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A surgeon's primer of errors

1990; Elsevier BV; Volume: 12; Issue: 1 Linguagem: Inglês

10.1016/0741-5214(90)90381-j

1097-6809

W. Andrew Dale,

History of Medical Practice

The article that follows is not precisely in the mold of the scientific essays that, by Editorial policy, make up the contents of the JOURNAL. It was the Editor's opinion, however, that its facile exposition of the wit and wisdom of a pioneer of vascular surgery should be placed before our readership. The younger surgeons should profit from it and the older surgeons will enjoy the recognition of many of their own thoughts delightfully told. None of us live without error. I propose to discuss errors that are common to us as surgeons and as people, classifying these as those of knowledge, preparation, experience, attitude, and leadership along with those of recognition and judgment, and of ommission and commission. The illusion of knowledge based on what is currently perceived as common sense, along with traditional myths of the time, has been an obstacle to discovery throughout history. The heroic and imaginative thrusts of the great discoverers have repeatedly overturned such illusions. Viewed against the background of accepted dogma of their own time they prove the innovative intellect of those giants. Thus in the sixteenth century it was accepted that the earth was stable and unmoving—the center of the universe until Nicolas Copernicus suggested in 1540 that the teachings of Ptolemy and of Aristotle were erroneous. You will recall medical illusions of knowledge, such as the practice of blood-letting for numerous illnesses, including the peritonsillar abscess of George Washington, whose death was probably due to iatrogenic blood loss. More recently, Nobel Prize winner Robert Millikan in 1923 pronounced “there is no likelihood (that) men can ever tap the power of the atom;” President Grover Cleveland vowed “sensible and responsible women do not want to vote;” and baseball centerfielder Tris Speaker in 1921 noted that “Babe Ruth made a big mistake when he gave up pitching.” My own worst illusion occurred in 1951 when I did not follow the suggestion of my teacher and friend. W. J. Merle Scott, himself an innovator, that I should go to hear Arthur Voorhees present his then new study of the fabric Vinyon-N to replace the canine aorta. I dismissed as far-fetched one of the most important papers ever presented to the surgical world. The significance of synthetic graft replacement of the dog's aorta escaped me at the time, yet proved to be the seminal discovery that launched the rapid evolution of arterial replacement. By the time this dog had carried such a graft for 7 years, vascular replacement had become widely accepted. An illusion of knowledge often affects an expert in a restricted field who assumes a similar expertise in other areas where he is actually naive and credulous. Such are known to us in terms of respected surgeons who become ridiculous figures in the world of theology, or who fail miserably at finance. It is one thing, however, to pontificate as a Monday morning quarterback concerning a sports team and another to advise remedies for social and economic, to say nothing of political problems, without a data base or experience. On the other hand, there are issues that we should address rather than pass all responsibility to others. Recall the reluctance of our profession to accept insurance programs, the reluctance to help write Medicare legislation, and the still continuing widespread belief that we cannot help solve the malpractice crisis. Many of us today act as though the serious problems of health care are entirely beyond our control. However, surveys show “that the American public still holds physicians in high esteem” to the extent that we may participate in deciding future programs if we espouse sensible and sound policies based on facts rather than mere hope. It is certainly an error to concede these decisions to politicians and social planners without our own active participation. Authoritarianism is an outgrowth of the illusion of knowledge. Accomplishment and age promote such dogmatism. Its antidote is a balanced skepticism, which questions established concepts, searches for explanations of paradoxes, and looks for new approaches. These are the characteristics of youth. They lead to the idea that our institutions and organizations would do well to bring on new leaders sooner than is customary today. Whether they be senile senators or senior surgeons, let the older heads contribute their knowledge and experience, but give way to the energy and ideas of their younger, energetic, and imaginative successors. The authority developed by knowledge and experience is often (and even usually) correct, but healthy skepticism is worthwhile. Herman Pearse taught this to me as a junior resident. To my question of why he did not follow the method of a famous surgeon who reviewed his background of 28,000 cases, he replied “Did you consider that perhaps he did it wrong 28,000 times?” We must agree with Archbishop Leighton, “Deliver me, O Lord, from the errors of wise men, yea, and of good men.” Errors of preparation. The Boy Scout motto of “Be Prepared” is an excellent beginning for the surgeon who must be ready for whatever lesion may be present under a variety of circumstances. Hence the need for study of rare as well as common problems before they are encountered. For who can foretell one's first cardiac massage or tracheostomy? Who can predict whether you or I will ever face a damaged portal vein. These and other acute problems require prior study, to the point that management will be at the level of a reflex triggered by the event. Preparation of the physical body is today at a higher level than ever before. But the resident who essentially collapsed after 6 hours of an unexpectedly difficult and prolonged operation made a difficult excuse in his habit of a cup of coffee as his only breakfast. The surgeon whose stamina fails when immediate reoperation is needed can hardly defend his failure of bodily preparation over the years, for stamina comes from regular repetition of hard conditioning of one or another sort. A sedentary surgeon or one who requires nicotine boosts during his day flirts with the charge of failure to prepare. Moral preparation nurtured in youth and cultivated without deviation throughout life is today said by some to be unnecessary. A while back one of our chiefs excused a resident—his private life is his own—but lived to see the man on page one, defending a later criminal charge. You may call me rigid, but I will not trust a surgeon who is a cheater at games, or a philanderer, or a gambler. Please give me “straight arrows!” Dishonesty in scientific research, a dragon whose smoky breath occasionally erupts, has unfortunately become known to all of us, if not through personal experience then from the front page of the Wall Street Journal. Well known examples in the vascular field include series reported without complications because the residents feared the chief's ire, or the follow-ups were simply shoddy. I can cite two such clinical series, one from your state and another from mine. Arnold Relman, editor of the New England Journal of Medicine, detected and published another, a flagrant example in 1984, which its author blithely excused. That author is well known to me and to most of you, so called “national authority” in the field where his article lied. So far it has not caused him any difficulty, since few of us read the New England Journal. The termination of surgical practice will be forced on some of us by illness or death. Yet many will survive physically beyond our time of capability. They will err by hanging on too long. You and I would probably agree that surgeons in their thirties and forties are at the height of their technical proficiency, whereas during their fifties and sixties their inevitable physical failings are for a time at least offset by experience, judgment, and acquired wisdom. For some, voluntary retirement from surgery allows redirection of energy and talent to different careers either within the field of medicine or entirely outside of it. Those who have followed this pathway testify to their satisfaction. In general they are people who have had a variety of interests. Some of our colleagues err by unreasonably resisting the advancing years. There is no certain solution for that problem. Mandatory retirement by age is too arbitrary. A better solution is yearly evaluation by a group of peers mandatory after a certain age, say 65 years. That too failed in a local case where a prominent surgeon threatened legal action and continued to work until his death. The hospital and its committee erred there when they did not forcibly retire him. We must resist such tyrants. They arise particularly among compulsive surgeons who pride themselves on their interest in surgery alone to the exclusion of everything else. Errors as a result of inexperience have placed countless ships on the rocks and surgeons into difficulties. The safe navigator benefits from the experience of others as recorded by maps and soundings. Medical practice without book knowledge parallels a voyage upon an uncharted sea. Furthermore, the surgeon must study the rare case along with the common, for who can predict what strange lesion will suddenly mimic the expected commonplace one? Sy Schwartz and I encountered such an unknown problem in 1953 in Rochester. The tiny common bile duct of jaundiced patient was clearly unusual. The problem was beyond our combined experience. Neither could several older surgeons place the diagnosis, etiology, or treatment until a seventh and last consultant identified it is sclerosing cholangitis. We corrected our lack of knowledge thereafter. Three other similar cases have been personally operated on since then. Unfortunately little more knowledge has accumulated in more than 30 years. We must admit that no surgeon's knowledge will ever be so encyclopedic that it encompasses all lesions, their variations, and their probable outcomes. Help must be summoned from time to time. The mature surgeon does not hesitate to call for advice nor even to leave the operating room briefly or to send to the library for help. The superior surgeon recognizes that the limit of his own knowledge is not an error comparable to an attempt to blunder on without help. That is the critical mistake of the surgeon whose insecurity does not allow him to call for consultation. The necessity for a strong leader, decisions that often must be made without complete data or time for reflection, and the constant recognition of likely error encourage characteristics in the surgeon, which in their extreme produce an authoritarian, autocratic, person who relies solely on himself and who may fail to seek or heed the advice of others, particularly those who are younger or less experienced. As Ulysses steered toward the Enchanted isles between Scylla and Charybdis, so must the surgeon avoid errors of authoritarianism by listening particularly to the young. Hear my own prayer: “Lord, help me listen to the resident.” Happily, Jack Cranley of Cincinnati did just that when resident Thomas Fogarty asked him to consider use of the now-famous endovascular balloon catheter, which bears his name. Students and residents bring fresh knowledge, innovative ideas, and new approaches. They are an essential part of the modern surgical team, which today is necessary to the first-rate performance of complicated cardiac and vascular procedures that have passed beyond the powers of a single individual no matter how expert and skillful he may be. My answer to the patient's query, “Who will operate on me?” is that I will quarterback the team that will perform the procedure. Of course, simple procedures such as vein stripping may be performed alone or with minimal help. Operations of the next order of complexity require skilled technicians or residents but are still primarily a one-man show. The tertiary level of procedures including vascular reconstructions calls for an experienced team. A few personal efforts in a hospital without residents or nurses experienced in vascular surgery soon convinced me that good results are dependent on the team rather than on one surgeon. The team may be two or more experienced surgeons or it may be a senior surgeon with a specialized resident or fellow. It is not an experienced surgeon with a “pick-up team.” Could John Unitas have functioned behind a high school line? Errors of recognition of reality. Realistic recognition of the situation implies the correct interpretation of existent facts. It is difficult when the reality is contrary to one's expectation (not to mention hope). Failure to listen to the contrary opinion of others is a characteristic of persons who rely chiefly on their own evaluation of facts. Historian Barbara Tuchman has recently recounted the errors of political leaders and their societies who discounted sound but adverse advice with disastrous results as long ago as the Trojan horse and as recently as the Vietnam fiasco. The same problems of evaluation effect the surgeon. During the postoperative period it is considerably more palatable to believe that fever is caused by a drug reaction than by an infection, that nausea is due to the anesthesia rather than to intestinal obstruction, and that an absent pulse is a result of spasm rather than thrombosis. In this regard let us remember Norman Rich's Vietnam Rule that arterial spasm is spelled C-L-O-T. Twenty years ago we treated early postgraft ischemia expectantly, reserving active corrective measures until the morrow. Further experience shifted this to middle-of-the-night explorations, and later to evaluation and reoperation at 5 to 7 PM. More recently completion angiography and pulse examination by the fingers and Doppler has disclosed errors while the wounds are still open and allowed most to be corrected at once, thus decreasing the number of early reoperations. This policy has also led to more care during the original operation, which further diminishes the incidence of error. During the late postoperative period it may be pessimistic to search for “big trouble” when any untoward event occurs, but that error is considerably less than the larger one of delaying definitive diagnosis and treatment in the hope that “things will get better.” Errors of judgment. More precious than technical skill, which a teenager may acquire, more difficult than knowledge, which is available to all, the most prized attribute of the surgeon is judgment. It is the ultimate characteristic. C. P. Snow has defined judgment as “the ability to think of many matters at once in their interdependence, their related importance, and their consequence.” Judgment must be diligently sought and carefully nurtured by examining the alternatives before execution along with criticism of results. Judgment benefits from knowledge of the applicable facts as well as from a correct assessment of the situation. Nothing is more important than a background of vicissitudes (whose origins have been studied) along with successes (Where luck has been assigned a proper role). Critical recollection of past experiences allows realistic projection of the probable outcome of the alternatives. Consequences must be projected. When the decision is difficult and there is likelihood of error the surgeon must choose the course of action that is safer for the patient. Thus one removes the appendix if there is serious doubt, repairs an aortic aneurysm when pain suggests perforation, and performs fasciotomy if there is a question of compartmental pressure. Errors will be made, but their results should be minimized. Errors of attitude. Humans characteristically associate with peers whose interests are similar. Such informal groups tend to become structured into unions, associations, and societies. Their perpetuity is sought by recruiting new and younger members as the originals are decimated by age, death, or disinterest. Some compulsive members insist that the interests of their particular group are better than others, that its goals are higher, and therefore that its members are superior—in short that they are an elite, a term defined as the “choice” or “best part” of a group. Not only do surgeons form associations and societies whose membership is limited to those perceived as the “best”—so do bankers, lawyers, and plumbers. I note wryly that the latter hold “conventions” while we go to “meetings.” Although associations and societies and their aims are admirable, limitation of membership of numbers rather than qualifications compounds the error of elitism. Such elite groups tend to nepotism by adding younger associates and partners, relatives, and those whose backgrounds seem similar while denying others whose accomplishments and credentials do not quite fit the pattern, albeit they are leaders and have made worthy contributions. Are some of our older and respected surgical organizations now with-ering on the vine because elitism has become more important than the addition of vigorous new blood? Elitism is not far removed from arrogance, a term that has been frequently used to describe surgeons. It infers a superior feeling, a haughty attitude, and an insolence that unfortunately has some truth as a characteristic of ourselves as surgeons. A newspaper columnist such as Sydney Harris might say, “He is arrogant, you are superior, and I am proud.” A recent editorial discussed “The Arrogance of the Surgeon,” terming it appropriate for someone who dares to change the balance of nature, to accept awesome responsibilities, and even to challenge divine design. Given the need for a lead editorial with some striking aspect that month, I find the argument thin and the defense flawed. The apologia would not convince Agrippa, and I reject it. If there is arrogance let us call it an error and substitute modesty and at least an effort toward humility. I submit that the surgeon is a semiscientist. I agree with Sir Henege Ogilvie's statement “the surgeon we wish to produce...gets his patient well.” The laboratory and the library are only means to that end. I cherish a peer's description of me as a “get'em well doctor!” Another attitudinal error is lack of interest, or perhaps, an incorrect division of interest—a term used in the sense of commitment. A balance must exist between the commitment to science, to patients, to family affairs, to recreation, and to other things, but it is inappropriate for a resident to carry the Wall Street Journal in his coat pocket, or for a supposedly busy neurosurgeon to read a science fiction paperback in the lounge between cases. “Moonlighting,” that is, working a second job for pay during a residency, is a young person's error that has often been tolerated by teachers. Incredulous as it may seem there is sound evidence that a radiology resident in Nashville 1 year made more money at nights and on weekends that the chairman of his department. The error has also occurred in surgical department. The error has also occurred in surgical departments whose chiefs have denounced it and at the same time professed ignorance of its local existence. Moonlighting is a sad misuse of valuable time. Given the need for money to allow study, it would be more intelligent to earn it in a few years' practice, and thereafter to devote full time to study. Fortunately the current salary levels of residents outmodes this need—except for greed, which indeed is not uncommon. Let us place the error at the feet of those who tolerate it. Errors of leadership. Often the task of the surgeon is difficult, his skill and knowledge may be unbearably taxed by situations so surrounded by disaster that a safe pathway can scarcely be found through the Valley of the Shadow of Death. Yet he is the responsible captain. He must decide. He must commit. Such harrowing experiences lead to the belief that courage and determination are more decisive than are pure intellect or sensibility. The spirit may be perturbed, the outcome may appear disastrous, yet there is required the resolution to overcome difficult situations, to guide the team through adverse circumstances, and to install the will to follow a calm, strong lead to a successful conclusion. The surgical suite, like the battlefield or the sports arena, requires a captain rather than a prima donna. A captain, in whatever adversity he finds himself, must never display a gloomy countenance lest he dismay his followers. The surgical team responds to a calm, continuing plan of action, which gathers up the spirits of the group. There is required character nurtured in youth, encouraged in training, and steel-hardened by the vicissitudes of experience. Errors of commission. Years ago I thought that Mack the Knife was a country music star or a Mafia type. Now I say that he is a surgeon. He believes that every patient “deserves” an operation. He says that every illness is thus best treated. He argues the low risk of surgery as an indication in asymptomatic carotid stenoses and has not learned that transient ischemic attacks usually occur before actual strokes. The “Everest” syndrome persuades him to repair a normotensive renal stenosis “because it is there.” He advises a palliative procedure when there are no symptoms to relieve. Oftentimes he has thus become a quite skillful technician. Alfred Blalock advised one of his residents that every patient did not need an operation before he died. Yet we continue to hear, “We didn't know what was wrong with the old man, he was obviously ill, and so we explored his abdomen last night. There were no findings. This morning we know that he has a myocardial infarction. He is dying.” In these times we surgeons overreach ourselves. Already indications are questioned by internists and neurologists, along with a few cardiologists, most of whose complaints are, however, silenced by their complicity. The laity, business groups, and politicians are listening. They are ready to join the hue and cry against current overuse of surgical techniques. Cardiac bypass have become suspect, carotid procedures are questioned, and limb revascularizations with little chance of success are well known to all of us. Errors of ommission. Failure to use preoperative and perioperative antibiotic prophylasis would be clearly defined omission in a vascular case (or you may say to me that such represents my illusion of knowledge). Failure to remove a gallbladder containing stones after graft replacement of an abdominal arotic aneurysm is usually an incorrect omission yet not so great an error as to fail to close securely the retroperitoneal tissues over the graft before cholecystectomy. Some omissions are so fearful in their consequences that they must be avoided even if it leads to an error in the other direction. It is certainly a lesser error to remove a “cold” appendix than to allow an acutely inflamed one to rupture and produce peritonitis with its likely complications. Similarly, the ruptured aneurysm. In the past it was feared that immediate operation on such patients without time for specific diagnostic procedures would lead to numerous needless (and even dangerous) operations. More recently our immediate operation policy has resulted in an occasional error, but although a few diagnoses have been wrong, the overall results are better. Errors include emergency laparotomy for a ruptured colonic diverticulitis concomitant with an unruptured aneurysm, a laparotomy for retroperitoneal panniculitis, and middle-of-the-night operative diagnosis of pancreatic carcinoma with metastases. Misdiagnoses have, however, been uncommon and have not increased morbidity or mortality for the few patients who did not harbor a ruptured aneurysm. Mean while the high salvage rate of ruptured aneurysms confirms the immediate operation policy as correct. Eighty percent of my last 25 such survived. Misconception of expected compensation. The surgeons' rewards are large and varied. Ego is satisified by patient and peer approval. A sense of accomplishment is frequently achieved. Financial rewards are generously supported by government programs such as Medicare, whose benefits exceed even those the government provides to the tobacco grower. The expected financial rewards have made some of us greedy. Thus it is difficult to justify compensation that may reach seven figures yearly for large numbers of coronary bypasses, a procedure that has now become commonplace with little risk. If that production line has resulted in lower fees, I have failed to learn of it. The errors of exorbitant fees will probably be corrected by legislation. From time to time we all complain of the large fees received by entertainers, a term that includes athletes as well as musicians and actors. The disproportion reflects the marketplace rather than any ideal ratio that you and I may espouse. One surgeon who recently compared his own earthy rewards to that of a particular professional athlete, received a humorous as well as perceptive reply, “How many thousand people watched you operate last Saturday?” We recognize that there is no relation or competition between surgery and entertainment yet there are increasing instances of television appearances by our brethren in the guise of public education, but with only a hairline separation from self-aggrandizement. The role of entertainer ill befits a surgeon. I will not even discuss the open advertisements in which a few have recently appeared. Technical faults. Whereas errors of knowledge, philosophy, and judgment override others, we must acknowledge the technical errors that also plague us. It hardly seems necessary to discuss the surgeon who is overmatched, that is he lacks the dexterity and eye-hand coordination to perform a manual task well. He should have been shunted elsewhere while still a resident. Still you and I do encounter him from time to time. He may even be found in academia, where his manual deficiencies may be covered by his ability to speak, and where residents provide technical skill. It is very well for a committee or chief to limit his actions, but the real error lies at the foot of those who allowed completion of training and then foist a continuing error upon the community. Lack of concentration during an operation has more than once resulted in a needless technical error. Frank Spencer recently remarked concerning activities such as casual conversations, which may hinder an operation by “distracting the operating team from total concentration on the procedure.” To that I will add loud music. The operating room is a work-shop and not a nightclub. Disinterest seems an unlikely cause of trouble, yet one observes senior surgeons who freely state their boredom with so-called routine surgery and therefore read a newspaper in the lounge while a resident performs the procedure. One of our most distinguished colleague's career was terminated under such circumstances when the resident erred while he dallied in the lounge. That was a degeneration of the teaching system and a close relative of ghost surgery. As we end this primer of errors I submit that we all make them and that our best intentions fail as the high-riding heroes falter and the dreams of a young man are stolen by the years. It is the destiny of us all. I say to you that we surgeons seek a grail beyond our reach, the search for which we must eventually leave to younger hands. Our successors must study our errors to prevent their repetition, they must seek paths were mistakes are less likely, and strive for better corrections when such do occur. Now, I hear the closing music. I see the autumn leaves. I remember the be-all and the end-all of the surgeon. Once again I see the green clad figures converge on a still form beneath the brilliant overheads. Once again I hear the soft staccato calls from a thousand operating rooms—and clamp, tie, cut. I hear the call for suction and for blood. I balance the anguish of the bereaved against the happiness of the salvaged success. I bow beneath my failure and search for surer judgment, wider knowledge, and greater skill. Finally, supported by education, backed by training, and borne upward by my association with you, the reason for research and the end point for experience is revealed, I see the patient who relies on us surgeons.