Thursday, February 12, 2009

Complications & Confidence

You walk home from the hospital with your head hung low. Throughout the day, you tried to appear upbeat, but your colleagues could tell that you were troubled inside. You have had your first major complication as a surgeon. Your co-workers try to encourage you, but their words don’t comfort the pain of knowing that you have hurt someone. They assert that complications are part of being a surgeon. They tell you of similar complications they have had. They remind you that you were doing your best. But no matter what anyone says, the disappointment in oneself and the guilt of having a bad outcome burdens your heart like a weight on your chest. Even as you go about your day and try to put it out of your mind, the patient’s face suddenly flashes across your mind, and that hollow ache in your stomach returns… You are literally haunted by the patient you have hurt., and can’t help but feel unconfident and unworthy to be a physician…to the point of feeling ill.

This is the part of being a surgeon that Grey’s Anatomy doesn’t capture.


Moving to another continent to practice surgery has been a substantial stressor for me. But, I suppose that every surgeon who finishes training and takes on the role of attending surgeon (the physician ultimately responsible for the care of the patient), experiences some growing pains during their first year of being “in charge”. And while it is always difficult to navigate the first year of independent clinical work, my being in Africa has amplified the insecurities and anxiety associated with being a young surgeon. I practice very general surgery and operate all over the body. For instance, today I did a skin graft, a sapheonous vein stripping, a testicular varicocele ligation, an orchiectomy, a thyroidectomy, and an urgent groin exploration for an incarcerated inguinal hernia…and today was an easy day. I had at least done all these procedures during residency. Many days, I’m doing an operation that I have only read about, and sometimes for more urgent matters, the reading is taking place while the patient is going to sleep! I’m fortunate to have two amazing mentors/peers here in Kenya that offer me guidance and support, and I can’t imagine what it would have been like here without them, but ultimately I have to accept responsibility for patients’ outcomes…whatever they may be.

Even without complications, the week can be overwhelming. My clinic is overflowing with patients with difficult to treat problems, and I have limited diagnostic and therapeutic modalities to manage them. Much of the time, I am struggling to get a history through a series of multiple interpreters… the pt speaks Somali, the friend translates to Swahili, the nurse translates to English (although my Swahili is improving), and I wonder if the impression I get at the end of the translation is even close to what is really going on with the patient. Then my operative days are filled with challenging cases that depend on some piece of equipment or material that is broken or run out. Meanwhile, consults are coming from every direction. Then, I have to prepare for conference to teach the residents, and medical students. (Oh, by the way, can you give Grand Rounds next week, Chad). And to top it all off, more than every 3rd night, I am on call trying to manage surgical emergencies (trauma patients most often), and tramping into the hospital at the midnight hour.

But I can handle the clinical chaos, the endless to-do lists, and the long hours…that is no different than residency. What really disturbs my peace of mind are complications. I have had two particularly difficult complications to cope with since I have been here. Both were patients that had elective operations, and they subsequently died. (One patient had a neck mass that I explored and found a carotid body tumor, which I successfully dissected off the bifurcation, but the patient suffered a stroke from the manipulation of his internal carotid artery, and died 7 days later. The other patient had an early diagnosis of esophageal cancer, so I did an esophagectomy, and she initially did well, but she suffered an aspiration pneumonia and died 16 days post-op.) These two cases haunt me most, because they were patients who came to see me and were feeling okay, despite their problems. I booked them for elective surgery, admitted them a couple weeks later, but they never left the hospital. I don’t get nearly as bent out of shape when one of my trauma patients dies or when one of my patients with a ruptured aortic aneurysm dies post-operatively, because they had life threatening conditions, and would have died without my care undoubtedly. However, to have a patient come to clinic with a problem that is not immediately life-threatening, and you tell them, “I think I can help”, but instead you hasten their death…that is painful to accept.

I am sure I am not alone in my feelings. Every doctor has to learn how to deal with complications. When I was a resident, I saw how upset the attendings (especially the young ones) would get when their patients did poorly. A small minority of the more experienced surgeons had healthy attitudes about learning from complications, and were able to grow from the experience. But most doctors tend to fall into one of two categories: Those that blame themselves and those that blame others for their complications. Some physicianss blame themselves entirely which can be very counter-productive, especially if they become so paralyzed with fear that they hesitate to intervene in other patients’ management thinking they may hurt someone else. On the other extreme, a handful of doctors have difficulty accepting that they may have made a poor decision or an error. One particular attending I worked with almost always found a resident or nurse to blame for her patients’ bad outcomes, and I could see how that limited her growth as a doctor.

In actuality, complications are inevitable. One cannot always make the right decision. We must be willing to accept that at some point, we will prescribe a medication or make a decision to intervene that will hurt someone. Even if we make all the “right” decisions, patients still can have complications. And though this is discouraging on the surface, it is merely a reminder of who is ultimately in control of the outcome: whether a patient recovers is in God’s hands, not mine. I have seen patients receive poor care with life threatening problems, but miraculously recover…And I have seen others with seemingly treatable problems, and they don’t make it despite perfectly executed care. The truth is that we must do our best, but recognize that we cannot save every patient. As the Kijabe Hospital motto states: “we treat, God heals”.

Even though I know that I am human, and cannot expect all of my patients to be cured, I still struggle to recover emotionally from serious complications. I just feel guilty…like if I was better doctor, maybe things would have turned out differently. My confidence (which is usually quite high) is shot momentarily. I try not to be this way, but it is hard to silence your inner critic.

In the midst of guilt and feelings of inadequacy, the hardest thing for me to do is to face the family after one of my patients dies. This one particular case that I mentioned above was particularly upsetting. I knew that it would be heroic to try to cure her cancer in Kijabe hospital, but I booked the surgery with a strong feeling inside that everything was going to be okay. So when the patient died, I felt betrayed by my intuition, and it hurt me so bad. To make things worse, I had gotten quite close to the family during the hospitalization.  But something interesting happened when I went to talk to the family…something that might only happen in Africa. I talked to the patient’s husband and sister, and explained that despite the patient recovering from the surgery initially, she aspirated, and developed a pneumonia, and her heart just was not strong enough to survive the lung infection. As I tried to explain what happened, and expressed my sorrow about how things ended, I got a little choked up, and the husband and sister ended up comforting me. They were so strong, and so accepting of her death. As I struggled to find the words to express my self, the husband put his hand on my shoulder and said in his best English, “Never you mind it, thank-you.” I am still in awe of that family, and how strong they were. I thank God for them, because that particular complication so early in my career might have been devastating to my confidence, but with their words, my faith was renewed in myself and the mission: to serve the people of this community as best as I can with my surgical skill...regardless of the outcome.

Grey’ Anatomy and other medical dramas sometimes depict surgeons as having impenetrable egos…That no amount of adversity can undermine their belief in their own abilities. In actuality, very few surgeons are this confident. The majority of us take it very personally when a patient dies, and we struggle to maintain our confidence and optimism in the midst of complications. Don’t get me wrong, by most standards we are all egotistical… but it is a healthy and necessary egoism for the job of cutting people open. But when that ego gets beaten and battered by a few bad outcomes, one can lose the desire to care for patients. I have had my brief moments when I did not want to be a surgeon anymore, but thankfully I have recovered my passion for surgery, and soon I am celebrating the miracle of a healing that I was able to participate in.
So tomorrow when I walk to the hospital, I will once again hold my head high in anticipation of what the day may hold. I’ll look forward to opportunities I may have to help my patients. I’ll be eager to get into the operating room and practice my craft. I will no doubt be confident that I am a gifted and talented physician with excellent surgical skill. And while complications will certainly occur sooner or later, I know that my job is merely to treat…and let God heal.

Yours in renewed confidence,

“With realization of one’s own potential and self-confidence in one’s ability, one can build a better world.”
~Dali Lama


At Sat Feb 14, 03:28:00 PM, Anonymous Ashley said...

I know that I say this a lot, but you are a fabulously wonderful person, and while I know nothing about surgery, I tend to operate (pun) under the assumption that you are good at it. Given the evidence, anyway.

On that note, it's kind of odd that you posted this today, because I'm actually working on a paper on this topic. So I am likely to quote you.

I miss you and I hope that you are well! <3 Ashley

At Fri Feb 20, 03:40:00 PM, Anonymous Patrick Jackson said...

Its taken me a number of years to learn how to deal with complications, and I still lose sleep when my patients don't do perfectly. I commend you for your maturity and perspective in dealing with this very challenging personal and professional issue. I hope you dont mind if I show your blog to my residents to help teach them a caring but not destructive attitude/approach towards complications.

At Tue Mar 24, 02:36:00 PM, Blogger Shobana Jayaraman (Srikumar) said...

Hi, I came across your blog as I was looking for information on acute subdural hematoma. My father (62) is in coma currently after a bad accident. Today is the 15th day and he was finally weaned off the ventilator. I've been having a barrage of emotions constantly slapping my face every now and then. When I read your very humbling post, I was touched and took courage in the fact that his doctor also cares for him at some level though he is compelled to maintain a placid face. It felt comforting to know that I can now surrender to the will of God!

At Tue Mar 24, 05:50:00 PM, Blogger Kacy said...

touching man...really touching...

don't hesitate to call if it ever need to talk about this stuff man...your ability to resolve you own emotional turmoil is admirable, but i am here if you want to talk...i know you don't NEED to talk...

At Wed Jun 24, 10:42:00 PM, Blogger Reina Proverbial said...

In response to all that you've written, I just wanted to share this song with you:


At Wed Aug 06, 01:27:00 PM, Anonymous Anonymous said...

Hi. You just expressed what I feel inside now. I wish I could find that renewed confidence right now.

At Mon Apr 06, 10:41:00 AM, Anonymous Anonymous said...

Found your post after searching the internet for some consolation after my first surgical complication. You hit the nail on the head. Thanks so much. Keep doing God's work in Africa, the world needs more surgeons like you.


At Fri May 06, 05:49:00 PM, Anonymous Anonymous said...

hi ..after years of successful surgeries my 2 recent complications made me so upset and defeated . self blaming,loosing confidence hit me hard...after reading your blog stated with all honesty ,i felt you have statde the state of mind i am in today...thanx for the healing words ...i am not quitting and have renewed my confidence


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