Perfectly Complicated

“If anything can go wrong, it will”. Murphy said so. Medicine is a trying profession. And contrary to the cliché it may not be entirely incorrect to call a doctor’s profession, ‘practice’ given that it is a highly iterative learning process involving other peoples’ lives. However proficient you become, you can never predict when your next complexity rears its ugly head. We all make mistakes and we all pay a price.

There is a difference between a mistake and a complication. A complication most often is an adverse event caused by pre-existing factors that are outside the doctor’s control. A mistake, however, assumes there was a lapse of quality, control or judgment by the surgeon or as my charming mother would candidly describe it as–‘kai bhaltoo kaapi nakhyu’. They both tread a fine line. Surgeons who tackle more difficult procedures and physicians who encounter more cryptic diagnostic dilemmas than others will have more obstacles and should not be penalized for dealing with them. This is the stuff of legends and heroes- and according to my father, the stuff that separates the boys from the men.

 

Decision making under pressure is the key to survival. Both for the patient and the doctor. These are essential decisions about when to operate and more importantly when NOT to operate. This is an imperfect and ambiguous science. It takes an average of ten years and ten thousand hours of tenacious practice to achieve a reasonable amount of skill and judgment to become competent. If you graduate from the bottom half of your class in medical school – which by default 50% of the doctors do; you might want to double that figure.

We are often asked by relatives of patients before a surgical procedure – “Doctor, what are the chances of complications, or of things going wrong?” – to which my natural response is “Don’t worry boss, everything will be alright” and then go on to quote figures of a vocabulary of complications from medical literature, leaving them completely perplexed. But does this offer them the assurancethey need? Numbers and percentages don’t mean much to most, because when it happens to their kin it’s a 100% for them.

In a world where doctors are being sued for malpractice, the average doctor becomes a defensive practitioner. It is interesting to state that Malcolm Gladwell in his book ‘Blink’ says that ‘People don’t file lawsuits because they’ve been harmed by shoddy medical care. What comes up again and again in malpractice cases is that patients say they were rushed or ignored or treated poorly’.

I am one of the strongest proponents of what I call “The Human Connection”. Without which, not only medicine, but any other activity in one’s life is rendered meaningless. In our world where we sometimes see up to 100 patients a day in the out-patient department,  and perform a 1000 complex surgeries a year and fill 10,000 forms in different formats; we are as you might like to think ‘at our wit’s end’. But there are no excuses for being unable to say a comforting word to an anxious patient or his family. To let them know that you are willing to acknowledge their state of confusion and bafflement and help them through it, while at the same time doing the best job that you were taught by your mentors to do. Here is where it all lies. We were raised in our community by our wonderful parents, with values that go far beyond medical practice statistics, and what the West is experiencing as a crisis in the ethics of a practice as noble as medicine.

Despite all this we still stumble and when we falter, some believe that the doctor is rendering his version of ‘another one bites the dust’. This is not true. We agonize over it. We obsess. Our yesterday takes up most of our today. We keep wondering what we could have done differently. We replay the moment of doom a million times and we do that with the microscope of our mind which only magnifies it up exponentially. Our families have to bear with our silence or anger depending on how we choose to introspect. Sometimes this struggle becomes our identity.

Therefore I firmly believe that one can never be above their profession. No operation is too simple or too small. It is sometimes the elementary surgeries that humble us the most if we are not mindful. Given the complexity of the human body, there are infinite things that can go wrong even in minor surgery. We must realize that the things we take for granted, someone else is praying for.

Medical literature is fraught with statistics of wrong patients being operated on the wrong side for the wrong diagnosis. Every theatrical performance of the Parsi General Hospital’s annual gala event derived its humour from this data. Every conference we attend has a symposium on complication avoidance, controversies and dilemmas. Sometimes, even the good we do is full of mistakes!

The introduction of the surgical safety checklist by the WHO has helped significantly reduce these lapses. Interestingly, studies of plane crashes in the aviation industry have shown that the occurrence of a disaster is never a single failure, but a series of slip-ups that dovetail into massive catastrophes. This has proven to be so in medicine as well. The trick is in anticipating all the things that could go wrong- foresee it and thus avoid it. This becomes a daily addiction. Just as after the inadvertent error has occurred – to go to unbelievable depths of the mind to identify the ‘root cause’ of the failure, so that it may never occur again. As my old friend Aristotle once said – ‘We are what we repeatedly do. Excellence, then, is not an act, but a habit.’

Now for some of us, this obsession with perfection, in order to transcend complications and mistakes, makes us difficult people to contend with, in mildly endearing ways sometimes even! If at a fancy restaurant, a strand of hair is found on the plate, the head chef will be called and the situation equated to leaving behind a sponge in the brain. If your plumber can’t fix your leaking tap on a Sunday morning, you compare it to you always managing to regulate his prostate problems, even on a Sunday. If your carpenter can’t give you a smooth satin finish, you threaten to leave an ugly scar if the need arises. At some point everyone will stop to ask, ‘But Sir, how can you compare these two?’ May be you can’t, but may be sometimes you have to. It is in this very pursuit that we find ourselves doing better. We thus become victims of the rules we live by. Yes, it’s perfectly complicated!