The orthopaedic ostrich: surgeons’ responses to complications

By Deepa Bose

“Science does not, ostrich-like, bury its head amidst perils and difficulties. It tries to see everything exactly as everything is."

Garrett P. Serviss

Complications are an inevitable part of surgery. It is said that if a surgeon has no complications he or she is either lying or not operating.

Surgeons respond in different ways to post-operative complications; denial, anger, despair, acceptance. It is a form of grief, as is evident by the similarity of the emotional responses¹. Of these, denial is fairly commonly encountered. Whilst this is not the most useful response in terms of dealing with the matter in hand, it is perfectly understandable if one considers the surgeon as a craftsman. Any craftsman, particularly one who has been practising the trade for a considerable period of time (for example a consultant), is wont to take criticism of his or her creation personally. It is this perceived apportion of blame which can result in surgeons “burying their head in the sand”, as ostriches are said to do, in an attempt to ignore the problem.

This essay will use the pitfalls in the diagnosis of fracture-related infection to explore the complex relationship between surgeons’ emotions and post-operative complications. This will be followed by some suggestions for how we can learn to deal with complications in a more productive way. The discourse does not pertain to incidents of incompetence or negligence, but to the potential risks which attend every surgical procedure, no matter how well performed.

Diagnosis of fracture-related infection

“Seeking his secret deeds

With tears and toiling breath,

I find thy tiny cunning seeds,

O million-murdering death”

Sir Ronald Ross
On the Discovery of the Malaria Parasite

The British Orthopaedic Association standard of care on fracture-related infection (FRI)² emphasises the importance of early recognition and management by specialists under the auspices of a multidisciplinary team approach. The consequences of missed or untreated infection can well be limb or life-threatening.

I work in a tertiary referral centre for bone infection, and I know from my own experience that the diagnosis of fracture-related infection (FRI) is fraught with difficulty. Whilst a sinus pouring pus is easy enough to diagnose, often the clinical signs are more subtle, especially in early infections. Erythema and cellulitis of skin overlying metalwork should be viewed with a high index of suspicion, and acted upon promptly. These signs, whilst not pathognomonic, are regarded as highly suggestive of infection by the international consensus group on FRI³.

The usual indicators of infection, such as white cell count (WCC), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are not reliably elevated in implant-related infection. Even if they are, they are of low sensitivity and specificity^3,4.

Imaging is not foolproof either; a multitude of imaging modalities are used in the management of FRI, either to diagnose infection or to provide information on fracture healing and anatomy. Computed tomograms (CT scans), magnetic resonance imaging (MRI scans) and isotope bone scans often fail to distinguish infection from other conditions with any degree of accuracy⁵. Even newer so-called 'hybrid' scans, which combine anatomical and physiological information, such as single photon emission CT (SPECT) or fluorodeoxyglucose (FDG)-labelled positron emission tomograms (PET scans), in spite of their higher diagnostic accuracy, are not entirely reliable in the diagnosis of bone infection³.

One may assume that a tissue diagnosis of infection would be the gold standard, and the culture of phenotypically indistinguishable pathogens from at least two separate deep tissue specimens is considered a confirmatory criterion of FRI⁷, but the literature suggests that without meticulous sampling and culturing techniques, the risk of either growing contaminants in the laboratory or of failing to grow any organisms at all, is considerable⁶. The chance of isolating a causative organism is only as good as how the samples are taken, and how they are processed.

All of the above makes it easy for surgeons to assume the absence of infection, as each individual piece of evidence is often only suggestive. Most surgeons are understandably loath to call a red or leaky wound a post-operative infection. In these cases, early investigations are not undertaken, and appropriate management is not commenced in a timely manner, thus compounding the problem. Even evidence which one would reasonably take to be conclusive, such as the presence of a discharging sinus, is often dismissed as a 'superficial infection'. This author’s opinion is that there is no such thing as a superficial infection in the presence of underlying metalwork, unless proven otherwise. The many confounding factors in the clinical picture and subsequent investigations necessarily mean that the diagnosis of fracture-related infection is based on a high index of suspicion, cumulative evidence, and a willingness to accept the possibility of a post-operative complication.

Given the significant implications of failure to treat FRI in a timely manner, what makes surgeons so reluctant to consider it (like the proverbial ostrich) unless faced with incontrovertible proof? A variety of reasons; complications may be perceived as an admission of incompetence, the surgeon may fear guilt or blame, and there are also legal and financial implications of litigation to be considered. Recent initiatives such as Getting It Right First Time⁸ and hospital and surgeon-specific outcomes have also unintentionally conspired to encourage fear of consequences. Perhaps more important, however, is the emotional impact on surgeons when complications occur, which we will
discuss later.

What is a surgical complication?

“History as well as life itself is complicated -- neither life nor history is an enterprise for those who seek simplicity and consistency.”

Jared Diamond (Collapse: How Societies Choose to Fail or Succeed)

It is necessary to understand first what counts as a surgical complication in order to investigate surgeons’ responses to the same. This is by no means as straightforward as it may seem. Whilst there is a broad understanding that it refers to an adverse event of some sort, there is no consensus on what constitutes a complication, although many attempts have been made at a definition^9,10. Dindo and Clavien⁹ propose the definition “any deviation from the ideal postoperative course that is not inherent in the procedure and does not comprise a failure to cure.” They divide negative outcomes after surgery into sequelae (a natural result of surgery, for example a scar), failure to cure (the purpose of the surgical intervention was not achieved) and true complications. They have classified surgical complications into five categories, beginning with minor ones which do not need intervention, and ending in the death of a patient owing to a complication. This was first proposed in 1992, and subsequently modified to include several subcategories¹¹. Other authors have found it to be a valid and useful tool, which can be adapted to different surgical specialties, including orthopaedics^12,13.

Visser et al.¹⁴ highlight the wide variation in and subjective nature of what surgeons report as complications. They quote the definition of a surgical complication according to the Association of Surgeons of the Netherlands in 1999 as an event which “negatively affects the patient’s health such that this requires their medical treatment to be adapted, or such that irreparable damage is caused.” Here we see the concept of harm to the patient, and there is further stipulation that the event should have occurred either during the hospital episode or within a period of 30 days following discharge. Interestingly, Woodfield et al.¹⁵ found that when patients reported complications themselves, there was a rate of over 40%, and that many of these, although clearly of significance to the patient, would not have otherwise been identified.

The notion of a surgical complication is closely linked to medical negligence in the minds of the general public and medical practitioners alike. However, negligence has a very specific definition whereby a duty of care must have been owed, the breach of which resulted in harm to the patient¹⁶. Although this essay is not concerned with negligence, as I have mentioned, the association in the minds of patients and surgeons is difficult to escape, and goes some way to understanding the reticence in acknowledging a complication.

Surgeons’ responses to complications

“Every surgeon carries within himself a small cemetery, where from time to time he goes to pray—a place of bitterness and regret, where he must look for an explanation for his failures”

René Leriche

There are numerous documented accounts of the negative impact complications have on surgeons’ wellbeing, and therefore on patient care^{17,18,19,20,21}. These authors found that emotional reactions range from anger and guilt to performance anxiety and fears about one’s surgical career. Furthermore, although the intensity of such feelings dims with time, there are a few cases that haunt surgeons for many years; this is the basis of the quote above by French surgeon René Leriche, a popular one amongst surgeons. Pinto et al.²² report the occurrence of 'acute traumatic stress' amongst surgeons following significant post-operative complications, and I can personally attest to this. Wu²³ has coined the term 'the second victim' for the physician affected by an adverse event, although some authors think this is insensitive to patients²⁴. It is important to recognise that all responses described above are natural – there are no right or wrong emotions.

Although adverse events are visited upon all medical specialties indiscriminately, there is something very personal to the surgeon when it comes to a post-operative complication. Surgery is often referred to as a 'craft' speciality²⁵, and indeed surgeons were originally identified with barbers rather than men of science²⁶. The idea of surgeons as craftsmen conveys the belief that surgery requires more than just sound scientific principles, and that the 'expertise' so avidly sought and so dearly won by trainees is to be found at the sweet intersection of manual dexterity, anatomical knowledge, delicate handiwork and creativity. This is embodied in the much quoted ‘Attributes of a Surgeon’ credited to Astley Cooper; “the eye of an eagle, the heart of a lion and the hand of a lady”²⁷. When a post-operative complication occurs, there is a sense that one has caused the event
'by one’s own hands'¹⁹. These feelings of failure, guilt and frustration are the seeds of our emotional reactions to adverse surgical events.

Surgeons are traditionally regarded as possessing a certain personality; emotionally tough, confident, meticulous attention to details, high achievers²⁸. One may be forgiven for thinking, therefore, that surgeons should be well equipped to deal with setbacks. Nothing could be further from the truth^29,30,31. On the other hand, the 'flip side' of the so-called 'surgical personality', if this can be said to exist, consists of some very negative characteristics; perfectionism, workaholic, poor delegators and poorly able to prioritise tasks^28,29. These can lead to an unhealthy response when things do not go according to plan, such as with the occurrence of a complication. Surgeons are taught and encouraged to take responsibility for their patients³². Consultants 'carry the can', 'the buck stops' with them; all these are viewed as good qualities, but they merely add to emotional stress and burnout when things go wrong. It is well known that medical practitioners in general are prone to burnout and mental health problems. The rate of burnout is especially high amongst surgeons^33,34,35, and Money²⁸ emphasises the contributory role of high stakes human outcomes in this.

Turning the tide; healthy responses to complications

“You people with hearts, have something to guide you, and need never do wrong; but I have no heart, and so I must be very careful.”

Tin Man (The Wizard of Oz)

Several years ago I attended an event organised by the excellent Surgery and Emotion project³⁶, run under the auspices of the Royal College of Surgeons of England. It was essentially speed dating between surgeons and members of the public. It was enlightening and fun. I found the members of the public to be highly insightful. Twice I was asked what support there was for surgeons when things go wrong. Having been in this unenviable position myself, I responded “Not very much, actually.” They were both taken aback; they had naturally assumed that such an important service would be readily available to us.

We have already seen how adverse events can have an enormous emotional impact on surgeons. How do we cope with this? Head down to the local for a pint with a friend? Speak to a mentor? Analyse endlessly? Adopt risk-averse behaviour? Accept disproportionate blame or shrug off any responsibility? There are as many coping mechanisms as there are surgeons, but importantly, many are self-learnt. Pinto et al.¹⁹ report that discussion, deconstruction and rationalisation (putting things into perspective) were the most common responses. These are very positive ways of dealing with a complication, and result in the emotional and professional growth of the surgeon. Unfortunately but unsurprisingly, there are also negative coping mechanisms such as alcohol and substance abuse^18,37. These can heighten feelings of depression, guilt and shame, and ultimately result in predictable problems on a professional and personal level.

The question we must now ask ourselves is how to manage the aftermath of surgical complications in a way which is both supportive and conducive to growth, so that the positive emotions are reinforced and the negative ones managed appropriately. Some authors have suggested that surgeons may not naturally have the tools to learn from complications^17,19, and it is noteworthy that this very important aspect of surgery is not usually addressed in surgical curricula. We, like our friend the ostrich, tend to bury our heads in the hope that the emotions will eventually pass, but this is a most unhealthy strategy.

Peer support, mentorship and a team structure which is encouraging to open and frank discussions have all been mentioned as vital in helping surgeons to deal with their emotions after an adverse event^19,30,38. These measures are often used informally, and there are certain advantages in keeping them so, not least the fact that a more formal arrangement may put off those who would most benefit. On the other hand, making them readily available as part of normal practice represents an acknowledgement that complications are not unusual, are emotionally challenging for the best surgeon, and that seeking support is not a sign of weakness.

Dorsey and Ritzer³⁹ have coined a marvellous phrase called “the McDonaldization of medicine” for the application of corporate values such as efficiency, calculability, predictability and control to the practice of medicine. These institutional values often result in a 'blame' culture when things go wrong. Several studies point out that lip service is paid to a supportive environment, but the reality is that surgeons are often made to feel that they are solely responsible for adverse events, and mortality and morbidity meetings are not as blame-free as we would like them to be^19,40. This pervasive culture is also seen in responses to complaints, where surgeons must 'apologise' for system failures beyond their control. A non-adversarial governance culture is essential in allowing surgeons and patients to benefit from the valuable lessons to be learnt from unintended outcomes.

Fear of litigation and malpractice is known to be a factor in the negative impact on surgeons after a post-operative complications^20,21. A no-fault compensation system for surgical complications^41,42 would foster a blame-free environment, and a better surgeon-patient relationship. Informed consent also forms a vital part of the picture when it comes to litigation; the Montgomery case⁴³ has raised this in the collective surgical consciousness. Close attention should be paid to the words we use and how we broach the potential risks of surgical procedures during consent. This carries with it a necessity to be aware of the complication statistics in our own institution, and to participate in meticulous data collection.

What lies ahead?

“There is no separation of mind and emotions; emotions, thinking, and learning are all linked.”

Eric Jensen

At long last, we are seeing the emergence of not just an awareness of the negative impact of complications on surgeons, but the necessary tools to combat this. A “second victim” support toolkit has been developed in various institutions^44,45. During the course of composing this essay, the Royal College of Surgeons of England released their exemplary publication entitled “Supporting Surgeons after Adverse Events”⁴⁶. In this they stress the role of a 'first responder' whose primary role is to focus on the surgeon’s wellbeing. It is to be fervently hoped that these measures are taken on board in our hospitals, and that they will eventually become standard practice. As with all such measures, a period of trial and error is required to determine their fitness for purpose and adaptability to different environments. Finally it seems, we are lifting our heads from the sand.

It is also vital to consider how we prepare our trainees to deal with surgical complications, and with the emotional fallout of these.

And last but not least, no orthopaedic piece would be complete without the words 'further research is required into the topic.'

Disclaimer:

The author is aware that ostriches do not actually bury their heads in the sand!

“One ought to hold on to one's heart; for if one lets it go, one soon loses control of the head too.”

Friedrich Nietzsche

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