Clinical

Is a perfect practice obtainable?

When I was a resident, one of my attendings sat me down and tried to elucidate what he considered my “unreasonable” expectations for excellence and perfection.

He asked me how many patients I planned to see each year and to write this number down (I proceeded to write “4,000”, a complete guess).  He then asked me whether I was going to have 100% perfect outcomes and 100% satisfied patients and of course I said no, but I didn’t have a clue as to how many ‘less than ideal’ outcomes I might have or how many ‘unsatisfied patients’ to expect. He suggested 3% as a ‘reasonable number.’  So he asked me to multiply 4,000 patients by 3%, giving me 120 patients (which I also jotted on my paper).  He then asked me how many years I thought I was going to practice orthopaedics, and I answered with: “perhaps 35 years”.  He then asked me to multiply 120 x 35, giving a result of 4,200 patients.  He instructed me to write this number down and to look at it carefully.  He proceeded to inform me that I would have either 4,200 unhappy patients or 4,200 subpar outcomes over the course of my career.  And that this “number” was something I needed to accept.  This concept and estimate were truly mind-boggling.

I have now been in practice 2.5 years, so by his estimates, I should have roughly 300 “less than ideal” outcomes. Although there are a handful of poor outcomes that I distinctly remember, I certainly do not think I have had several hundred.  However, there may be patients and families that were unsatisfied with their care, but I may simply be unaware.  Although I understood his teaching point, learning to accept ‘subpar outcomes’ remains difficult.

My first ‘bad’ outcome occurred in a lovely teenage female with a middle phalangeal neck fracture which extended into the shaft.  She started with a really malrotated finger and after a closed reduction and percutaneous pinning, she still ended up with a malrotated finger, albeit less pronounced from where she started.   When I saw her in clinic at the 4 week appointment for pin pulling, I was absolutely devastated.  She didn’t mind in the slightest, and thought it was ‘kind of neat,’ to use her words, but I dwelled on it for months.  To be honest, I am still concerned about taking someone with a middle phalangeal neck fracture to the operating room because of this outcome, and in a pediatric practice, that can certainly be a problem.  The strange thing is, I don’t worry in the slightest about proximal phalangeal neck fractures, but have not yet figured out this weird psychology…

I also had an unbelievable postoperative Pseudomonas infection in a sweet 9-year-old female with a type III supracondylar humerus fracture that I opened.  This occurred during my board collection period and I really struggled with the fracture.  In the operating room, it was very unstable, transitioning from an extension-type to a flexion-type fracture.  I was not satisfied with my reduction and decided to open the fracture.  In the end, I’m not sure my reduction was that much better than it was when I reduced it closed.  I think I will always question if I should have accepted the alignment I had achieved with a closed reduction, and if that would have prevented the postoperative infection.

The most devastating failure I have had actually had to do with the decision-making process.  I saw a teenager with a non-displaced Bennett’s fracture and spoke with the patient and his parents about his injury.  I always print out films for them to see and understand the underlying pathology.  I remember very vividly saying that he was very ‘lucky’ as these are almost always operative.  I placed him in a cast and did not see him again until the 4-week mark.  By the time he followed up, the fracture had displaced and was now healed in a suboptimal position. At this point in time, I felt that I had lost the trust of this patient and his parents, and enlisted the help of my senior partner, who recommended surgery.  He offered to take over the management of this patient, and I happily acquiesced.  This scenario was a huge learning experience for me for several reasons.  If I really wanted to treat this nonoperatively, I should have followed him with serial radiographs and intervened the moment the fracture displaced.  I have a much lower threshold for taking these injuries to surgery right from the get-go.  I did not completely, thoroughly offer the surgical option at the first appointment and usually I take pride in the fact that I meticulously and systematically explain all of the options in full detail.  I admittedly simply cursorily brushed over the surgical alternative.  I also learned that it is wonderful to have a senior mentor who is willing to help out in these situations and ‘lean on’ for support, both in decision-making and execution, if necessary.

With regard to “unhappy” campers, I have been fortunate to develop very good rapport with the vast majority of my patients and their families.  I would like to think that I have ‘above average’ bedside manner (and many of my patients have gone out of their way to indicate this).  Perhaps because of this quality, even when outcomes are not as ‘perfect’ as I would like, families are remarkably kind and compassionate, and are often more understanding than I am (admittedly, I am my harshest critic).  I think the ‘luck’ I have had with these interactions is due to laying out appropriate expectations, discussing all risks and benefits (and not painting everything in rose color), and communicating effectively every step of the process.

Most of us surgeons are of the ‘type A’ variety and set the highest expectations for ourselves.  When our decision-making proves less than ideal, or our surgical outcomes are not perfect, it is difficult for us to cope.  I know that I will have some subpar outcomes and perhaps unhappy patients throughout my career, as no one is ‘perfect.’  Perhaps it will become ‘easier’ to come to terms with these situations as I become more experienced.  I have a feeling that I will always struggle with these difficult scenarios and they will continue to be a burden on my shoulders.  What I will always try to do, however, is strive to provide the highest quality care, keep an open line of communication with my patients and hold their hands through challenging times, explain to the best of my ability all of the possible options and outcomes, and continue to learn and improve each and every day.

I understand now what my former attending was trying to convey, and that in reality, I agree with his assessment that perfection does not exist in medicine.  But isn’t striving for perfection what makes a good doctor?

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Dr. Samora is a pediatric hand and upper extremity surgeon at Nationwide Children’s Hospital and clinical associate professor at The Ohio State University in Columbus, Ohio. At work, she loves taking care of children with congenital differences and traumatic injuries. At home, she enjoys spending time with her family, exercising, watching movies, and more recently, has been watching her son play in tennis tournaments, and her daughter participate in swim meets.

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