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Peace of Mind

By James J. Kelly, MS, DO, FAOAO

I would like to think that every surgeon, sitting down to begin a case, has the expectation of the best outcome possible.  We educate our patients about their various conditions and what we can do to address their problems, making clear that we can never offer a guarantee. We quote statistics, where available, but even a complication with a 1/10,000 likelihood of occurrence becomes 100% for the patient who suffers that complication. Patients themselves handle bad outcomes in different ways. Some understand and accept that medicine and surgery are not an exact science. Some recognize that their injuries or conditions are serious and are not expecting perfection or complete resolution. Some patients are bitter. Some are depressed, or become depressed. This may change how I deal with the individual patient, but at issue here is what I take away and how I am shaped by the experience.

I have certainly second-guessed decisions when things did not turn out as expected, even when the outcome may not have been “bad”. I believe this is true of every good surgeon. It is always appropriate to seek perfection and ask ourselves if or how we can do better next time, even when things turn out ok.

I teach medical ethics to third year students. Among the ethical principles covered is that of “Double Effect”.  We prescribe and administer antibiotics with the intent of preventing or treating an infection. It is never our intent to cause C. difficile enterocolitis yet that is a possible, though unintended, side effect.  We may recommend open reduction and internal fixation, rather than closed treatment, for a given fracture in hopes of more rapid functional recovery and a better long-term outcome all the while knowing we are statistically increasing the likelihood of infection and inviting the possibility of hardware failure.  Every decision we make in life has a double effect.

If ever there is a bad outcome, I ask myself a few questions. Was the complication anticipated or avoidable? Did the hoped-for benefits outweigh the risks taken? Did the patient clearly understand their options and provide appropriate informed consent? Were they compliant with treatment recommendations and post-operative precautions? Were nutritional deficiencies addressed? Were they a smoker who refused to quit? Ultimately, did I do my part to adequately assess and address any of those potential problems to the best of my ability? Introspection is always my starting point.

At the end of the day, having someone to share the experience of a bad outcome with is invaluable. It may be a colleague, relationship partner, counselor, friend, or some combination of these.  Though introspection and the resulting self-critique are necessary, it is important to seek a greater sense of perspective outside of ourselves.

Knowing that I have, with beneficent intent: recommended the appropriate procedure or procedures for a given condition/injury;  prepared for each case by reviewing the patient’s pathology, pertinent anatomy – including variations, potential complications, and alternative techniques (plans B, C, etc.) is what ultimately gives me peace of mind in the face of any less than ideal outcome.

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