For better or worse, doctors are human

Speaking only for myself (but guessing I’m not alone), I can say when a patient develops post-op problems, there’s a strong tendency to deny it: not to deny there’s something wrong; not to dismiss the patient’s concerns or symptoms. Just to grasp first at the less dire set of possible explanations. Maybe it’s just the flu, constipation, drug reaction. That sort of thing. It’s not about blowing it off — because I never did. It’s about hoping against hope, both for the patient’s sake, and mine. Rationalization is a powerful instinct. In reading various forums and blogs and seeing innumerable patient complaints that their doctors took a long time to take them seriously, I’d guess that in many instances the desire to believe you didn’t screw up is at work. That doesn’t excuse it: maybe it explains it to a degree. For better or worse, doctors are human. I know I am.

When I saw my patient in the emergency room, her abdomen was distended, she had a low-grade fever and a bit of a red incision, and her x-ray was the usual hard-to-be-sure early post-op belly film: possible obstruction, possible ileus (a condition of bowel laziness often seen for a while after abdominal surgery).

I admitted her, of course. Intestinal leakage — from where the bowel has been sewn together, or from an unrecognized surgical injury — is always on the list of possibilities in such a situation, but I didn’t think so here. How tender is tender? How red is too red for an early incision? She didn’t, I told myself, look all that sick. Time and a stomach tube, antibiotics for a possible sub-clinical (meaning not obvious) leak or abscess at her anastomosis ought to do the trick. Indeed, she looked better the next day. Not that “looked better” is an objective criterion.

When intestinal content began to drain from her wound after a couple more days, it all became clear. Since the point of the post is not to discuss treatment of intestinal fistula (leakage of intestinal contents to somewhere — in this case, to the skin –let me simply say I opted for the safest and most frustrating approach: high-calorie intravenous feeding, local wound care, and waiting. And waiting. With drainage, she stabilized and we both hunkered down for a long haul.

At some point, while inspecting the wound daily, I noted the suture with which I’d hooked the bowel while closing up. And I told her about it straight away. I explained why, in my opinion, going back in at this stage could cause more harm than good, and that there was a reasonable chance it could heal with no need for surgery; and that if not, it would be much easier and safer to go in after time for the reactions to settle down.

So there she was: a living, breathing testament to my failure, for all to see, for a couple of months. Each time I approached her room on rounds, I felt a tug in my gut. I imagined that everyone was talking about it, probably questioning my competence. (Years later, I sort of doubt it. But it’s how I felt, with every complication, big or small.) The lady was remarkably hardy and good-hearted. That made it a heck of a lot easier. With each visit, we talked about it, about how it was going, about our comfort levels with the current plan. Frustrated at times, stir crazy on occasion, she never evinced anger toward me. I was deeply grateful for that. She healed. I fixed her incisional hernia a couple of years later.

It’s a terrible triangle: the patient, the injury, and me. The patient first and foremost is in need. Whatever the effect on me, their situation is way worse. Yet facing him or her can be tough: It may be unspoken, but there’s the sense of permanent accusation. My shame, my guilt, my sadness all interfere with my connection. Magical thinking can keep me from facing the reality of whatever is wrong. At some level, I want the patient and his complication just to go away, because of what they say — or seem to say — about me. So, it’s complicated.

I was lucky, I guess: In those rare cases where bad things happened due to what I felt was an actual error, my patients stuck with me, and we got the problems resolved. It’s a key point, however complicated in its own right: Impossibly difficult as these situations can be, hostility from the patient only makes it worse. If my reaction is “complicated,” the patient’s is — understandably and necessarily — complex to the power of ten.

It is, of course, unreasonable and probably impossible to expect patients to hang in there no matter what. It’s like, oh, saying questioning a war emboldens an enemy. If there comes a point when you think your surgeon is simply a screw-up, it’s time to pack up and go. Yet, I’m trying to say, early on it’s at least a theoretically good idea to give him/her a little breathing room. Sometimes figuring things out takes time; sometimes problems can’t be resolved as fast as the injured party would like. Hell, they never can. I think it’s a truism that the attitude of both the doctor and the patient is crucial to how things end up when facing complications. If it’s true that the patient’s attitude is heavily influenced by their doctor’s, so is the opposite.

But, given that it’s the patient who’s the injured party no matter how upsetting (violins, here) it is to the doctor, the patient has first right of refusal to take the advice. Still: In the ideal world (remind me where that is again?), it’s immeasurably better when each side keeps his powder dry for a while.

A commenter asked had I not canceled my bill or offered to pay her expenses? It is something about which I’ve ruminated a great deal. I have generally, for example, (and despite suggestions from insurance companies to the contrary) not charged for a re-operation for bleeding — a rare occurrence. That’s a small thing. The larger question, I think, ought to be addressed in a larger way: something like flight insurance, as a top-of-the-head analogy. Patients deserve compensation when things go wrong, and it ought to be available outside of the adversarial court system. But if every surgeon — every doctor — were expected to pay out of his/her pocket for every adverse outcome, I daresay even fewer good people would choose the profession than are now doing so. I don’t have an answer.

In my view, there are three categories of bad outcomes: the ones I’ve already mentioned are those that clearly result from an error — the most horrible to face because there’s nowhere to hide. The second is imperfect results from proper and well-managed care; and the third is having to clean up another doctor’s mess. That middle one can be the most frustrating of all, posing the greatest challenge on many levels. I’ll see if I can explain it in my next post.

Sid Schwab is a retired surgeon who blogs at Surgeonsblog and is the author of Cutting Remarks: Insights and Recollections of a Surgeon.

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    Man, i’d love the see the neurosurgeon who only has 4 years residency. Requires minimum 7 years last time I checked… As it should be.

  • Carolyn Thomas

    Dr. Schwab, that “tug in your gut” when you realized your own error was, as you describe it, pretty minor compared to the literal tug in the gut of that poor patient.

    Throughout this story, we read of how embarrassing this was FOR YOU (“I imagined everyone was talking about it”), how “tough” it was FOR YOU to even approach her, how “complicated” your own distressed reactions were FOR YOU, how her good-hearted nature made it “a heck of a lot easier” FOR YOU.

    Then comes acknowledgement at last that all of this was actually “way worse” for her, and that “it’s the patient who’s the injured party” – as if that actually needed to be said! I was glad you finally mentioned those last bits, because until then it seemed as if this tragic medical incident was somehow all about you instead of all about that poor woman. (And did you say that complications went on for her for two months?!?) Try putting yourself into the hospital booties of her and all patients experiencing preventable suffering like this, and then you might have something unique to say about “bad outcomes”.

    Of course, doctors are “human” (as if that actually needed to be said, too). But it seems that docs sometimes forget the reality that it’s their equally-human patients who do the actual suffering and then the actual responding to bad medical outcomes – no matter which of the three ways their doctors choose to categorize those outcomes. The end result – for patients – is still bad. And your ultimate ruminations that guided your decision not to alter her bill or offer compensation after what she had been through tells us that, although you may have felt sincerely bad about this particular bad outcome, clearly you didn’t feel THAT bad….

    • rbthe4th2

      Oh I can say something on this, as to how the hospital management did me when their doctor clearly missed some things, as did the other doctor they sent me to. When I asserted my right by law to put in the corrections to the records and other doctors who did notice it, their response was to bully and intimidate me by sending a lawyer at me (who has stayed silent so far because I have done nothing illegal or unethical), follow me on public property, take photographs of me, calling the police on me for standing on public property (apparently indicating I was trespassing, etc.).

      It only takes ONE doctor to pull stunts like this and to be supported by hospital admin, when I never have had a lawyer talk with them, never once did anything but assert my rights under the law to get my records correct, when I’m the one who will and is paying the price both financially, in my job, & most of all – my personal life, for me to remember how much that doctor said *I*.

      *I* did what *I* thought was right.

      Didn’t ask me, didn’t talk with me, just based everything on *their* life preferences, styles, financial situation, job situation … Yes doctors are human, but when they act like this in response to human mistakes, instead of working with a patient to get it fixed, how do you think you should be treated?

  • Martine Ehrenclou

    Medicine is not a cookbook. Dr. Schwab, I really appreciate you being so honest and vulnerable in this article. As a patient, I’ve had doctors make mistakes and never tell me about it, or if I brought it to their attention, deny it at first and then call me back (probably after checking with their legal department) admit it with barely an ounce of empathy. But that was years ago. Times have changed.

    I appreciate reading what you went through with this patient. It shows compassion and empathy. I hope all physicians will read your story.

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