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Editorial

The Gift of Complications

Hinchcliff, Katherine M. MD; Shin, Alexander Y. MD

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Techniques in Hand & Upper Extremity Surgery: June 2022 - Volume 26 - Issue 2 - p 69-70
doi: 10.1097/BTH.0000000000000392
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It is a certainty that every surgeon will eventually experience a surgical complication some time in their career. While some surgeons will have fewer complications and others will have more, complications remain an unfortunate part of surgery for all of us. The negative connotations of surgical complications are so pervasive that evaluation of complications can be seen as punitive for some. The manner in which a surgeon manages and works through their own complications is as important as the initial surgical planning. More importantly, complications and how we deal with them mold us into the surgeons we ultimately become.

A discussion of an intraoperative complication occurred between the authors. A tendon lengthening was performed but the degree of release needed was misjudged and resulted in a tendon rupture after manipulation. This was salvaged by performing a tendon transfer, which solved the problem. After reflection of the complication and careful review of the literature, it was humbling to discover that a tendon transfer, as opposed to a lengthening, was the best solution. It became clear that the intraoperative complication was most likely avoidable. Days after the event, the surgeon still deep in the throes of self-recrimination, the authors discussed this complication. In addition to providing a venue for confession and discussion for the surgeon, the reviewing surgeon briefly said “this complication is a gift to you and your future patients—because you will learn from this and not make the same mistake again.”

A surgical error is defined as performing either the “wrong thing,” or “the right thing incorrectly,” and is categorized into the following errors: Errors in surgical technique, errors of judgment, inattention to detail, and incomplete understanding of the problem.1 While it has been shown that most complications are because of individual error,1,2 not all surgical errors result in complications, defined as deviations from the normal postoperative course.3 Surgeon’s stage in career, technical capacity, and even personality can leave us each uniquely vulnerable to different types of surgical errors.

Whatever the cause, there is a natural common response to surgical error. The surgeon is often mired in feelings of anxiety, guilt, shame, embarrassment, and even anger.4 Unfortunately, our ability to handle these emotions does not appear to improve with greater experience.2 In a study by Patel et al,2 87% of surgeons dealt with the emotional fall-out of complication by talking with a surgical partner. More recently, there has been increasing awareness of the collateral emotional damage of surgical error (the so-called “second victim5”), which has led to participation in support groups for surgeons experiencing complications.6 Addressing and not ignoring our emotional response to a surgical error is a more humane way to practice medicine and has mitigated physician burn-out.6

We would be remiss, not to evaluate a root-cause analysis of the error. Morbidity and mortality conferences provide an open forum for objective evaluation of complications, but have been criticized as not promoting candor because of the fear of professional backlash.7 Unfortunately, these conferences do not capture the surgical error that results in a so-called “near miss” and not a complication. The silver lining of the complication lies in what we do with the complication. Each surgeon must carefully review their own complications, and seek the lesson that can be applied to future patients. This is the unrecognized or serendipitous gift of the complication.

In whatever forum it occurs, open and honest evaluation of the error is an important tool for improvement. All errors, regardless of the perpetrator, should be discussed and learned from by everyone on the surgical team. Surgical complications and other misadventures are never welcome, but they all do have something to teach us. That lesson is indeed a gift that we, as surgeons, must be careful not to ever waste.

REFERENCES

1. Fabri PJ, Zayas-Castro JL. Human error, not communication and systems, underlies surgical complications. Surgery. 2008;144:557–565.
2. Patel AM, Ingalls NK, Mansour MA, et al. Collateral damage: the effect of patient complications on the surgeon’s psyche. Surgery. 2010;148:824–830.
3. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a Cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–213.
4. Han K, Bohnen JD, Peponis T, et al. The surgeon as the second victim? Results of the Boston Intraoperative Adverse Events Surgeons’ Attitude (BISA) Study. J Am Coll Surg. 2017;224:1048–1056.
5. Herring JA. Complications: second victim. J Pediatr Orthop. 2020;40:S22–S24.
6. El Hechi MW, Bohnen JD, Westfal M, et al. Design and impact of a novel surgery-specific second victim peer support program. J Am Coll Surg. 2020;230:926–933.
7. Pinto A, Faiz O, Bicknell C, et al. Acute traumatic stress among surgeons after major surgical complications. Am J Surg. 2014;208:642–647.
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