It's Complicated

Whether it is getting a speeding ticket or burning dinner in the oven, complications are inevitable. We do, however, learn from them: go slower on that street, lower the oven temperature next time.

The same holds true for complications in surgery and medicine. There are basically three types of complications that we experience as surgeons:

1. Iatrogenic complications from doing something incorrectly. This can be part of the learning curve of novice surgeons or it can be incompetence for those who do not learn from these missteps.

2. Complications that occur when the standard of care is followed. The surgery can go perfectly, but noncompliance on the part of the patient or caregiver can cause problems.

3. Unusual, random problems that are not under the control of the surgeon or patient. Several years ago, I performed a facelift on a patient who developed pyoderma gangrenosum. I did a really nice surgical procedure and the patient was extremely compliant, but Mother Nature threw us a curve ball.

Rare, Lucky, or a Lie

Another variable: A given procedure may work great in the hands of one surgeon but fails in the hands of another. The take home here is “dance with the one that brung you.” In other words, stay with procedures that you do well and avoid procedures that are less predictable in your hands.

In the face of complications, we have all said, “I’ll never do that again!” When I say “embrace your complications” I mean that you should document them, learn from them, and teach from them. I give a great lecture on cosmetic facial surgery complications not because I have so many or am a complications expert, but because I meticulously take pictures and video and document these cases. Sometimes when I give this lecture people may think, “Wow, this guy has a lot of complications.” My complication rate is actually low, but my excellent documentation of cases spanning three decades tells a longer story. It is easy to forget about cases that did not go well.

If you find the doctor that “doesn’t have complications,” you either found a rarety, a lucky soul, or a liar. If you operate, you will have complications. I have performed more than 1,000 facelifts and do several per week. When compared to another surgeon who does 10-12 facelifts a year, I will statistically have more complications. Busy doctors see more complications due to sheer volume. Also, for some procedures, I have a reputation (as do many other docs) for fixing problems from other surgeons. This means that I am seeing patients who already had complications at the hand of another surgeon. These cases are more complex and, hence, can yield higher complication rates.

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I once read an article that started off by saying a certain doctor had 85 percent of the patients he operated on die. The article also referenced a hospital where 90 percent of the patients admitted died before discharge. This certainly got my attention, but upon reading further, the surgeon only operated on terminal cancer patients and the hospital solely provided hospice care for terminal patients. As they say, “the devil is in the details.”

Caring, competent surgeons should not be embarrassed about discussing their complications. Instead, they should study each case to investigate what exactly went wrong and how it could be avoided in the future. If their cases are meticulously documented, they can be used to enlighten others to help them avoid these mistakes.

What Can We Do To Make You Happy?

So much can be learned (especially by students or novice surgeons) from experienced surgeons who don’t allow their egos to get in the way of education. If I did something that affected a surgical outcome and I can transfer that knowledge to a student, intern, resident, fellow, or new surgeon, I have done them (and their future patients) a huge favor. I have helped them possibly avoid that problem and potentially saved a life. Like the saying goes, “Those who ignore history are doomed to repeat it.”

There are several other layers to complications that include patient relations, legal and financial implications. All patients deserve the right to an accurate, blunt, and to-the-point informed consent. There is no place for sugar coating here. Conventional wisdom holds that a problem that was discussed prior to surgery is a sequela where a post-op problem that was not discussed before surgery is a complication. Informed consents should be dynamic documents that can be easily edited to conform to contemporary changes, such as medicines, anesthesia, and governance. Filler patients must be aware that they could lose vision from treatment. Surgical patients must realize that death is a possible outcome from anesthesia.

If and when a complication occurs, the patient must be informed about what is happening and the standard of care options. If a facelift patient experiences necrosis or flap breakdown, they must be walked through the possibilities of treatment from wound care to hyperbaric oxygen therapy, among other options.

In the aftermath of a complication, the first question we ask the patient should be, “What can we do to make you happy?”

Patients who experience complications warrant special treatment. Many lawsuits occur because the surgeon backs away from the responsibility and attempts to deny or transfer blame. Sometimes a simple statement—“This happened, it was discussed before surgery, I am sorry it happened and I will do everything in my power to get you through this.”—goes a long way and keeps lawyers out of the equation. In addition, lawsuits can occur from not bringing in a second opinion. Patients who sustain significant complications should be offered the opportunity to see a colleague to get a second set of eyes on the problem.

Do What Makes Cents

Finally, there is a fine line involving complications and refund requests. Patients who experience complications may ask or feel the right to a refund. There are many ways to look at this, and it varies from simple disappointment and lost investment to extortion. Although this is a complicated subject, my basic advice for doctors faced with this is to simply refund the patient. If any monies are refunded, it is imperative to have a formal legal release (varies from state to state) that delineates that the refund is in the interest of patient relations and is not an admission of wrongdoing. The legalese must also go on to say that the patient agrees not to defame the surgeon or office in any manner including on the Internet. If a patient requests a refund, it should be handled by the manager, not the surgeon. Sometimes they may only request a part of the original fee. In the several times in my career that I have been confronted with this, we refunded what they wanted up to the sum of what they paid for their surgery. You can argue a lot about it not being your fault and not refunding, but most patients know they can file a suit which at the very least will force a doctor into a settlement. Having it your way and not refunding may sound like the right thing to do, but after the third day of missing work and sitting in depositions, you will wish you opted for the refund. Sometimes it just makes sense and cents to put something behind you and move on.