The chance of complications

High expectations and disappointments

Fortunately, it happens only rarely that a patient is angry with me. But people who are blaming their doctor of something, will always be very angry. Even though I am not happy with that, I can often appreciate that they feel that way. They see my beautiful website, they hear about the leading-edge robot that I work with, and know the success rates of the operations I perform. Of course their expectations will be very high. And when it doesn't happen like that, they feel that I have disappointed them.

Two examples. One time I decided to not operate on a patient, because he would not change his lifestyle. But that change was necessary to increase the chance that surgery would be successful. The patient was angry about this. I also received threatening letters from a solicitor, because a patient suffered from a nasty complication after surgery, even though I had warned the patient in advance about the risk of this and even more serious complications.

Tiny chance of complications, but not to be ignored

At school I already hated mathematics, but now I just have to talk about probability calculus. That will give insight in the nature of the problem. The chance of complications after a neurosurgery procedure is tiny, but cannot be completely ignored. During surgery I un-pinch nerves. Nerve tissue, other than for example muscle tissue or blood vessels - is difficult to repair once it has been damaged. It is possible that a nerve had already been affected before surgery (because it was pinched between the slipped disk and the small joint in the spine), that the pain will remain even after I've made more room for the nerve. Surgery successful, pain still there. Unfortunately, we cannot predict beforehand if this is going to happen. And if you happen to be among the 5% of patients that will still be in pain, or who even suffer more, you will of course be totally fed up.

In case of a slipped disk in the neck, the worst case scenario is paraplegia. Or a fatal bleeding, but also a less dramatic complication is possible, like permanent hoarseness. Thank god I have never experienced that a patient became an invalid, but permanent hoarseness does occur in 1 in 100 patients. However professional, every dedicated physician will find such a negative result almost as frustrating as the patients themselves. I did choose this profession after all to help people. When a patient sends me a card, saying, "Thanks to you I have my life back”, this makes my job a pleasure and gives it meaning.

For a physician it is always quite an art to give the correct information in the preliminary meeting. You don't want your patients to be seriously stressed when they go into surgery, because you have given them each and every improbable doom scenario. But you also don't want to keep silent about the risks, because that would make a less positive result even more disappointing. Of course I'm hoping that I have been able to find the proper balance in these blogs and in my office. That said, and in spite of the honest information that I've been giving, many patients still expect a guaranteed 100% success. That is is because man has not been programmed to accept coincidences. Michiel Van Elk, psychologist at Amsterdam University, gives an explanation. "Coincidence does exist, but it just doesn't fit in the human brain. You don't incorporate it in your life. And that's how it should be, too, for otherwise you wouldn't dare go out the door. The human brain builds a model of the world in which all events have a cause. This is based on evolution; it’s an evolutionary advantage to start out from causal connections, to think that where there's smoke, there must be fire. To assume that smoke is just a coincidence, can cost man dearly." The same applies to pain. To continue the comparison with fire: if your hand wouldn't hurt if you hit the barbecue, you might leave it there too long with all the nasty consequences.

The manipulability of our health

In the 21st century we live in the illusion of manipulability. Around the year 2000 we have as good as caught up on creation and exceeded the laws of nature. You don't want a child? Anti-conception is available everywhere. You do want a child, but you can't? You can buy egg cells from a woman in the States and rent a surrogate mother in India. You don't like how you look? Flatter ears, bigger breasts, fewer wrinkles? No problem! And every day we read the newspaper, telling us about astounding medical breakthroughs that bring eternal youth and health even more within reach.

In such a world you will certainly think that coincidence has been reduced to zero. 'They' can do anything nowadays, can't they? No they can't. The human body still has many great secrets, and coincidence still exists. Bad luck and success are not under control. But based on the medical factual knowledge which is growing every day, we are able to calculate a probability. For example we all know people who smoked their entire lives and still happily lived to be a hundred. Anybody concluding from this that there is no connection between smoking and lung cancer, is wrong. In 2012 90% of deaths from lung cancer in males and 78% of deaths from lung cancer in females, were caused by smoking. Your nice great-uncle or neighbor who lived to a very old age in spite of all those cigs, was simply extraordinarily lucky. Coincidence does exist.

With the necessary factual knowledge and probability calculus, I try to avoid coincidental bad results of an operation as much as I can. And I do need the patient's help with that. We know that in some cases the chance of success of a certain procedure is significantly larger when the abdomen is not so fat. Or if the bones are stronger. If that's the case, I'll ask patients to change their lifestyle. I know that it's quite a sacrifice to give up those lovely crisps or that relaxing cigarette. But I also know that the chance of a complication will be reduced significantly when I ask to sacrifice them. Moreover, their overall health will then improve, which will make them recover faster after an operation. Sometimes it's difficult for patients to change their lifestyle, and then they get angry with me.

People also know that in the States you can get a lot of money if the doctor has made a mistake. It happened to me in the past that I had honestly warned a patient about mild and serious complications, that may occur after an operation. He got relatively mild side effects, but still sent me a lawyer. He thought I had to pay up!

Coincidence does exist

Coincidence really does exist. And the smaller the chance of bad luck, the smaller our capacity to deal with it. People with a fatal disease such as cancer, will often be prepared to put up with the most horrible side effects of chemo treatments. You reckon you will lose your hair, will be nauseous, deadly tired, have aching hands and feet, and so on. But you want to enjoy your life for as long as possible, so you endure all that misery for the higher purpose.

In spinal surgery there is very rarely also a price to be paid, in order to achieve the higher purpose, the major reduction of pain. The good news is that this price has to be paid by only a few patients. But we must remain realistic. Mutual respect and trust, sincerity and the willingness to openly discuss solutions, are important for the repair of the damage. I am really quite thick-skinned. But when too many physicians will be blamed, this will result in other patients suffering from the even more drastic safety precautions that I will have to practice, like scaring everybody witless with horrible stories.

The psychologist says: we would not even go out the door anymore if we were thinking of everything that could go wrong in a day. As a physician, I say: what a wonderful profession I have been practicing for years now, helping so many people getting rid of their depressing pain.

PS: It's not a coincidence that this blog deals with bad luck. It's my 13th column and I wrote it on a Friday.

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