Dr. Stanley Aruyaru is a Consultant General and Laparoscopic Surgeon and a Healthcare Manager. He has solid experience in managing
“That was a very liberating statement you made, it has helped me deal with difficult cases,” my colleague once told me.
We had met over a long-overdue meal. I enjoyed the Molo lambs while he opted for the stir-fried beef. There were Indian naan and french fries among the repertoire of starch servings. A little smoke billowed in the nearby fireplace before giving way to clear flames and soon there were red-hot embers radiating warmth into the picturesque room.
We drifted a little into the work again. This time discussing a short message the colleague had received from a patient’s relatives. They complained about something they overhead from the ward rounds which seemed to go against what the doctor (he) had advised. And now they were raising ‘concerns’. The type that speaks like ‘I would like a second opinion’ or ‘did this happen because of what you did?’.
“Leave them doc. Do your part and document. And let them know it is their right to seek a second opinion”, I interrupted the somber prose.
Was my colleague crying for help? He had suggested this meet up and had promised to share something. And the said something seemed to have disturbed his peace. That text was totally intrusive to say the least, especially on a Sunday for heaven’s sake. He hoped to be free with his thoughts and his family.
Slowly, we drifted to other matters special to the young consultant. How do you establish a private practice while establishing boundaries and safe guarding some private life?
‘It is a slippery slope!’ he cautioned me. Sometimes the hospitals hold your money running into exorbitant sums that you just cannot walk away from. You end up being ‘hooked’ to them as they owe you, he reflected. I countered that I would put a limit to how much a single hospital would owe me in arrears before I stopped patronizing them. This was wishful futuristic talk for someone who was (and still is) yet to cut serious teeth in private practice.
Patient care versus Self-care
“Patients are not your friends”. This was not the advice he recalled me having given. This was one I received from my classmate, a contemporary in the same specialization as me. He had heard the same wisdom from the venerated lips of another senior colleague. It had cleared all the cobwebs in his conscience when drawing clear boundaries between patient care and self-care. I have since adopted this self-help mantra. “Explain fully and obtain informed consent”, my classmate advises, “then deal with complications when they arise without beating yourself up”.
But my ‘liberating statement’ to my colleague was itself borrowed from a senior surgeon and professor during my specialist training. It was in one of those weekly mortality and morbidity conferences where we would pour out our contrite and remorseful hearts. “In retrospect I should have ordered this test and intervened earlier”, we would refrain again and again as the outside observers in other consultants would keep the all-important question begging, ‘what would you do differently?’. And so on one of those mornings, instead of the professor dancing in tune to the self-incriminating reflective epithets, he told us to stop being doctors and accept that some patients are so sick that they will just die in spite of what you do or fail to do.
“You are just being doctors. You just intervened because you could not fathom not doing anything. And now you cannot stand the patient’s death because as a doctor you just needed to see your interventions prevail, not fail”.
Restore structural Normalcy
Years down the line, on a busy operating day, I stepped into the adjacent theatre as I waited for my next patient to be wheeled in. My orthopaedic colleague was engrossed in a procedure. With pin drop silence, he looked down on a badly injured leg, deciphering a formula to restore structural normalcy to a mutilated bone. I walked over to the illuminated panel holding the patient’s X ray a distance from the operating table. I could see the shattered bone with a joint in disarray. Every surgeon knows those cases where you feel pity for the colleague handling it while thanking gods that such did not land under your care.
I opened the greetings with the common gambit, ‘sorry doc, this is a terrible one’ to which he responded by acknowledging the frustrations he was withstanding as he tried to bring fragments of bone to shape, then restore the joint.
” You cannot be God doc. Just restore the length here and the alignment. You may contend with a dysfunctional joint. You are not the one who injured the patient”.
It is that statement that I would learn, eons later, was the driving force for my colleague’s psyche every time he faced a difficult case. I never thought it carried such gravity and validity when I uttered those words.
Many doctors battle with beating themselves up when the patient outcomes are not perfect. As a select group of type A personalities, high achievements only lead to a desire for a next high. And errors or inadequate outcomes beat us down, awakening the internal self-critic and self-doubt. When we take the ‘walk of shame’ to face a family and break the news of a complication or death of their kin, we suffer vicarious trauma of the grief.
‘I am sorry for you too, for I know you have lost a patient you fought so hard for’, a staff once told me as we broached the topic of the death of his mom. I had operated on her for colon cancer and she had been taken ill months later having suffered a life-threatening complication of chemotherapy called mucositis. She never recovered from this.
Not many families will come to the doctor and say ‘sorry for the loss of your patient’, the doctor gets to find a way to heal.
Declare Self Pity
Nowadays I intentionally declare self-pity when I face a complication. It helps me get it out. “Let me go and clear my mind. I have had to abandon a very difficult case as the patient became unstable”, I once told a senior orthopaedic colleague after such a case. I did not expect him to offer tidbits of advice as we are in different specialties. I just knew that I owed it to myself to let that experience out. When the intern called a few minutes later asking if he could meet me briefly, I replied that I had gone looking for lunch and for a way to decompress after the stressful case.
I also quickly vent off to close colleagues when I have faced a challenging case.
‘I have rusted in that skill man. I hate it”, I once texted my close colleague after I had found myself a little out of zone when called to assist in a gynecology-turned-general surgery laparoscopy case.
In his book Complications, Atul Gawande argues that some of the ways surgeons deal with complications include M&M conferences.
“…There is one place, however, where doctors can talk candidly about their mistakes, if not with patients, then at least with one another. It is called the Morbidity and Mortality Conference–or, more simply, M & M-and it takes place, usually once a week, at nearly every academic hospital in the country. This institution survives because laws protecting its proceedings from legal discovery have stayed on the books in most states, despite frequent challenges. Surgeons, in particular, take the M & M seriously. Here they can gather behind closed doors to review the mistakes, untoward events and deaths that occurred on their watch, determine responsibility and figure out what to do differently.”
Here the consultant in charge of the patient takes responsibility of everything that happens to their patients. And so, the consultant carries along the barrage of weighty cases that did not go so well.
“…When things go wrong the attending is expected to take full responsibility. It makes no difference whether it was the resident’s hand that slipped and lacerated an aorta; it doesn’t matter whether the attending was at home in bed when a nurse gave a wrong dose of medication. At the M & M, the burden of responsibility falls on the attending…”
There is evidence that the character make up of surgeons makes them resilient people. That they harbour the backbone to walk through an avalanche of medical complications and errors and come out ‘unscathed’ compared to other medical specialties. It could be a case of nurture, not nature, me thinks. But what is frightening from evidence is that errors cause more harm even to the said thick skinned surgeons.
From the story of the professor cautioning against unrealistic doctor expectations, the approach that comes to mind is what I recently happened on in a Podcast discussion. Maybe we should aim to care for our patients instead of aiming to cure.
When we aim to care, we still pour in our best evidence-based practice and enjoy the process of giving it our all. The outcome becomes secondary. The journey of care becomes the focus. The results become secondary to the process.
Granted, patient outcomes are important quality metrics but those can be left to the hospital quality directorates, not to the doctor’s overloaded heart and mind.
In this way, it will be easy to take care of a critically injured patient without the pressure that success will only be defined by bringing them out alive on the other side of the care pathway. When we have a mangled limb, we will not approach the patient like that car accident never happened. We will recognize that as a result of the car accident, this patient’s leg is definitely not going to be as natural as it used to be. The accident will have to remain a life changing moment for the patient. Probably even with perfect restoration of the leg, the emotional experience will linger into perpetuity and have a mental health impact on the patient.
“What should be the default approach to a patient by the doctor? To CURE (heavily dependent on patient and disease factors) or to CARE?”
I posted this as a Linkedin poll and it attracted 169 votes. Of these 36% voted care, 11%cure and 52% both.
I would vote that we aim to care. That way, we do not take over the responsibility of the patient outcome. Wu et al observe that although it is crucial to focus on the needs of patients and their families when errors occur, there is need to recognize that surgeons may be the ‘second victims’.
“Second victims are healthcare providers who are involved in an unanticipated adverse patient event, in a medical error and/or a patient related injury and become victimized in the sense that the provider is traumatized by the event. Frequently, these individuals feel personally responsible for the patient outcome. Many feel as though they have failed the patient, second guessing their clinical skills and knowledge base.” -Susan Scot , 2011
The concept of ‘second victim’ is observed to apply in 10 to 40% of the doctors surveyed in a research.
What coping strategies can we employ when we fall second victims?
Suggested individual coping strategies include:
Problem-focused coping strategies:
1. Discussing the complication with colleagues
2. deconstructing the complication to identify lessons that could be learned
Emotion-focused coping strategies:
1. Rationalizing by putting what happened into perspective
2. Talking openly to patients as a way of finding closure
3. Seeking Reassurance
At the system level, providing professional counseling and initiating quality improvement programs based on the complications and errors will ensure better experiences.
We can be proactive by reaching out to a colleague who has had a complication and saying “sorry about that”. I remember a case where a patient I was operating on suffered cardiac arrest on the table. It took abandoning the surgery and continuing resuscitation for 15 minutes to bring him back. Then he had to be sent to the ICU.
When I ran into a junior colleague along the corridors, she looked at me and said, “I am sorry about the surgery”. I was not expecting it. I was busy trying to move on. But that was a welcome thoughtful consideration from a colleague.
This looking out is even more important for younger colleagues who have not faced such complications before. It eats into their conscience all night and they cannot sleep.
“Thank you for calling me today doc. It felt encouraging to know I have people who understand what I feel,” a junior colleague texted me. I had called and cheered them up having heard of a mortality they experienced. I knew from the circumstances around the case that it must have been a daunting experience.
The balance between self care and patient care might not be easily struck. It our endeavour to keep chasing it.
“At some point we must all bring medical mistakes out of the closet. This will be difficult as long as both the profession and society continue to project their desires for perfection onto the doctor. Physicians need permission to admit errors. They need permission to share them with their patients. The practice of medicine is difficult enough without having to bear the yoke of perfection….” -David Hilfiker, 1984