A Reality Check About Surgical Complications

“I come to bury Caesar, not to praise him.” – Julius Caesar, William Shakespeare

Okay, not Caesar — but the shibboleth that good surgeons don't have complications. Amour-propre is high among physicians, and especially among surgeons. Like drivers (80 percent of male drivers believe their driving ability is “above average”), surgeons tend to have high levels of confidence when it comes to their surgical skills. This confidence is not misplaced. When I am a passenger on an airplane, I want the pilot to have 100 percent confidence that s/he can land the plane safely. Undoubtedly, patients want surgeons to be equally confident. As Caesar, who would have been a tremendous surgeon, said: veni, vidi, vici ( I came, I saw, I conquered).

Lamentably, surgical complications can erode a surgeon's confidence. All surgeons have witnessed heretical morbidity and mortality conferences in which some pitiable surgeon was pilloried for a complication. Then there is the slew of published papers lauding the efficacy of one surgical technique or device over another because evidence shows fewer complications. The surgeon is regularly bombarded with the message that complications are bad, as if s/he needed reminding. Despite the onslaught, surgeons should resist the formalism:

I strive to be a good surgeon.

… Complications are bad.

… I have complications.

… I am a bad surgeon.

This is destructive self-flagellation (and others abound willing to do it for you — why do it yourself?). No surgical authority candidly admits that during a surgical career there will be a quantifiable number of complications. Yet, a little calculating shows this to be so. A surgical career spans 30-35 years. During that span, a surgeon performs 300-400 cases per year on average. (Determining an average number of cases per year is difficult, but in literature searches, I find a range of 200-500 cases per year per surgeon.) Over a career, it is likely a surgeon will perform 10,000 or more procedures. The complication rate of those procedures is highly dependent on patient factors and on the type of procedure being performed. Patients who are otherwise healthy 45-year-olds with Stage I breast cancer, or healthy adolescents with indirect inguinal hernias, are certain to have low complication rates, possibly approaching zero. Unfortunately, too often patients have addictions to food, tobacco, alcohol, or illicit drugs — all factors that raise the complication rate. Another group of patients is made up of octa- or nonagenarians with cardiopulmonary disease. Some patients may have mechanical heart valves requiring bridging anticoagulation or be steroid dependent. Given the manifold patient presentations, and the general inability of surgeons to select the most favorable cases, I hypothesize (with no supporting evidence whatsoever, I admit vulnerability on this point) a one percent complication rate. From this percentage, I exclude such complications as urinary tract infections, pneumonia, and IV site infections. While these may be important to hospital administrators, insurance companies, and government agencies, they cause the surgeon little loss of sleep. The complications that surgeons do worry over are things like surgical site infection, anastomosis leak, post-operative hemorrhage, organ injury (spleen, bladder, ureter, intestine), wound dehiscence, abscess, death. These all, I include. Assuming a one percent complication rate, over a career a surgeon can expect to have roughly 100 such complications or 2-4 per practice year. To the surgeon who may now be feeling a bit smug, I point out that complications have a way of coming in clusters and reversion to the mean is powerful.

When thought turns to complications, it has been helpful for me to remember a quip from residency. There are only two kinds of surgeons who don't have complications: liars and those who haven't done much. Surgical perfection is a commendable but elusive goal. Surgeons should not pretend otherwise. Doing so is a prescription for disillusionment. Complications will always stalk the surgeon.

Sages tell us, “To err is human.” And it is — reflect and learn from complications, then forgive yourself. This is the way forward.

Image: GoodStudio / shutterstock

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