Sunday, September 21, 2014

Medical Complications Torture Doctors Too

If you are a physician like me who performs procedures, then rarely you will cause a medical complication.  This is a reality of medical life.  If perforation of the colon with colonoscopy occurs at a rate of 1 in 1500, and you do 3000 colonoscopies each year, then you can do the math.

Remember that a complication is a blameless event, in contrast to a negligent act when the physician is culpable.  These days, for many reasons, an actual complication is confused or misconstrued as an error.
Some complications are more difficult on physicians than others.  For example, if I prescribe a medication and the patient develops a severe rash, I do not feel personally responsible.  It’s the drug’s fault.  However, when I perforate someone’s colon as a medical complication, I feel responsible even if this act was a blameless event which will occur at a very low but finite rate.  (Of course, there are perforations of the colon which result from medical negligence, but I am leaving these aside to make my point here.)  

I Didn't Cause This Rash.  The Drug Did It!

I feel responsible because my hand was on the instrument that caused harm.   I can’t as easily blame the scope, as I blamed the rash-causing drug.   I’m sure that surgeons feel the same painful emotions when they perform a routine operation and serious bleeding results that requires additional surgery and complicates what should have been an uneventful recovery.

When your hand is on the colonoscope or the scalpel, and the unexpected happens, it’s an awful experience for the doctor even if we have performed according to proper medical standards.
Of course, serious medical complications are much more difficult for the patients and families involved than they are for us.  But, we physicians suffer greatly when a patient is harmed from a procedure that we recommend and perform.    You can imagine how we torture ourselves with second-guessing when these events occur.

Complications are inevitable.  The only gastroenterologist who hasn’t had a perforation of the colon is one who is brand new.   So, if you are drawn to a gastroenterologist because he has a 0% perforation rate, caveat emptor!   Paradoxically, the most experienced colonoscopists have accumulated many more complications over their career because of a much higher volume of cases or that they are referred very challenging cases by virtue of their skill and experience. 

A medical complication is an especially difficult event when it occurs in what was expected to be a routine outpatient examination.   Patients who come to our office for a screening colonoscopy understandably expect to be home 2 hours later.  So do we.  On those rare occasions, when this recovery path is altered, we must have a very serious, sober and unexpected conversation with the patient and the family.  Our plan is always to tell the truth and reassure all involved that we will do all that we can to make it right. 

Medicine is not a simple or predictable endeavor.  Sometimes, it can be rather complicated.

6 comments:

Barbara said...

I fear it is about to become far more complicated with the integration of "alternative therapies" and "holistic medicine therapies". Lumped under the term "Integrative Oncology", it is even showing up at the cancer centers. All I see is the medical establishment providing unnecessary practices for hypochondriacs who are miraculously "cured" or even slightly helped by quackery on occasion, because the establishments are lured by the lucrative addition of "complimentary medicine". I'd love your opinion of the article at a site I'm happily investigating called sciencebasedmedicine.org. The article is here: http://www.sciencebasedmedicine.org/announcement-integrative-oncology-really-the-best-of-both-worlds/?utm_source=rss&utm_medium=rss&utm_campaign=announcement-integrative-oncology-really-the-best-of-both-worlds

I'd also love to know your opinion of the medical facilities that are offering this add-on.

Barbara said...

Don't miss this one: http://www.sciencebasedmedicine.org/quackademia-update-2014/?utm_source=rss&utm_medium=rss&utm_campaign=quackademia-update-2014

Michael Kirsch, M.D. said...

Thanks, Barbara. I read through the article. I'm in Cleveland so I know all the players. My opinion on the integrative stuff is what you would expect, and has appeared on this blog. While I do not suggest what practitioners of western medicine have all the answers, at least is demands medical evidence produced, when possible, by the scientific medicine. The integrative/holistic enterprise is market driven, in my view, to respond to a growing hunger for alternative healing by the public. Strangely, the public demands no evidence of efficacy and is pleased to rely upon junk science or a few anecdotes. No FDA approval needed, which these companies are grateful for. Why would they want to subject their treatments to objective and rigorous scrutiny?

Barbara said...

They will eventually have a day of reckoning. It's going to be costly in more than one way. A sad era for medicine has arrived when we should be celebrating the real achievements. Thanks for your always honest answers.

Anonymous said...

I don't think that you can paint all of alternative/holistic/integrative medicine with one big broad brush.
I am an MD who suffered for many years from a mild case of chronic fatigue syndrome. I would have what seemed to be a mild cold, with a little scratchy throat and fatigue, on and off for years. The wife would say, Go to the doctor, and I would reply, I am a doctor, and they have nothing to offer me. (I read the chapter in Harrisons, multiple times over the years.) To humor her, I went to several doctors, and indeed, they had nothing to offer.
Then, this year, someone gave me a copy of a book written by some quack up in Michigan, David Brownstein, and I ultimately decided that I was desperate enough to try his anecdote-driven medicine, and guess what, I am already 50% better. Maybe I will pay for it in the long run, but I couldn't keep laying around on the couch each and every evening.
Evidence-based medicine is a nice mantra, but there will never be enough randomized clinical trials filling all of the niches in medicine. Furthermore, evidence comes from money -- big money -- and no blockbuster drug will ever be made from vegetable juice, vitamin B6, or DHEA.

Michael Kirsch, M.D. said...

Anonymous comment appreciated. I completely agree that the presence of 'medical evidence' does not guarantee healing. Conversely, the absence of evidence does not meant that the treatment will be ineffective. I am happy to hear that you found a treatment that is helping you. I presume that we both agree that the pursuit of evidence should be the desired avenue and that selecting treatments that have not been tested should be done with appropriate skepticism. While an anecdote may have value, it is not sufficient for declaring a therapy as effective.

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