Some Thoughts on How to Deal with Complications in Practice

Editor’s note: The Final Cut is a recurring editorial series written by a member of the AAOS Now Editorial Board.

Recently, one of my young partners in his first year of practice had a complication while performing an arthroscopic anterior cruciate ligament reconstruction. During the surgery, he caused a posterior wall blowout. He used alternative fixation techniques, and the patient ultimately did very well. However, this complication really affected him on a personal level. He found himself ruminating over it, questioning his skill level, and, most importantly, being tuned out when interacting with his family. He sought me out and asked me how I deal with complications and bad outcomes.

I really like my new young partner, and I know that he’s going to be an excellent orthopaedic surgeon and physician with time and experience. I asked him to meet me at a local bar, where we had a few beers and talked about it at length. Before we met, I thought long and hard about what advice I was going to give him. I thought back to my old mentors from residency and fellowship and imagined what they would say in these particular situations.

I have been practicing orthopaedic surgery for 30 years—each year, I see approximately 5,000 patients and perform about 800 surgeries. With this volume, any orthopaedic surgeon is, without question, going to have some complications or bad outcomes. Complications such as injuries to intraoperative nerves or blood vessels and wrong-site surgeries can occur, but with very careful preparation and communication with the OR team, these types of complications can be minimized or eliminated.

The types of complications and bad outcomes I am referring to are those that occur even when you try your absolute best given your years of training and experience—“human error.” I am also referring to complications or bad outcomes that may be out of our control, such as nonunions or postoperative infections, which occasionally happen despite our best attempts at doing everything correctly.

I recently had a case where I performed a simple open reduction–internal fixation of a finger phalanx. I have done this operation probably a few thousand times. It was one of those surgeries where you leave the OR feeling that you did a great job. The patient was doing great for the first 4 weeks and was very pleased with his progress. At the 4-week mark, he presented with a swollen, erythematous finger. He ended up having a pseudomonas infection that involved the bone. He required hardware removal, extensive debridement, an infectious disease consult with several weeks of IV antibiotics, and ultimately a joint fusion.

Thank goodness the patient was very understanding of his condition. Obviously, as the operative surgeon, I was quite frustrated. How in the world does someone get a pseudomonas infection 4 weeks after surgery when everything initially was going great? Was this a complication? Technically yes, but I would describe this more as a bad outcome, meaning it really was out of my control. I did everything I could, including perioperative antibiotics and appropriate postoperative wound care. Unfortunately, these things happen, and sometimes we have no control over them.

If this had happened to me 20 to 30 years ago, when I was much younger, I would have felt exactly like my young partner did with the anterior cruciate ligament case—upset, guilty, ruminating, not paying attention to my family, and not enjoying the moment. Age, experience, and wisdom have greatly helped me to better deal with these occurrences on a personal level. Unfortunately, complications and bad outcomes happen to all surgeons over the course of their careers. That is just the nature of our business.

Many of us, at some point, have wondered whether complications and bad outcomes may contribute to the high rates of suicide and self-harm among orthopaedic surgeons. Perhaps some individuals would still be alive today if they could have better psychologically processed these issues. I am hoping that younger and even older physicians reading this article will take my advice and perhaps cope better when confronted with complications and bad outcomes. Ultimately, after carefully thinking about what I was going to tell my young partner, I told him the seven things I think about in these situations and how they have helped me deal with complications and bad outcomes on a personal level.

1. You are human; you are not God.
Unfortunately, many patients and certainly plaintiff attorneys hold us to a status of perfection. However, religious beliefs tell us that only God is perfect. We must remember that we as human beings are not perfect. We are fully capable of making mistakes, despite our best efforts. I think we should always try our best as orthopaedic surgeons, but we need to accept the fact that we will never achieve perfection. We need to give ourselves a break and forgive ourselves for not always being right and for making errors. You will make mistakes in your career, and that’s OK—it’s part of being human.

2. Guilt is a ‘wasted emotion.’
It’s OK to feel bad for a brief period if you have a complication or bad outcome, but continuing to ruminate over it is not healthy. Guilt is a “wasted emotion.” It is based on things that have happened in the past that you cannot change. The past is done, there is nothing you can do to change it, and being stuck feeling guilty for a prolonged period will do you no good. You need to move forward and figure out the best course of care going forward with your patient. Ruminating about past events is just a complete waste of time. Learn from your mistakes, but do not hang onto them.

3. It’s just a job.
Remember that being an orthopaedic surgeon is your job; it does not define who you are. You are much more complex and special than that. Always do your best as an orthopaedic surgeon, as you would in any other occupation. Ultimately, being an orthopaedic surgeon is just another way to make a living and provide for your family and future.

Muhammad Ali had a famous quote about his occupation: “It’s just a job, grass grows, birds fly, waves pound the sand. I beat people up.” Your job is to provide the best possible care for your patients. A job is a job. It’s a way to pay for a living, but don’t let it define your happiness. You work to live, not live to work. Work on what makes you happy.

4. Treat patients like family.
Always treat patients like members of your family. It is something that I embraced a few years ago, and trust me, it makes the job more fun and less stressful. Get to know your patients a bit better than you have in the past. Don’t just start appointments with medical questions—take a few minutes and ask them about themselves. It gives you a better connection with them, and if you have a complication or bad outcome during their care, I believe they will trust you more and remain under your care than they would if things were kept superficial and strictly about their medical condition.

5. Embrace gratitude.
Whenever a complication or bad outcome occurs, it is natural to fall into negative thinking patterns, such as thinking you are a failure, overgeneralizing that everything will go wrong, ignoring all your positive outcomes, jumping to negative conclusions, magnifying things out of proportion, blaming yourself, failing to acknowledge the complexity and nuances of practicing orthopaedic surgery, and mistakenly identifying yourself as the cause of certain complications and bad outcomes. It is not healthy to feel this way, so you must embrace everything in your life which is good: friends and family, the fact that so many of your other patients are doing well under your care, the health of you and your family, etc. Practicing gratitude at these difficult times can stop the unhealthy, negative thinking patterns.

6. Become a great doctor (again).
When first starting in practice, most of us probably felt that if we just did everything they taught us in residency, things would go perfectly. As we all know, this is never the case, and when complications and bad outcomes occur, they tend to negatively affect our care of other patients. We may feel that if we have a bad outcome that we are not good doctors, and the next patient we care for will have a complication as well.

It is at these times that you must remember all the great qualities you already have as a doctor. You must continue to believe in your excellent problem-solving skills and strict attention to detail. You must communicate well with your patients, and you must be respectful and empathetic. When a complication or bad outcome occurs, that is when your patient needs you the most. Always be there for them. Let them know you are available at all times for them.

Something I say now to patients is, “I am always around if you need anything.” I think that goes a long way. Always believe that you are a great doctor, and always remember that it is the “practice of medicine,” not the “perfect of medicine.” Never stop learning, as this is best for you and your patients. Attend conferences and courses and discuss your cases with your colleagues. All these things make you a better doctor.

7. Remember to live.
Remember that you were put on this earth to live and not just to work. We are here only for a brief period of time, and we must do our best to enjoy life. Embrace it and live it to its fullest. People outside of your job depend on you. Be there for them. Try your best to leave your work problems at the office, and only give those problems some of your time, not all of your time. Do your best to never ruin a good today by thinking about a bad yesterday.

Hopefully, this advice will improve your view of the practice of orthopaedic surgery as much as it has mine.

Gregory G. Gallant, MD, MBA, FAAOS, is a hand and upper-extremity specialist at the Rothman Orthopaedic Institute in Philadelphia, clinical assistant professor at the Sydney Kimmel Medical College at Thomas Jefferson University Hospital in Philadelphia, and a member of the AAOS Now Editorial Board.