The difference between complications and negligence

A patient who was minutes away from his colonoscopy, asked me how many colonoscopies I had performed. Before I could answer, he quickly followed-up asking if any of my patients developed perforation of the colon after the procedure.

I satisfied his initial inquiry when I informed him that I have intruded into at least 20,000 colons in the past 2 decades. With regard to his second and more ‘penetrating’ question, I told him, yes, there have been a few perforations. I continued the dialogue in order to place the issue in context for him and his wife so he wouldn’t be spooked before his procedure. We didn’t want a panicked patient leaping off the gurney and high-tailing through our waiting room in a flapping opened-back gown to the parking lot. Fortunately, our discussion accomplished its purpose and his procedure proceeded calmly and uneventfully.

Sure, complications matter, but numbers can deceive. Our most highly experienced physicians have likely had more complications than other medical colleagues, although their complication rate may be very low. For example, a known complication of heart surgery is the dreaded complication of a stroke. A heart surgeon, who has operated on thousands of patients, may have had 25 stroke complications. A younger surgeon, however, may have only have had 3 or 4 stroke complications in his briefer career. Which surgeon would you choose?

In addition, a doctor’s higher complication rate may reflect that he accepts more risky and challenging patients that other physicians have rejected.

Perforation of the colon after a colonoscopy is a terrible event, mostly for the patient and the family, but also for the physician. While it is rare, it is inevitable. If your gastroenterologist has never had one, he likely has very limited experience. If this is the case, don’t jump off the gurney. Recognize, however, that a perfect record doesn’t mean medical perfection.

Keep in mind that complications are blameless events. They are not negligent. If you prescribe penicillin to a patient who denies allergies, and a severe rash develops, then a complication has occurred. The physician is not culpable. However, if the patient had a known penicillin allergy, and the physician neglected to inquire about medication allergies, then the same rash is not a complication, but is the result of medical negligence. The distinction between complications and negligence is not appreciated by most lay individuals and many plaintiff attorneys.

Physicians will be increasingly tracked on various ‘quality’ measurements that will be accessible to the public. While knowledge is power, incomplete and deceptive knowledge can mislead and confuse. When you are reviewing the quality statistics on your doctor, be skeptical that this data is a true measurement of medical quality.  In medicine, what really counts can’t be easily counted.  Conversely, what’s easy to measure rarely measures up.

While poking a hole in the colon is thankfully a rare event, pay-for-performance and other medical quality initiatives have more holes than Swiss cheese. These are not complications.  It’s negligence.

Michael Kirsch is a gastroenterologist who blogs at MD Whistleblower.

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