the time I felt it was just his skilled reputation that allowed him to survive this complication, but now I realize it was the correct way to acknowledge a surgical mistake.

I was reminded of this discussion recently during a postoperative conversation following a distal radius fracture repair. I performed a volar plating in a 40-year-old mother of three who was extremely anxious about surgical intervention preoperatively.  The case went extremely well and I gave myself a mental pat on the back afterward.  She returned to clinic 10 days later.  I peeked at her radiographs and noted the implant was in good position and the bone was well aligned.  I was looking forward to a good conversation.  When I went into the room, she informed me she had felt extreme pain and a pop about 2 days prior.  Since then, she was unable to extend her thumb.  I examined her and understood right away she had ruptured her extensor pollicis longus tendon.  With struggle I suppressed the urge to obfuscate, and told her what had happened.  I discussed that it may have been related to the fracture type, may have been related to surgeon error, or may have been hardware placement.  She was understandably upset, but I convinced her to return to the OR so we could repair the damage, transfer her extensor indicis proprius tendon, and return her function.  This was a patient who cried at the mention of the primary surgery during her first visit and now she was going to have to go back to the operating room immediately for a second surgery. 

The case does, fortunately, have a happy ending.  The tendon was ruptured, but the hardware was not prominent.  Her tendon transfer fortunately had an excellent outcome.  She achieved pain-free, full range of motion at 3 months after the transfer surgery and was discharged happily.

The statement “complications make you smarter” has been uttered from many a podium presentation that I have attended at national and regional meetings.  My understanding of this had always been that they made you technically better at surgery – you learned what not to do and what mistakes not to repeat.  Now I understand that they make you better at the most difficult part of being a physician: counseling your patients, understanding their needs, and providing the psychosocial aspects of care. 

Comment (1)
Efrain Farias
October 11, 2019 1:28 am

I couldn’t agree more. Good essay. Thanks.

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