AAOS Bulletin - October, 2005

Coping with complications: A recurring medical liability theme

By David E. Attarian, MD, and Laura L. Forese, MD

Delays in diagnosing complications and failure to take adequate action are common themes in many medical liability lawsuits. Knowing this, one would think that physicians would take great pains to look for these complications and take appropriate action.

But in many cases, physicians do exactly the opposite. They deny the possibility of the complication, thereby delaying the evaluation and treatment that could eliminate, reduce or ameliorate the clinical problem.

As a group, physicians are goal-oriented perfectionists. According to Gabbard, they have obsessive-compulsive traits and anticipate that each and every patient will benefit from the services provided.1 Physicians believe that in every patient encounter, their knowledge, expertise, and hard work can solve the patient’s problem. Failure or mistakes are not options. This is the physician’s starting point. Add to that the ubiquitous, daily stresses that physicians are increasingly experiencing, such as loss of professional autonomy, increasing subspecialization, more complex technology, increasing workload, decreasing income, increasing practice expenses, declining public esteem and escalating risk of litigation. It’s no wonder that many physicians have expressed being temporarily or briefly overwhelmed by their professional responsibilities and pressures.

The inner conflict that arises in this environment may induce a coping mechanism that will ultimately lead to delays in diagnosis or failure to act appropriately in certain clinical situations. Specifically, some physicians cope by unconsciously denying that the patient is experiencing a complication or poor outcome. “Bad things can only happen to other doctors’ patients, not mine,” they think. A physician who is already pressed for time and energy looks for any opportunity to avoid one more hassle in an already busy schedule. This avoidance of reality by retreating from possible complications inevitably leads to unfortunate consequences for the patient as well as the physician.

Example: TKR infection

A 66-year-old woman has a routine total knee replacement (TKR) for osteoarthritis. Her initial postoperative course seems uncomplicated but she never stops complaining of pain and swelling. Three weeks after surgery, she complains of a low-grade fever. In the office, her physician sees that the knee is healing without drainage but the entire leg is red and swollen. The surgeon orders a complete blood count, which reveals a white count of 11,500. He also orders a venous duplex, which shows no deep venous thrombosis, just soft-tissue edema. The surgeon advises the patient that everything is okay. When she asks him about infection, he tells her that he has never had an infected total joint in his practice.

At six weeks after surgery, the patient returns, still complaining of pain, swelling, redness and stiffness. Her radiograph is unremarkable. She is doing everything the surgeon has requested, including elevation, ice packs and participating in the prescribed physical therapy. Her knee motion is only 5 degrees to 70 degrees. Her temperature in the office is 100F.

The following week, the surgeon performs a manipulation under anesthesia. He continues to reassure the patient that she does not have an infected joint. At three months, the patient feels no better and seeks another opinion. The consulting orthopaedic evaluation reveals grossly elevated sedimentation rates and C-reactive protein levels. Knee aspirate cultures grow methicillin-resistant Stapholoccoccus aureas (MRSA). A two-stage revision is advised and carried out by the consultant orthopaedist. The patient eventually requires knee arthrodesis for an inability to eradicate the infection. She sues her primary orthopaedic surgeon for negligence in diagnosing and treating the infection.

Obviously, the primary orthopaedic surgeon had been trained in how to identify and manage infections in total knee replacements. And, although it may be possible that he had never had a patient with an infected total joint, surely he knew that he could have one. What could have led him to miss something so obvious in retrospect?

This physician was in total denial that his patient could be having a problem. The patient gave him ample opportunity for intervention but the physician kept wishing that this was not really an infection. Perhaps he simply didn’t like this patient and so tried to avoid dealing with her. Perhaps he felt so stressed by other events in his personal or professional life that he could not face having one more problem. Regardless of what his reasons were, he clearly missed an opportunity to address a serious problem.

Communicating concern

John R. Tongue, MD, has frequently reported on the Bayer model for communication with patients (see AAOS Bulletin, April 2003). Research shows that patients want to be engaged in the process and taken seriously. Patients intensely dislike the feeling of not being heard by their physicians. Even worse is feeling abandoned. Patients often cite abandonment as a reason for pursuing litigation. A physician who unconsciously denies a complication is likely to be sending out signals to the patient that state, “Go away. Your problems are not serious.” The patient hears, “I am abandoning you.” In the example above, the patient assumed that her primary surgeon did not take her seriously and got so fed up that she sought care from another physician.

Because bad things sometimes do happen to patients, physicians should not only be aware of possible complications, they should do everything possible to avoid the perception of being too busy or unconcerned about the patient. If something does go wrong, a patient who thinks that the physician did not care is more likely to pursue litigation.

Example: Deep venous thrombosis

A 35-year-old man has an outpatient arthroscopy for a medial meniscal tear. The procedure is uncomplicated, with a tourniquet time of 15 minutes. Two days after the procedure, the patient calls the surgeon’s office complaining of knee and leg swelling but with no fever or drainage. His pain is mild but persistent. He is advised to elevate his leg and knee, and place ice packs on the knee three times a day.

On the third day, he calls again and is reassured that his recuperation, although somewhat slower than usual, is still on course. The fourth day after surgery is a Friday, and the patient calls again with further complaints of a very swollen leg and knee that does not seem to be responding to elevation. The patient asks for an evaluation appointment, but after a discussion by phone, the surgeon advises him to come in on Monday.

Over the weekend, the patient experiences severe chest pain and shortness of breath; his wife calls 911 and he is taken to the local emergency room. Deep venous thrombosis and pulmonary embolus are diagnosed; the patient is anticoagulated and eventually recovers without problems. The patient sues the orthopaedist who performed the knee arthroscopy.

In his suit, the patient said he got the impression that the physician wanted to get away for the weekend and did not want to see him. The physician denied this claim, and stated that he genuinely thought the patient could be seen on Monday. However, the physician also acknowledged that he could have spent more time explaining to the patient what could go wrong or what to do for ongoing problems. Did he subconsciously wish to avoid seeing the patient over the weekend? Was he already thinking of the myriad things that he had to do that weekend? Assuming that the physician’s assertion is correct, what could have sent the wrong message to the patient?

Strategies for coping

What should the physician do? Are there specific strategies for coping with complications?

First, every physician needs to acknowledge that bad things sometimes happen to good physicians. There simply is no physician who can ever be completely free of complications. Human beings are complex organisms and their health care can sometimes be unpredictable. Patients are not immortal and physicians are not infallible.

Second, every physician should establish avenues to seek other opinions or confirmatory tests. Wishing that a complication will go away simply won’t work. Rather than miss something, look for confirmation. Physicians should acknowledge that they are under considerable stress and take pains to make accommodations to it. Being over-tired, working long hours and caring for sick patients all place heavy stress on the physician. If physicians recognize in themselves a tendency to not want to find complications, especially when they are feeling overworked, frustrated and underappreciated, taking steps to find confirmation may help avoid a problematic scenario. By always considering the worst possibilities and addressing them sooner rather than later, physicians may be able to prevent delays in diagnosis and treatment, and thus reduce the risk of litigation.

Consider how the first case might have ended if the physician had implemented these strategies.

The patient complains of persistent pain. The orthopaedic surgeon tells the patient that although he does not think there is an infection, he takes her concerns very seriously. Therefore, he is requesting another opinion because he wants to address all possibilities.

The consulting orthopaedic surgeon, working with the primary orthopaedic surgeon, diagnoses MRSA. The patient undergoes a revision knee replacement, which is not successful, and ultimately requires arthrodesis. The patient, while disappointed that her course of treatment resulted in the arthrodesis, does not feel abandoned. Rather, she considers that she participated in the process and worked closely with her physicians at every step of the way. As a result, she does not bring forward a claim of negligence.

References

1. Gabbard, GO. The role of compulsiveness in the normal physician. JAMA, Nov 1985; 254: 2926 - 2929.

Orthopaedic Risk Manager

Orthopaedic Risk Manager is a special section of the AAOS Bulletin, prepared by the AAOS Professional Liability Committee. The section editor-in-chief is David E. Attarian, MD; the section managing editor is David T. Teuscher, MD, chair of the committee.


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