Reducing the Risk Related to Unplanned Serial Surgeries

Imagine this scenario. You perform surgery on a patient and the patient does not heal as expected or has a complication. You perform another surgery to correct the problem, but the patient eventually needs further corrective surgery. Your relationship with the patient has deteriorated, and the patient decides to seek treatment from another physician. In the meantime, the patient’s bills are piling up and the patient is having a tough time paying the bills. To make matters worse, the new physician criticizes your surgeries. The patient decides to sue you.

Unfortunately, we see this scenario happen a lot. Allegations against the physician may include failure to obtain informed consent, failure to perform an appropriate pre-operative workup, failure to consult, failure to perform an appropriate surgical procedure, performance of an unnecessary surgery, improper performance of a surgical procedure, failure to perform appropriate post-operative monitoring, and more.

How can a podiatric medical physician reduce the risks related to unplanned serial surgeries? Here are some risk reduction strategies that you can implement in your practice.

During the pre-operative period, you can proactively seek to avoid repetitive surgeries and poor outcomes. 
Ask yourself these questions:

1. Is my selection of the procedure to be performed appropriate? Did I consider and discuss alternatives with the patient?
2. Have I fully considered the patient’s social determinants of health – such as a psycho-social history and the patient’s ability to comply with post-operative instructions?
3. Is the chosen procedure fully within my skillset, or would the patient benefit from referral to another surgeon with more experience?
4. Do I have a “Plan B” and “Plan C” in place should a complication arise during surgery?
5. Am I sure this procedure is truly the best for the patient, or would it be better to refer the patient to a colleague instead? 

Intra-operative decision-making can make the difference between a successful first surgery and an unsuccessful surgery requiring additional surgeries. 
Use these tips:

1. Do not rush. Often, the difference between a good outcome and a poor outcome down the road is an extra 5-10 minutes of double-checking, taking an extra X-ray, putting in another screw, etc.
2. Do not accept an “OK” result. Seek to leave the surgery as close to perfect as possible. The best time to have a great result is with the first surgery.
3. Discuss with your team when a complication arises. You are still captain of the ship, but many people have different experiences that may be helpful in resolving the complication and it’s wise to ask your surgical team for their opinions.
4. Treat your patients like they are family. Take care with your patients – they do not deserve any less.

Post-operatively, you can take steps to reduce the likelihood of repetitive surgeries.
Follow this advice if a complication arises:

1. Do not bury your head in the sand and wish a complication away. It doesn’t work. Stay objective and identify a complication as soon as possible and act to resolve it immediately.
2. Communicate clearly and emphatically to the patient. Perhaps include one of their trusted family members to help identify a complication. Communicate your plan to resolve it.
3. Seek a second opinion if necessary.
4. Try to resolve the complication yourself the FIRST TIME. You know what surgery you performed, what went on in the operating room, and you have the best relationship with the patient.
5. If revisional surgery does not solve the complication:
   • STOP. There is a very real tendency to lose objectivity at this point. Try once and then ask for help from a colleague.
   • Consult another doctor and possibly even ask that doctor to join you. This demonstrates humility and concern, as well as objectivity to the patient – it shows you have their best interests in mind.
6. Be sensitive to the financial situation of your patient. A big generator of claims is when a patient is going through complications and repetitive surgeries and then they receive a big bill.

In general, patients are very accepting of the reality that a complication can occur. Prompt recognition of the complication and a conversation about resolving it can go a long way. Repetitive surgeries with poor outcomes can generate claims when the patient loses confidence in the doctor’s performance and bedside manner. Open, honest communication with the patient and the patient’s family is key in maintaining a good physician-patient relationship. Consider referring the patient for a second opinion from a trusted colleague – most patients will appreciate your concern for them and that you have their best interests in mind.

Do not minimize a complication or blame it on the patient. Use inclusive terms such as “we” have a complication and here is what “we” are going to do about it. Stick by your patients and they will stick by you.

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Disclaimer: The information contained on the PICA Blog does not establish a standard of care, nor does it constitute legal advice. The information is for general informational purposes only. We encourage all blog visitors to consult with their personal attorneys for legal advice, as specific legal requirements may vary from state to state. Links or references to organizations, websites, or other information is for reference use only and do not constitute the rendering of legal, financial, or other professional advice or recommendations. In the event any of the information presented conflicts with the terms and conditions of any policy of insurance offered by ProAssurance Insurance Company of America, the terms and conditions of the actual policy will apply. All information contained on the blog is subject to change.