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The orthopaedic ostrich: surgeons’ responses to complications Deepa Bose
This article is an abridged version of the winning entry for the 2021 Robert Jones essay competition.
“Science does not, ostrich-like, bury its head amidst perils and difficulties. It tries to see everything exactly as everything is.” – Garrett P. Serviss
Deepa Bose is a Consultant in orthopaedic trauma and limb reconstruction at the Queen Elizabeth Hospital Birmingham. She is Vice Chair of the Specialist Advisory Committee for Trauma & Orthopaedics, and the lead for CESR application reviews. She has also contributed to the revision of the curriculum. She holds an MSc in Medical Education and is a member of the Academy of Medical Educators.
Complications are an inevitable part of surgery. It is said that if a surgeon has no complications he or she is either lying or not operating.
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urgeons respond in different ways to post-operative complications; denial, anger, despair and acceptance. These are perfectly understandable if one considers the surgeon as a craftsman. Any craftsman is wont to take criticism of his or her creation personally. It is this perceived apportion of blame which can result in surgeons “burying their head in the sand”, as ostriches are said to do, when complications occur.
What is a surgical complication? “History as well as life itself is complicated - neither life nor history is an enterprise for those who seek simplicity and consistency.” – Jared Diamond (Collapse: How Societies Choose to Fail or Succeed) What constitutes a surgical complication? Whilst there is a broad understanding that it refers to an adverse event, there is no consensus, although many attempts have been made at a definition. Dindo and Clavien1 propose the definition “any deviation from the ideal post-operative course that is not inherent in the procedure and does not comprise a failure to cure.” They divide negative outcomes after surgery into 1) Sequelae (a natural result of surgery, for example a scar); 2) Failure to cure (the purpose of the surgical intervention was not achieved) and 3) True complications. Other authors have adapted this to different surgical specialties, including orthopaedics2. Visser et al.3 highlight the wide variation in and subjective nature of what surgeons report as complications. Interestingly, Woodfield
22 | JTO | Volume 09 | Issue 03 | September 2021 | boa.ac.uk
et al.4 found that when patients reported complications themselves, there was a rate of over 40%, and that many of these, although clearly of significance to the patient, would not have otherwise been identified. The notion of a surgical complication is closely linked to medical negligence in the minds of the general public and medical practitioners alike. Negligence, however, has a very specific definition whereby a duty of care must have been owed and the breach of which resulted in harm to the patient. This association in the minds of patients and surgeons is difficult to escape, and goes some way to understanding the reticence in acknowledging a complication.
Surgeons’ responses to complications “Every surgeon carries within himself a small cemetery, where from time to time he goes to pray—a place of bitterness and regret, where he must look for an explanation for his failures.” – René Leriche There are numerous documented accounts of the negative impact complications have on surgeons’ wellbeing, and therefore on patient care5,6. These authors found that emotional reactions range from anger and guilt to performance anxiety and fears about one’s surgical career. Furthermore, although the intensity of such feelings dims with time, there are a few cases that haunt surgeons for many years; this is the basis of the quote above by French surgeon René Leriche, a popular one amongst surgeons. Wu7 has coined the term “the second victim” for the physician affected by an adverse event, although some
