Thursday, April 28, 2011

We Cause Complications

This is one of the most distressing elements of our profession.  Even when we keep our knowledge up to the highest levels, even if we use the knowledge and the skills we have with a high level of competence, we will cause a complication.  Since many aspects of applying medical knowledge are subject to different opinions and controversies, it is not difficult to locate a physician who would honestly be of the opinion that (in retrospect, of course, and with 20/20 hind-vision) a certain treatment that led to a complication is worth criticism.  For God's sake, it does not take an expert to determine that.  Everyone of us, when we think back, we can identify ways of doing things a little bit, or much, better.  Isn't this what we do everyday, no matter how experienced we are?  Otherwise, how do we improve? Is there any point in one's career that one can claim that she/he reached the level of perfection that there is nothing more to be learned, and no more need to learn from bad experiences?

One problem is that the current healthcare environment in the United States is fiercely suppressing this healthy attitude.  A complication may result in a malpractice claim, in a peer review process, in an investigation, and every one of those events can have a detrimental impact on a physician's career and livelihood.  There is no single incentive to stimulate an open and healthy learning and accumulation of more experience in most hospitals.  The current punitive environment gives a clear message: every complication may and will be used against you, possibly to the fullest extent.

Ask any well-experienced and skilled physician or surgeon if the medical school and residency taught her/him every contingency that can be faced and that no complications will occur whatsoever.  This is impossible.  The best doctors are the ones who were allowed to grow and accumulate experience and wisdom with time and hard work.  In doing so, inadvertent complications do happen, and they add to the wealth of knowledge, experience and wisdom and help more and more patients.  Give me a doctor who never ever caused a complication, and I tell you, she/he either is too early in the career, has no experience yet, or avoids treating other than the most straight-forward cases.  Worse still, a surgeon who never saw a complication will probably be not as good in managing a complex situation after a complication arises.  The bottom-line, an environment that rewards perfection and punishes the normal occurrences of complications is inherently against patients' best interests.

Where to draw the line when complications are acceptable products of a healthy process, and when they are the products of an individual person's poor practice or a system error?  Only if a fair and an impartial/neutral auditing process is in place that such a differentiation may be made.  Most hospitals in the US simply do not have access to a process like that, nor do they have any provisions in their Bylaws to mandate such a thing.  Constructive auditing and constructive peer review does not exist in the majority of hospitals in the US.  The only available mechanisms are judicial or quasi-judicial, adversarial, and their outcomes are often punitive and destructive. The process is very arbitrary.

I have not read Dr. Atul Gawande's book, "Complications".  So, I have no idea how this posting will agree or disagree with that new classic.  Patients and their physicians are the victims of an environment that is obsessed with senseless finger-pointing, punishment, elimination and revenge, and shows very little desire to truly address quality issues in a constructive manner.