Impact of a Devastating Patient Complication on the Aesthetic Plastic Surgeon

As a second-year resident in general surgery at New York University (NYU), I spent much of my time at the infamous Bellevue Hospital. Our Thursday afternoon mortality and morbidity conferences were simultaneously educational and nerve-racking. In those days, the individual primarily responsible for a patient’s care would present his/her case of complications or death to the assembled faculty, residents, and, frequently, medical students. As a more junior resident, it was customary to sit toward the back in the old-fashioned auditorium, where the seats were progressively elevated the farther back one went. The sessions were led by Dr Frank Cole Spencer. When Dr Spencer became Chief of Surgery at NYU, it was said that “fear came to Happy Valley.” An overly confident and brash young resident, I was appalled at some of the complications presented. At the same time, being determined never to make those mistakes, I compulsively kept a notebook, neatly labeled with the conference date, a summary of the complications, and the collective recommendations of the attending staff to prevent said complications. Armed with this indispensable canon, I believed myself well prepared when I became a Chief Resident in general surgery. I felt certain that constant perusal of my little surgical “bible” would somehow keep such unfortunate and preventable complications from happening on my watch. Much to my dismay, during my first 2 months serving as Chief Resident on the Trauma and General Surgery units at Bellevue, I encountered every one of the complications and untoward patient events I had meticulously noted during the previous 3 years. Complications can and do happen. So do unexpected patient deaths. Clearly, the impact on patients and families can be devastating. In the broader context of such situations, it is important to also consider the impact on the surgeon. Aesthetic surgeons may be thought to inhabit a privileged world far removed from the fraught existence of specialists who deal with extremely sick and fragile patients. After all, we operate on relatively healthy individuals, who, when necessary, obtain medical clearance. Our surgery is performed in the safety of an accredited facility, and, where appropriate, a qualified individual is in attendance to provide anesthesia. So, what could go wrong? The dictionary definition of “complication” is sadly lacking, particularly when discussing its meaning in relation to aesthetic surgery. So let me give you mine: an unexpected, unanticipated event, consequence, or condition that negatively impacts the course of a patient’s intended outcome. The personal, psychological aspects of dealing with complications are not taught in medical school and, at best, are picked up by osmosis during residency training. Subsequently, the newly minted surgeon is thrust into practice alone, in a group, or at an institution, and left to learn the hard way. It is inevitable that every plastic surgeon who performs aesthetic surgery will sometime during his/her career have a patient who suffers a significant complication, even death. Perhaps a pulmonary embolus, stroke, facial nerve injury, or blindness following an injectable. How will he/she handle the situation, both professionally and personally? A senior resident in plastic surgery at NYU had eagerly anticipated performing a face lift on a patient at Bellevue. During the surgery, he came across a parotid tumor on her right side. To a resident, this was manna from heaven. A total parotidectomy and a face lift on the same patient! Not unexpectedly, the patient developed a massive fluid leak which was resistant to all the resident’s attempts to stem the flow. Having seen the patient and her family on a daily basis for an extended period, he was understandably relieved when his rotation ended and he went to an affiliated private hospital, only to have the patient promptly appear at the residents’ clinic. Nevertheless, the resident was consoled by the thought that after a month he would rotate to the Veterans Administration (VA) hospital. As it turned out, however, the patient was a veteran and followed him to the VA. Although some aspects of the story may sound humorous, there is no question as to the devastating emotional toll that this sequence of events had on the young resident and his unfortunate patient. Clearly, the surgeon’s primary responsibility is to the patient and the patient’s family. This aspect of the surgical-complication scenario has been discussed in innumerable articles and books. Interestingly, the effects of a cataclysmic event have been explored far less frequently in terms of the surgeon’s own psyche. There is no question that such an event has an immediate and lasting impact in a multitude of ways—emotionally, physically, and socially—perhaps similar to being served with a malpractice lawsuit, the psychological effect of which has been investigated, with one study suggesting the possibility of a resulting posttraumatic stress disorder.1,2 There are innumerable factors that play into an individual’s response to the situation of an unexpected complication or a patient death. These include experience of the surgeon, circumstances surrounding the event, connection to patient, peer support and family situations, local news coverage, social media, and the threat of a malpractice lawsuit as well as self-esteem and confidence. Often, a critical analysis of the events leading up to a complication yields little more than second guessing. There may be a certain amount of finger-pointing: “it was anesthesia” or “the internist should never have cleared the patient for surgery.” Naturally, this sort of thinking is counterproductive. In some circumstances, it may be best to have a disinterested colleague review the circumstances leading up to the event. This retrospective analysis cannot alter the situation, of course, but may prevent a recurrence going forward and perhaps help to assuage the surgeon’s feelings of guilt. Talking with a peer may lend objectivity to the event, much in the same way as presenting an incident at a morbidity and mortality conference.3 One of my co-residents in general surgery was a technically skilled, Harvard Medical School graduate. One would think he would be an ideal surgeon. Unfortunately, he lacked confidence in his own abilities and judgment. I received a page from Jimmy late one evening. He sounded extremely distraught, having convinced himself he had neglected to oversee the duodenal stump when performing a Billroth II procedure. He asked me to assess the patient. This occurred at Bellevue Hospital in the late 1960s. In those days, there was no attending oversight, and the descriptive “see one, do one, teach one” was a reality. I dragged myself out of bed and met him at the patient’s bedside. The patient was resting comfortably. Jimmy actually looked worse than the patient, shifting from foot to foot, wringing his hands, with beads of sweat dripping from his forehead onto the floor. The patient was afebrile, his “numbers” were fine, and his abdomen soft. I reassured Jimmy and went back to bed. Two more phone calls ensued. During early morning rounds, Jimmy decided to return the patient to the OR where, of course, he found an intact duodenal stump. At the other end of the spectrum was Baron, a surgical resident from Canada who was a few years senior to me. He was known for his monumental ego and overinflated sense of self. He returned to the United States a few years later to take his American Boards in General Surgery. I happened to bump into him several months later at which time he related to me that one of his Board examiners had asked him how he would handle a colon anastomosis that leaked. He told the examiner that would never happen in his hands. He flunked his Boards. Most of us have egos, self-esteem, and confidence that lie somewhere between these extremes. Yet, as responsible, caring human beings we cannot help but experience a serious patient complication, or a death under our care, as an emotionally devasting event. Some of us will handle it better than others. As a group, surgeons tend to be self-critical. Consequently, feelings of remorse, anger, inadequacy, incompetence, depression, and even thoughts of suicide may surface. If such feelings are allowed to continue unchecked, they can profoundly impact our professional and personal lives. Proactive intervention may be necessary if an individual feels incapable, or is perceived by those close to him/her to be incapable, of managing the situation alone. One-on-one psychological counseling, short- or long-term, is an option. Additionally, there are a number of hotlines devoted to helping physicians cope with stress and other issues arising from their professional duties. None, to my knowledge, is specific to plastic surgery or aesthetic plastic surgery. One of our professional societies might wish to consider making available a support hotline for the benefit of its members who find themselves confronting unexpected complications and need advice on how to cope with the aftermath. Seeking help in such situations is nothing to be ashamed of. Rather, it is often what is needed in order to carry out one’s professional responsibility to patients and their families as effectively as possible. Dr Bernard is the founding editor of the Aesthetic Surgery Journal. The author received no financial support for the research, authorship, and publication of this article.

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