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IC 104-2023: Complications - Surgeons' Worst Enemy ...
IC 104 - Complications - Surgeons' Worst Enemy & B ...
IC 104 - Complications - Surgeons' Worst Enemy & Best Teacher (1/5)
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I think, but we'll get started just for the sake of time. And I'm Matt Tao, I'll introduce the rest of the panel here shortly, but we're excited to be here. This is our third year doing it. We're grateful to be able to do this again. It's a topic that we think is important. It's a little bit on the softer side of medicine, but something that really matters a lot once you get to the ground level of dealing with cases. And so especially with a small group like this, we certainly would encourage you to ask questions, think about tough cases. I think the more that we're discussing the less that we're just talking and lecturing, probably the better. So feel free to interrupt along the way with a small group. It makes it really easy to do that. So the rest of these guys, you probably know these names. They're Beth and Chris are from New York. Allison's from North Carolina. And then I'm from the middle of the country in a state called Nebraska, which is somewhere between the East and the West Coast. But I've been there for six years now and really enjoyed it overall. So I'll start by just saying that, at YCLs, typically we try to do something that we have some expertise in, which hopefully all four of us have not become an expert in having complications, but it is something that we think is important and try to approach thoughtfully. I think you'll see that in how the rest of these guys talk and go through everything. We'll certainly go through some specific pathology, but also really talk about just the approach to how you manage complications, really kind of the non-medical side of it. And again, certainly ask questions along the way. So this is kind of the premise of it. This title, and this is Beth, what you told me maybe four or five years ago when we first talked about this is, this is what most people have some apprehension about starting practice and even well into practices. What do you do when this happens? Because it's gonna happen, it's inevitable. I actually love this quote from the former Secretary of Defense, Jim Mattis, because this is true for us, right? I mean, not just in our professional lives, but personal lives too, that we get revealed when things don't go the way that we think that they should. And it's an important enough topic that this article actually was just in this year's AVOS WLA, if you do that online portal for recertification, but just about the effect that complications have on us as surgeons. This quote to me was at the beginning of it, and it's just very sobering that we don't necessarily think about how it affects us long-term, but there really are effects of this. This was a systematic review. It had about 8,500 people in it, so pretty good number of surgeons. And they found kind of four themes here. The first one, no surprise, is that there's an adverse emotional influence on us as surgeons when bad things happen to our patients. The second one, coping mechanisms, just like in anything else, there's positive and negative coping mechanisms. So they talked about how outlets like exercise and art and music are healthy things, but we also see higher rates of depression, anxiety, substance abuse, those kinds of things. The institutional support, especially at academic places, you know, we're used to having M&Ms and those kinds of things, and some institutions, even private hospitals, have better support mechanisms than others, but one of the things they mentioned was having mentors to talk through these things with, and it made me think, Allison, you probably remember this. It was probably four or five months into practice. I did the shoulder stabilization on a girl, and she got a brachial plexopathy. You remember me calling you on a Friday at like 4 p.m. about this? And it was just, it was the first complication that I had where I had done something wrong, like I had caused this, and I just remember being totally devastated, and you said, you should be devastated. Like, you should remember this feeling because this should always be hard. Like, this is happening to somebody that you're taking care of. You should remember how this feels and take it seriously for the rest of your career. So I think having people to talk through that can be very helpful, and there are consequences going forward, too, but I think that, you know, one of the important things, hopefully we emphasize here, is they don't all have to be negative consequences. Like, these are hard, but it can also drive you to improve, and so they mentioned that in this article as well. One of the things that I've appreciated, so this is the start of my seventh year, so I'll still consider myself on the young side, although my kids keep saying you have so many gray hairs, which has changed a lot in the last 10 years, but I've appreciated the fact that there is a difference between knowledge and wisdom, right? Knowledge is something that we gain from meetings like this, from reading, but wisdom is really something that comes with time, and so there's something, I think, that should be honored by the perspective of people that have gained wisdom over time, and so these are just two quotes from guys that I respect a lot. Bill Richardson's a spine surgeon, and Kevin Garvin is a total arthroplasty, a total joint surgeon. So these are just some pictures of some of my least favorite complications of my own. It's always easier to look at somebody else's complications, especially when you're in a conference like this, but they're hard when they're your own, right? Okay, yeah, yeah, yeah. So I've kind of split it up, at least in this intro, to talk about how we manage things intraoperatively, post-operatively, and then how we try to get better, and the intraoperative side of it, I think, is a source of a lot of anxiety, particularly for people starting practice, and the biggest thing, I think, is just to know, yeah, that's probably better. You guys see that better? Yeah, okay, thanks, Alvin. To know how you're gonna respond, and so this is a great book. They've written a couple books. These guys are former Navy SEALs that now do business consulting, but I think what they have to say applies to us, certainly, as well, that particularly in really challenging, time-sensitive situations, that you have to fall back on this principle of prioritize and execute, which is certainly true in the operating room, as well. This is a really good book about the historically great teams throughout the world, and that the one unifying factor in them was the leader on the team, and he has another quote in it about how, particularly in decisive moments, how our emotional control as leaders has a profound effect on the team. So for a leader in the OR, whether you wanna be or not, you are, as the surgeon, and so I think it's a sobering thing to think about. What I would say is that, you know, I mentioned you wanna know how you're gonna respond. The first thing that I'll try to do when something goes wrong in the OR is just pause for a second. It does not have to be this prolonged thing, but just pause, take a deep breath, close my eyes, relax my shoulders, and then go. It just kinda helps me reset, and the middle one there, focus, is just so often there's other stuff going on, like the circulator's talking, or there's loud music, or whatever it is. In a case where something's going wrong, just take any of those distractions out of the way. Whatever you have to do to focus on the problem at hand, make sure that you do that, and then don't be afraid to call for help, you know, whether it means calling one of your partners into the room, asking the other people in the room, whether it's a med student, the scrub tech, the nurse, you know, hey, what do you think we should do here? Do you have any ideas? Or phoning a friend, calling somebody and saying, I'm in a tough spot, you know, what do you think I should do in this situation? And I've done all three of those. I don't feel guilty or ashamed about it at all. Like, when you're in a tough spot, do not be afraid to ask for help. I think what you cannot do is these two things. So, you've probably either been in cases of your own, or somebody else's, where you've seen it snowball, where one little mistake just starts to compound, and then the case just gets totally out of control. You cannot let that happen. And then move on. The other thing you can't do is you cannot let it derail your day. So, my dad's an ophthalmologist, retired now, but I remember him saying this even when I was growing up about when bad things happen, you gotta get through the rest of your day. You may have more cases, you may have clinic, whatever responsibilities. Take time to reflect on it at the end of the day, but don't let it completely throw off your entire day, because you have a lot of other people that are depending on you during the day there. So, this is just one example. It's not a super oppressive chondral example, but she had an OCD that had been operating on a couple of times, so the bone underneath was bad, so we were doing an OCA. So, nothing super exciting about the case itself, but it was going along well, I'm happy. I took the graft first, and then I reamed the defect, and then I went to put the graft in, and they had given me a bigger reamer that I didn't check, and so the graft was about two millimeters smaller than the hole. And so, this, Mike Barron is a Duke grad that would call this the not-so-fresh feeling, and it's not the worst situation in the world, especially when you're sitting here, but in the midst of the OR, you know, you can, you have a lot of options. You can scream, you can stomp. One of my partners likes to stomp when things don't go well. So, you know, you have a lot of options, but ultimately, you still have to fix it, right? And so, this is something where I've made plenty of mistakes in terms of how I've handled these situations, but this is one where I just said, guys, look, this sucks, I'm not happy about it, but ultimately, honestly, it's my responsibility. I didn't check that reamer. You handed me the wrong one, but I didn't look at it, and look, we're just gonna fix it. We just have to take the graft from a different spot. It was a pretty good-sized plug, so I was not super happy with the contour. I don't know if this is gonna come up, but, you know, you can tell on the sides, there's some indentations here. It's not quite as good of a fit as probably you'd like, but it looks fine, and she's probably three years out now and fine, but it's just to say that, you know, the more you can handle that well, I also think it really instills confidence in the OR team. You know, the more you yell and scream and shout, the more nervous they get, and nobody works well under tension like that. So, the, we'll switch gears to go to the post-operative side of it. I don't have this up here just because Chris is here, but this is actually a really great book. It's, like, right at my reading level. It's very short. It's very easy to get through. So, if you, it's just a good book about how to get better, but the post-operative side of it is something where I think many of us struggle with taking ownership and taking responsibility for things, and it's something that you just have to do. It, it can be hard because you want to kind of dance around the issue, and many of our first tendency is to lay blame. I would say just fight that urge. You have to try to take ownership of the situation, and make it right, and these always seem to happen at the wrong time, right? The clinic's behind, or you have a bunch of other responsibilities. You have to catch a flight or whatever it is, but I would say, regardless of the situation, just stop the clock. Give that patient and that issue the time that it deserves, and I think your posture, both physically and emotionally, matters a ton here. So, I really think sitting down, getting eye-to-eye with the patient, and just telling them, we're going to be fine. Like, we're going to get through this, that we will walk through this together. We're going to get you, you know, back to the point where everything's okay, and then you actually have to do it, which is not always easy, and sometimes you need help, and so I'll show you that in a case example here. This was one, also from my first year practice, when I was in board collection. Sadly, I still take trauma call, so one of our residences joining you guys this next year for fellowship at HSNU is like, they're going to be so embarrassed that you still take trauma call, and I'm like, I know, but I still have to do this kind of stuff. So, so anyway, so I was doing a HEMI, and we have our intraoperative film on the left there, PACU film on the right, and I'm happy with both of those. She comes in the clinic for her first appointment, and I see this before I walk into the room, and I thought, oh man, this is terrible. This is like the first month of board collections, and I walk in, and before, literally before I could say anything, the patient and her daughter just start effusively praising me, how happy they are, how great of a surgeon I am. They're so thankful for everything. I'm just like, oh, this is just terrible. So then I had to tell her, I broke your femur, and so I went out, and I called my partner, Bo Konigsberg, who's one of our joint surgeons, and went back in, and I just said, look, guys, this is really, this is not a good situation. You just had surgery, but we have to fix it. Bo is one of my partners. He does this all the time. He will take very good care of you, and then they, no joke, said, will he be as good as you are? And I said, well, it's ironic that you asked that since I broke your femur, but yes, he will be better than I am, and he will fix it. But just, it's hard to take that time, but I think the more that you can do that, even if it's an extra five minutes, it really matters a ton in terms of your interaction with patients like that, because this part of it, and I think the medical-legal side of it would bear this out, but just even from a human-physician standpoint, the better that you can interact with them, the better they will do, and the better your relationship will be going forward. And the tendency for so many of us when things go wrong is to pull away. Maybe I don't need to see them as often. Maybe the PA can see them, but I would say fight that urge. Press into these people. See them often. Let them know you care, and just give them the sense that you're on the same team, that you're in this together. You're gonna get through this. They have to know that. I'll just do a quick aside and just say much of what we're talking about here is kind of on the individual level, but if we flip it and talk about when we succeed, even as surgeons, this is familiar for sports medicine, but we succeed as a team, right? So to whatever degree you can, build the team around you that has this unified vision, that is willing to go through these things and work together. This article from the New England Journal is actually a great article from the late 80s, and it's a short article, but it juxtaposes these two ideas of the theory of bad apples and the theory of continuous improvement. Basically, how do you motivate people? And it's a really good look at how we manage things, both in clinic, but certainly in the OR. So this idea of being better and seeking improvement, I'm just gonna go through a few things here. This seems fairly intuitive, but I think the truth is that most of us will not get better unless we try to get better. And it just doesn't necessarily happen on its own. Atul Gawande in one of his books talks about how it's interesting in medicine because in so many other fields, they have coaching and other ways to improve, and we really don't have that, right? And so you kind of have to seek that out. This first book, Think Again, is by a guy named Adam Grant. I've read it relatively recently, but he talks in it about the importance of a challenge network, about people in your life, personally and professionally, that are willing to ask you tough questions, to redirect you, to help you make changes when you need to, which certainly we need. And my OR team, Allison's been in the OR with me, are not shy at all about telling me if I can do something better, which I appreciate. And then this book, Grit, is one of my favorites. It's about the idea of passion and perseverance and how to succeed at a high level. You really need both of those things. The critical evaluation, this is hard too. You know, when things don't go well, I think we have to be honest with ourselves just to take a look and say, you know, where did I screw up, but also where did things go well? And sometimes it's asking advice, whether it's calling mentors, or it doesn't even have to be people in your discipline. One of my spine partners has been a great mentor to me. He's probably five or six years ahead of me, but he's a really good surgeon, a really thoughtful guy, so I love bouncing stuff off of him. Taking notes, Chris actually talks about that in his book as well, particularly when things go badly, but also when things go well, take notes on cases. If there's a tough case that you don't do that often, taking notes is really something that helps you solidify it, and then also when you go into that case the next time, helps increase your confidence and your ability to do well when you step into the OR. Hard work, this is no surprise to any of you, there's just not a substitute for hard work. This book is actually a little bit of an older book now. It's a great book by a lady named Carol Dweck, and the premise of it is just that we have the ability to improve even in areas we don't think, and so she talks about athletes and rock stars and these people that we look at and say, well, they're just built differently than I am. When the reality is that those people worked and labored for years to get to where they are. And she also has a great quote, for those of you that are parents, something to the effect of, if we wanna give our children a gift, teach them to love learning, to embrace difficulty, and to keep on going, and I think that's so true for us in the OR as well. This is David Heron, who's one of the joint surgeons at Duke. He used to give us a talk in residency about patient selection, and he said, basically the first five years of practice, you're just learning how to operate. The next five years, you learn who to operate on, and then the five years after that, you learn who not to operate on. And it's, I mean, there's some truth to that, and it's hard. The first one to admit, I'm not really sure who's gonna do well and not do well, and you have to balance the ethical obligation of what you think is right, but also who you think's gonna do well. And so especially for elective surgery, I think that matters a lot in terms of how you select people. This preoperative planning, there's this idea in psychology of deliberate practice. It's nothing real crazy, but just to say that you're intentionally investing time and effort to try to get better, but the key to that is that it's an active process and not a passive process. And so there's this concept called flow where it results in things going, essentially, just really smoothly, but it doesn't happen with all the work on, unless you have all the work on the front end. I put the example of boys in the boat in here. It's a book about the 1936 gold medal rowing team, and they talk about this idea of swing in rowing, where when everything's in unison, that the boat has a different feel, like it's almost gliding across the water, but again, it only happens when that team is in perfect unison. We talked intraoperatively about how you need to have strategies, especially with specific cases, kind of know where your weaknesses might be, know where some of the issues might come up, and know how you'll deal with them if they do arise. And then this last thing with walkthrough, the year I was with Beth in New York, the Giants were good that year, so we had a good year and made the playoffs, but one of the things that I enjoyed seeing, which most teams do, is a walkthrough the day before a game. And the military does this too. We have a resident that was actually just graduated, that was in the Air Force, and said, oh, we call this armchair flying for pilots. But I would say this, for me, has been a huge thing over the first few years of practice, of just going into a difficult case, take time, it doesn't have to be a huge amount of time, but go in a quiet room, close your eyes, and walk through every step of the case, like force yourself to think about everything you're gonna do. It sounds silly, it sounds kind of zen, but it is amazing when you do that, how often you think of, oh man, I really need that one retractor from this pan, I'm gonna have to ask them for that, or I need to talk about this with the rep, or whatever case may be. But for me, especially going into a difficult case, or something that I don't do that often, it's really helpful to feel like when I step into the room, that I'm ready to roll. And then the last one is that these are hard, right? Sometimes these are a total gut check. One of my co-fellows, in I think our first year in practice, had a lady, a 20-something-year-old lady, die after a knee scope. And sometimes these are just awful, awful things. But Anil Ranawat told us at one point, the best thing that you can do after a complication is get back in the OR. And it feels a little bit counterintuitive, but I think he's totally right, that we cannot let that failure stop us from being willing to operate. So I can't help but end with a couple shameless sports quotes so I loved Kobe. These 10 rules for success mirror much of what we're talking about today. And then this is probably my favorite quote of all time from the GOAT, but I think it applies to us as surgeons as well. Like if our goal is to be elite performers, we can't let these failures and complications define us, but we have to learn from them and try to help us be better going forward. So that's kind of the end of the intro. We're gonna switch it a little bit this year. I just wanted to do a Q&A here. If you have questions on things or cases, does anybody have any thoughts on that? Like anybody have examples of where this has gone well, either yourself or somebody else, or times of things have gone poorly? Yeah. I think this course is fantastic. I think, you know, these kinds of considerations, this mental preparation, this is something that everybody like needs and I have a few gray hairs, so I've seen a few things that have gone along. And, you know, this idea of mental preparation, one thing I've always done is I will basically do the case the night before in my head. You know, I'll review a few things, look at the patient, this and that, take some notes, and then I will mentally go through and do the case and look for the stupid stuff. You know, what stupid thing can happen and just have these alternative plans. And especially a case that I haven't done as frequently or it's newer, like for instance, most of my life I've done BTB ACLs. So just a couple of years ago, I started doing quad tendons, you know, I really love it. And most people my age would never think about doing a new thing, but I've always been kind of a kid at heart, so whatever. And, but then, you know, if you're doing a case that you're not as familiar with, then a couple of days before I'll do that. Then I have, you know, the retractor, the thing, you know, I need that quarter inch curved osteotome that they never seem to have, so I can do, you know, the notchplasty. And then I call the center, you know, and say, hey, here's these extra things I need. And then it just gives you that extra thing of confidence as you're doing the case, all of a sudden it's something stupid and then the instrument's not there, but if you've done this, it just helps so much. You know, it's like recently I was doing a quad tendon case and done a bunch, everything is going fine. Somehow, I was using that Arctrax harvester and it like deviated a little bit. And so it like did this oblique split. And so I had these two pieces of quad that weren't long enough, like whiskey tangle fox trot, you know, that's the other thing. It's good to learn to curse in another language, or say something like whiskey tangle fox trot, because some people know what that is and they'll laugh. And sitting, you know, on the back table looking at it, I'm like, well, it's a great graph, it's nice and tight, and I'm sure not gonna go after another one. So I did this like long repair, you know, with lots of suture and it did great and everything went fine. But it's like, you know, stuff will happen. I think this course is absolutely brilliant. I commend you for doing it. Yeah, well, thank you. You know, I think especially as somebody who's still early in career, it's great to hear examples where you're saying, hey, I'm still willing to learn and do something differently, you know? And I think that we see a lot of examples of that, as you said, on the other side, where people just say, oh, this is just how I've done it. Like, well, that was, you know, 30 years ago, or however long it is. So I love that, you know, my dad is very much that way too, is always learning, always, you know, trying to get better. But I think that, like you're saying, just as you go through stuff ahead of time, it really is amazing how it mitigates some of these issues. And we see that, you know, I think, it's maybe a separate issue, that the communication ahead of time too matters so much. You know, one of our OR coordinators said a couple of years ago, thank you for talking to us before you started. And I said, what do you mean? She said, well, we just had this last year, a surgeon show up for cases on their first day at the institution, never communicated anything ahead of time about like what hands they needed, what they wanted to do, like what their practice was gonna look like. Thankfully, this wasn't orthopedics. But like, man, like that, there's just no way that works out well, right? Like, unless you happen to be at a place where, you know, they know you already and they know exactly what you're gonna do at that preparation side of it, I think matters a ton. So, Chris, what do you think? I mean, you think a lot about this stuff, about the mental side of it ahead of time. You have thoughts on that? All right. Yeah, thanks, Matt. Great comments. The science of cognitive rehearsal is strong outside of surgery. People who go through cognitive rehearsal, they negatively simulate the procedural and the activity that they're gonna do, especially after this takes years. For example, they're going through the downward force numerous times in their health. And cognitive rehearsal activates your brain almost like the physical activity itself. And so, the more you mentally rehearse, the more reps you get, the more reps you get, the more automatic it becomes and the more cognitive capacity you have in the moment to manage problems at that period. I'm glad you brought that up because when people ask me what has been most beneficial to my personal practice after surgery, it is, and my answer is always the same, it's the ability to rehearse surgery and it's actually very hard. To mentally go through an operation is extremely hard. And when we have a large training program in California, when we interview potential residents, I ask them what their favorite operation is, and they say, whatever comes to their mind, and I can miss the L5 as well. And I'll say, follow your steps. And you can quickly get a sense of when you go in surgery, you can actually see the operation. But can you see it? And the more you mentally rehearse, the more you can see it in your mind. And even visualizing success, you know, there's a lot about that too. I think we've talked about that before that we're talking kind of on the hard side of it, but also seeing, you know, where things go well. And I remember, you know, somebody mentioned that in fellowship when I was with you guys, Beth, and just said, you know, watch some of these, they're all mistakes, but watch how they respond to that, because a lot of times it's just not a big thing. They don't make a big scenario out of it and say, oh man, I can't believe I did that, and now you're getting, how bad is this? You know, but you just kind of move past it and you don't let that throw off what you're doing, unless it's something that really needs to be addressed. So I think that's certainly true too, of just, you know, trying to make sure you can visualize how are you going to do well in this case, and not only just how you avoid problems, so. Other questions, other case examples of where things have gone well or poorly? If not, we can keep rolling with Chris. Okay, good. Yeah, go ahead, Beth. Yeah, of course. Something that actually Chris told me about when I first started practice, which is be brief in your head afterwards. In your own head, give yourself a break. You know, one of the things that we often do is get constant feedback during our fellowship and our residencies, and be constant with telling us what we did well and what we did poorly. But the minute you get into that OR and attending, nobody's there to do that anymore. And I think being your own judge and critic, both for the good and for the bad, but at the end of every case, you know, I got a B plus on that case. Here's what I did well, here's what I should do differently next time. In this case, obviously, think about the case. Is that okay with you in the OR? But what are the things that I would do different on the next time? Is there gonna be a next time? And that will help the whole time. Make all the better decisions. Yeah. Missed me? I had one. Yes, I'm struggling. Not starting? I don't know. I was gonna get that up. I'd say another thing that was pointed out about, we talked about the mental rehearsal, but the younger you are, you don't always, especially if you haven't done a case much before in your practice, you can't anticipate all the problems because you really don't know them in your head. Right? So the first time you're doing an anesthesia transplant is a great example of one that is always a little bit of a challenge to do. And so I encourage at least our former fellows to, before they're gonna do a case they haven't done, let's like, give me a call and tell me the steps you're gonna do. And I'm gonna tell you each step, like the problems I've seen. And then like, given that for 22 years, how many mistakes I've made and have them take notes and say, ooh, I never would have thought of that. They say that all the time. I wouldn't have thought of that. And so I'd also say the younger you are, the more you should probably call somebody else and go through that in your head. And I tell them like, don't worry that you don't feel like you know everything. You're not supposed to know everything. I'm still your mentor. It's okay to call and say, I don't know everything. You shouldn't. And so being willing to reach out to people who are more experienced, even if you're 10 years into practice, one of our fellows would say, I haven't done an X in so long. I just sort of feel like I should talk to someone about what to do. And like, you know, almost always, they change their plan a lot based on talking about different tips, and just like we talked about, you just don't know, if you haven't done the case, you really don't know the steps to reverse. So I really think it's good to reach out and almost always your mentors are happy to do that. So I think it's something good to think about. I was wondering if you could like just go, you said you had a patient that had, you know, some bad health issues. Great. Yeah. You just go with the way the post-op folks have done. Yeah. So without making it too long, maybe this just happened now.
Video Summary
In the video, the speaker, Matt Tao, introduces a panel discussing the importance of managing complications in medicine. He emphasizes the emotional impact that complications have on surgeons and the need for support mechanisms and mentors to help cope with these situations. The panel discusses strategies for managing complications both intraoperatively and postoperatively. They emphasize the importance of pausing and taking a deep breath when something goes wrong in the operating room, as well as focusing and calling for help when needed. They also highlight the importance of taking ownership and responsibility for complications and providing support and communication to patients who experience complications. The panel encourages continuous improvement and deliberate practice in order to become better surgeons. They share personal stories and examples to illustrate their points. The speaker concludes by emphasizing that complications should not define surgeons, but rather serve as opportunities for growth and improvement. <br />No credits were acknowledged in the video.
Asset Caption
Matthew Tao, MD
Keywords
managing complications
emotional impact
support mechanisms
strategies
continuous improvement
personal stories
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