Can Doctors Prevent Complications?

It's harder than you think.

When I was training to be an emergency physician in a Philadelphia hospital, I spent several months rotating through the intensive care unit. I remember one particular patient that I cared for because I made a mistake in judgment and how I communicated with his family. This one was not the usual error.

Mr. Evans was a 48-year-old man who presented through the emergency department with a severe alteration in his mental status. The work-up indicated that he had, among other medical issues, liver failure due to chronic heavy alcohol intake. Alcohol is a toxin that can, over time, destroy the liver and its ability to remove harmful chemicals from the bloodstream. One of the toxins that builds up in the bloodstream is ammonia.

We tested Mr. Evans’ ammonia level in the blood, and it was quite high. On examination, he was unresponsive and comatose. The medical diagnosis for the loss of cognitive function due to liver failure is hepatic encephalopathy. This may have been the first case that I had seen who appeared in this most advanced stage of illness. He was admitted to the intensive care unit, and treatment was started.

The treatment in the short term was to start a medication called lactulose, which is a synthetic sugar, that works by drawing water into the colon. By doing so, lactulose helps reduce the concentration of ammonia in the blood. It is usually taken by mouth but in a comatose patient who cannot swallow, it must be given through a tube that goes into the stomach or the colon directly. The amazing ICU nurses get tasked with that unenviable task.

When I spoke to the family members who were visiting, I explained what the team believed to be Mr. Evans’ condition. He certainly looked, as they say to be on death’s doorstep. I told them that he was critically ill and could die within the next day or two. They were understandably upset and were going to call other family members to come. At the end of my shift, I went home to have dinner and get some rest.

Early the next morning, when I arrived to check on my patients in the intensive care unit, I could not believe what I saw? Mr. Evans was sitting up in bed, very much awake, and talking with one of the nurses in his room. Boy, was I wrong about having that certain conversation with the family?

Of course, they let me know it, too.

“You said he was gonna die.”

“I am happy to report I was wrong about that,” I sheepishly admitted. I also apologized for worrying them prematurely.

I learned a lot from that mistake. I needed to know a lot more about what I was talking about before I informed a family about the timing of the end of life. I certainly needed to know a lot more about the course and treatment of hepatic encephalopathy.

All doctors and nurses make mistakes, and the procedures we perform certainly have complications, even when performed correctly. Our goal is to put procedures and systems in place that minimize mistakes because our mistakes can harm people. One of the most thoughtful explorations of this theme is by Dr. Atul Gawande.

During medical school and years of general surgery residency, when the rest of us were struggling to show up with clean clothes and combed hair, Atul Gawande kept a journal and crafted the tales of his experiences and special interests.

The essays he wrote were published in The New Yorker and later, in 2002, compiled into the book Complications: A Surgeon’s Notes on an Imperfect Science (Metropolitan Books), the first of Gawande’s many books.

As the son of two physicians, he saw the pleasures and pitfalls of the practice of medicine from an early age. Lucky for us, he has shared his prodigious talents as an author, surgeon, professor of public health studies, and entrepreneur.

Gawande divides the book into three sections that correspond with the general topics of his essays and anecdotes. The first section, titled “Fallibility” includes several personal experiences and insights from the early days of his residency. Fallibility means the tendency to make a mistake or to be wrong. It is something that can happen everywhere, including in medicine.

Some fallibility arises from there being a learning curve for every skill, particularly those in surgery. Gawande’s own experience of central line insertion is highlighted in an early chapter. Subclavian central line insertion is difficult to do correctly the first time (particularly before the advent of bedside ultrasound).

For a physician to learn how to do a central line, he or she must have the first patient to try it on. Gawande missed his first three times and worked himself into quite a funk before a supportive senior resident talked him through a successful attempt. He discusses the concerns that arise as to which patients receive care from the inexperienced versus the experienced practitioners. Regarding the training of physicians, he writes,

“We want perfection without practice. Yet everyone is harmed if no one is trained for the future.” (page 24)

Fallibility occurs in even the most experienced doctors, and Gawande reports in the chapter “When Good Doctors Go Bad” on one orthopedic surgeon who became so careless that he was no longer allowed to practice. Unfortunately, his colleagues let him continue for quite a while, even when they had concerns about multiple complications.

The author explains the uncertainty of medicine and how it can take a long time to see a pattern of truly irresponsible behavior as opposed to just having more complicated cases. Gawande makes the point that the discipline of physicians works best when it is done by a group outside the peer group or employer because it is more objective.

Gawande candidly shares a painful personal experience with a difficult patient airway and the deadly delay he caused while performing an emergency tracheostomy. He found himself full of guilt and shame as he sat through a discussion of the case in a weekly Morbidity and Mortality (M & M) conference at his hospital. He observed,

“In fact, the M & M’s ethos can seem paradoxical. On the one hand, it reinforces the very American idea that error is intolerable. On the other hand, the very existence of the M & M, its place on the weekly schedule, amounts to an acknowledgement that mistakes are an inevitable part of medicine.” (page 62)

The second section of the book, entitled “Mystery,” relates several stories of unusual signs and symptoms that are not easily explained or treated. Gawande includes events such as blushing, nausea, and pain. In each of these cases, the doctors could not explain why the patient had the condition. Much of the time, the patient just wanted the doctors to believe them and take their problem seriously.

The patients were more willing to accept that there was no conclusive medical explanation than the doctors. The physicians had trouble accepting that the diagnoses remain elusive. Both lay people and physicians will enjoy Gawande’s telling of the medical mysteries.

The final section, “Uncertainty,” addresses the problem doctors have when it comes to making an important decision, like making the right diagnosis or making choices on a course of treatment. He discusses the declining use of the autopsy.

The autopsy is one way for physicians to determine what was actually wrong with the patient. It is the final way to get rid of uncertainty and to instruct doctors on how to recognize such conditions in the future. He laments that autopsies are done less and less either because physicians no longer request them, the costs involved, or the family of the deceased are opposed to the procedure.

Another recurring point of discussion is the decision-making power of the patient. Gawande notes that patients have become more proactive in their desire for decision-making ability, but they are much more ambivalent about exercising it. In situations of great uncertainty, patients do not feel comfortable or emotionally able to make tough decisions. Some do not think they can handle the responsibility if it turns out to be the wrong decision.

Gawande notes that doctors prefer to make tough decisions. One of the skills the author had to learn as a resident was how to persuade patients to make the decision he thinks is best. He clearly developed a classical paternalistic approach to the physician-patient relationship as the son of two physicians and a general surgeon in training. Nearly twenty years later, as our patients go online to read reams of medical information and misinformation, the ongoing challenge for physicians is to determine what the patient wants and to collaborate on the plan.

Readers will find Complications to be accessible with the medical topics explained clearly. At the time of publication in 2002, the essays may have felt to the lay public to be shockingly honest and insightful “behind the scenes” accounts of what was happening in the American medical system. Healthcare professionals know all too well what Gawande speaks and, like me, may reflect on the mistakes we have made along the way.

The perfectionist tendencies we curate so skillfully to become professionals will often leave us feeling inadequate and unworthy. As human physicians, we are susceptible to mistakes and uncertainty while considering the many tests and treatment options that lay before us.

He writes,

“No matter what measures are taken, doctors will sometimes falter, and it isn’t reasonable to ask that we achieve perfection. What is reasonable is to ask that we never cease to aim for it.” (page 73)

As an emergency physician faced with high-impact decisions and tons of uncertainty, I identified strongly with Gawande’s feelings of guilt and remorse over the mistakes that he made. The spotlight he has shone on medical errors through his many essays and books, such as The Checklist Manifesto, has surely opened this discussion and reduced the incidence of mistakes.

As just one notable quote from the book illustrates, Gawande exposes himself and his medical colleagues as not quite the scientific and infallible beings glorified in the movies and on television.

“The fact is that virtually everyone who cares for hospital patients will make serious mistakes, and even commit acts of negligence, every year. For this reason, doctors are seldom outraged when the press reports yet another medical horror story. They usually have a different reaction: That could be me. The important question isn’t how to keep bad physicians from harming patients; it’s how to keep good physicians from harming patients.” (page 56)

Yes, indeed.