“Look at every path closely and deliberately, then ask ourselves this crucial question: Does this path have a heart? If it does, then the path is good. If it doesn't, it is of no use.” ~Carlos Castaneda

Tuesday, April 3, 2007

You are only as good as your last case ...

“If I have seen further than others, it is by standing upon the shoulders of giants.”

~Isaac Newton

Last week was a tough week, I understand it is part of the job, these weeks happen. For the pediatric orthopaedist, the summer is filled with elective cases and trauma. I understand that like most things you have good weeks and bad weeks, and as the saying goes, "this to shall pass." If you put your head down and continue to work, the next thing you know is that your done. So, long days usually don't get me down. The thing that can really be a downer on a day is when "that" patient comes in to the office. The patient that you remember like yesterday. You can remember every nuance of the patient. You remember the time, date, and room when you first met the patient. If not all then most physicians will have a patient or patients that they remember the name, medical record number and the specifics about the case. These are the patients we call our albatross. I think when those patients come into your office it can be worse than the hardest work week, because it brings back all those past memories.

There is nothing like follow-up to ruin your good surgeries. In orthopaedics, we follow our patients for years, especially pediatric patients. Sometimes the problems won't display their ugly faces until 6 months or more later. You may have one of your perfect surgeries fail; or maybe you missed a diagnosis when you first saw someone and now they require surgery. Regardless of what the cause, it causes your heart to race when you hear the name. You may loose your appetite while eating your favorite meal. We all have those patients. So how do you deal with them?

As a resident, except when I was truly wrong with a reduction or treatment in the ER, etc., I don't think I ever felt the sick feeling that you get as an attending when a problem occurs. Residency gives you that attending protection. If you are in a case that was over your head, you always have (or should have) someone to back you up. There should be an attending with the experience to prevent any major error and correct any minor deviation. But, as an attending, not so much. There are times when I am in the middle of a big case when I look up and wish someone would make the pain stop; "take the scalpel, someone, anyone. Ah, but alas, there is no one." Residency and fellowship protects you from the albatross. Usually, you are not on the service long enough to see the final outcome. Yes, you may remember bad cases and it will effect the way you approach patients and surgical cases; you will see cases at M&M and remember the specific problem; but you don't "own" them.

Over the last few years, I have learned from many of my partners experience and support. The most important thing that I have learned is not to avoid a problem. As a resident, one of my chiefs said to me, "if you think it is infected, you have to prove it is not." This was in a particular case, but it holds true for most of what we do. Each surgical case is like your child and it is very hard to see you own child's flaws and defects. So, you have to be truly honest with yourself. Phone a friend (partner) to give you an honest opinion and listen. There was a nice article written on Neurologic Risk Management in Scoliosis Surgery. It made some nice statements on dealing with the family. There are several points that are important. When you deal will patients with complications you should have honest communication with the family, see the patient frequently, document clearly, and consult others (or spread the base). When you are having problems in clinic or in the OR, these are principles to use.

Every physician has an albatross. Maybe it is an ego issue or maybe we genuinely feel for the patient and family, regardless of the emotional cause of our discomfort, you still have to treat the patient; you have to answer the calls; and you have to see them in clinic. In the end, you should "do the right next thing" for your patient. Do not let your ego get in the way of proper treatment of your patient. In the end, if you are open and honest with yourself and ask for help when you feel you are over your head, you will be a better physician. We take an oath to do no harm; don't let your shortcomings prevent you from keeping your oath.

“I claim to be a simple individual liable to err like any other fellow mortal. I own, however, that I have humility enough to confess my errors and to retrace my steps.”

~Mahatma Gandhi


Brent said...

I always look forward to your entries, because I'm in that unique position as a former orthopedic PA to remember those patients where your heart sinks when they come back and they are infected or whatever. Your like "Any one else, why this person, why the head nurses husband, or the star quarterbacks ACL re-ruptures, etc" I remember as a PA I felt that protection, but many times I still had to deal with the patient before my physician would get there or get into the room, and I would feel the anxiety, the rush you get when things don't go as they should. And if I made a mistake as a PA, I still had that "backup", but it didn't make me feel any better. It's such a nauseous feeling. I wonder how it will be as a resident or attending and if there will be any difference for me since I've experienced actually practicing in some respect having a minor part of responsiblity in patients care. I know it will still be huge adjustment when the buck stops at my door stop, but you know what they say...."if you don't have any complications from your surgeries, than your not doing enough surgery" Keep up the good work!

Anonymous said...

I remember the orthopods I worked with (all peds) talking about summer being the busy season - kids are out of school, so they get injured and/or they can have an elective surgery and rehab without missing school.

One of the cool things about peds ortho is you get to see the kids grow and (if everything goes right,) improve. That, and you get to work with kids!

No point, just thanks for reminding me.