You’re in the middle of surgery when it happens: a slip of the blade, an unexpected development, and things go wrong. Suddenly your routine procedure involves a complication. Maybe it’s minor, maybe it’s serious. Maybe you’re not sure. What do you do?
“The first thing you need to do is get control of yourself and not yell at your nurse, not yell at your assistant if you have one, not swear.” That’s the advice of Bruce Spivey, MD, former Academy executive vice president, who has been a professor of ophthalmology in several academic departments, as well as the department chairman at Pacific Presbyterian Medical Center in San Francisco. His surgical practice focused on strabismus and cataract.
“When something does go wrong, one has to continue to stay focused,” says Susan Day, MD, a pediatric ophthalmologist and former Academy president. “One of our jobs is to control our emotions when something goes wrong.”
Part of that control comes from anticipating problems, said Mark Mannis, MD, a corneal surgeon and chairman of the department of ophthalmology and vision science at UC Davis Eye Center. “You’re walking into the operating room with a calculated risk that something will go wrong,” he said. “Attention is always to be focused on the unexpected. To me, that’s part of preparedness … part of the mindset that you should have when you walk into the OR.”
Dr. Spivey agreed. “You think about [a possible complication or error] beforehand. It’s like anything else: you prepare for it,” he said. “You should have thought about the possibility of it happening, if it does. It’s preparation for the entire experience of what could go wrong – not only surgically, but verbally or emotionally.”
Importance of Quality Assurance
Dr. Day also stressed the importance of quality-assurance measures, such as surgical time out. “The most important thing is to avoid” a medical error, she said.
But even with improved systems and procedures to prevent wrong site/wrong IOL-type errors, things can still go wrong. “The only surgeons who do not have complications are surgeons who are not telling the truth, or surgeons who do not operate,” Dr. Mannis said. “Even the best surgeons are going to encounter complications.”
“Everyone has seen a nucleus drop into the vitreous, or a larger retinal tear being created, or a number of untoward events,” Dr. Spivey said. “That’s the time when I say you have to exhale, get control of yourself, and get help, if you don’t think you can handle it. If you can foresee that it is a problem beyond your own capacity to deal with, immediately request help. Don’t try to literally and figuratively dig out of it.”
Once the immediate crisis is addressed, all three physicians stressed the importance of being honest with the patient. Sometimes that may mean immediately alerting the patient to the problem, as Dr. Mannis did during a recent cataract surgery involving a broken capsule, during which a particle dropped into the back of the eye. “I informed the patient in the operating room,” he said, because the complication required a follow-up operation.
“You don’t have to tell the patient everything that happened, and you don’t have to describe how badly you screwed up, but you should describe what happened,” Dr. Spivey said. “‘These are the steps we’re taking, these are the possibilities and/or actions that will occur going forward’ and any additional actions that will be taken.”
Dr. Mannis agreed. “I can certainly remember when I was a senior resident,” he said, “I was doing a case with the pediatric ophthalmologist at Washington University, where I trained, and in the course of reattaching an extraocular muscle, I perforated the eye — which is a not-uncommon complication, but it was my first surgical complication ever.”
“The approach I learned at that event is one I’ve used throughout my entire career,” he said. “Immediately after that procedure, my attending said, ‘I want you to go out and tell that family what happened.’”
“We must be honest with our patients,” Dr. Day said. “If something does go wrong, we need to fess up.” Not only is honesty “wise medicine,” she said, it is also a key component of the trust crucial to the doctor/patient relationship.
“There is a distinct difference between the power, being a doctor and being a patient,” she said. “A patient is terribly vulnerable, and a doctor is there with some degree of authority and experience, but there still needs to be this element of trust, which is built when the doctor somehow allows the patient to understand that he or she is still a human being as well.”
If that trust has been lost, Dr. Day said the most appropriate follow-up might include referral to someone else. “If trust doesn’t exist, it is very appropriate that the ophthalmologist consider who might be the best physician to move this forward,” she said.
“You need to be willing to switch gears,” Dr. Mannis said. “Be willing to change the course of action based on the new situation that’s been created by a complication.”
Part of that adjustment involves not only that particular patient but also future patients. “A patient who is wronged wants to have the medical wrong cured, but very close behind that” is a desire to ensure someone else doesn’t go through the same thing, Dr. Day said. “It is incumbent on us to grow and be better.”
“There’s something to learn from every procedure,” Dr. Mannis said. “If you complete a course of treatment and consider the outcome, be it positive or negative, that’s an opportunity for you to examine your clinical skill set. ‘How can I make myself a better surgeon? How can I make myself a better clinician?’”
And in the process of self-reflection and evaluation, the same principle applies, Dr. Spivey said. “Be honest. See what you did wrong, think what you can do to avoid that situation in the future, and go through a period of self-reflection. Self-reflection is hardly ever contra-indicated.”
Ideally, honesty is part of a department or institution’s culture, Dr. Mannis said. “The really fine training programs in the country are training programs that encourage honesty and self-evaluation, as opposed to fear of making mistakes and concern about a performance,” he said. “Obviously performance is important, but the good teaching programs are the programs that teach residents how to self-evaluate their performance for better or worse.”
Dr. Spivey agreed. “Where I trained, which was a distance from [San Francisco], and a long time ago, the environment was a marvelously candid, open environment where people shared their experiences, good and bad, and they were talked about openly at morning rounds,” he said. “That left an impact on me.”
He acknowledged, however, that such openness isn’t always the case. “If you see people who hide their mistakes or don’t admit their shortcomings, that can be a self-fulfilling prophecy” for the culture of the whole department, Dr. Spivey said.
The bad news? “It’s almost impossible for someone to come in from the outside and start telling someone else what to do,” Dr. Spivey said. “If there’s not a way in which you can either talk to the chairman or talk to someone in that department and get their help in dealing with it, you have to decide whether it’s untenable.” In that case, the nature of rotations can help. “You’re not forever with that person,” he pointed out.
“Sometimes you have to just suck it up and get through it,” Dr. Spivey said. “But, remember, never do that yourself. Do not mimic bad performance. And if there’s a way to help the person see themselves in a mirror, literal or figurative, look for ways to do it.”
Pearls from the Experts
- Dr. Spivey: “To be honest has been proven over and over again to help avoid malpractice situations or difficulties of relating back and forth, patient to physician.”
- Dr. Day: “NEVER alter the documents. If something goes wrong, it is unethical, it is illegal to alter the documents. Never, ever alter the documents.”
- Dr. Mannis: “Don’t ever go into the operating room without a thorough intellectual understanding of the procedure. That’s an absolute prerequisite.”
The Vulnerability of the Early Years
If a difficult rotation can be one of the challenges of residency, Dr. Day said the first few years of practicing on your own present their own perils. “There’s a particularly vulnerable point right after you finish residency, because you suddenly aren’t required to have the same supervision,” she said. “It takes a really wise recent graduate to understand that asking for help is a good thing, and that just because you’ve graduated doesn’t mean that you won’t be faced with problems that others can help you with.”
Dr. Mannis acknowledged that this can be challenging. “The person who goes into practice by himself or in a community where he’s perhaps one of the only new ophthalmologists is someone who doesn’t have all of the resources to draw upon to help him with those kinds of situations,” he said.
“Of course, with the Internet and e-mail lists, people have a lot more resources to draw on than ever before,” Dr. Mannis said. “If one encounters a daunting circumstance, there are resources one can turn to even without the direct camaraderie of a partner or someone right there.”
After all, learning is not restricted to residency. “Lifelong learning is not just studying the book,” Dr. Mannis said. “Lifelong learning occurs every time you encounter the patient in the exam room, every time you sit down at the operating table.”
Complications are part of that process. “I’ve had a few mistakes in my day,” Dr. Day said. “Everyone does. It’s very unnerving when it happens, but making it right means making it right for your patient, for future patients and for your own values.”
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About the author: Christi A. Foist is the managing editor for YO Info and the Web and member communications editor for the Academy.