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Working Toward Consensus on What Is a Surgical Complication
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Posted on: 06/16/2009
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What surgeons consider a complication of surgery and what patients view as a complication are often very different. And since differing opinions can lead to unrealistic patient expectations, there's a need to clear this misunderstanding up right from the start. The authors of this article hope to lend a hand with that task.
They point out that the first problem is defining what is and what isn't a complication. And secondly, there is a need to decide whether that complication is a major or minor problem. The goal is to improve communication between surgeon and patients before surgery takes place. A secondary goal is to create some basic ways to define and report on complications in order to conduct studies in the future that can be compared to one another.
In this study, a survey was developed and sent to practicing and spine surgeons. Most were orthopedic surgeons with more than five years experience performing hundreds of spine surgeons every year. The survey presented 11 different patient cases to the surgeon to decide: 1) Was there a complication? and 2) Was it major or minor?
The same set of patient stories was also given to a group of patients who came to the spine clinic for evaluation but had not had surgery yet. The cases were rewritten slightly for the average (nonmedical) person. They answered the same two questions. The opinions of the two groups were compared for the complication scenarios.
In general, they found that patients were much more likely than surgeons to consider a problem as a complication and to see it as more serious (major) than the physician. For example, a temporary problem swallowing was considered major by patients but minor by surgeons. The same was true for blood loss during surgery. In both cases, the surgeons knowledge that these problems were short-term and not life-threatening influenced their choice in placing these complications in the minor category.
On the other hand, some complications (e.g., heart attack, blood clot, nerve palsy) were viewed as major by both patients and doctors. In a few instances, the surgeon recognized a problem (usually some kind of infection), as being major when the patient classified it as minor. Again, knowing that such complications can lead to serious health problems (even death) probably aided the surgeon in choosing to label that problem as major.
There are no previous studies like this one comparing surgeons' perceptions with patients' opinions about surgical complications. This is the first attempt to solve the problem of reporting and comparing complications after spine surgery. Once the definitions for severe (major) complications and minor (adverse) events are determined, then further research can be done.
With the new direction toward evidence-based medicine and the need to show that the benefit of an operation outweighs the risk/adverse effects, future research will need to incorporate measuring sticks of this type.
Patient satisfaction (now considered a valid measure of a successful outcome) may depend on better communication between doctor and patient. It's easier for a physician to allay patients' fears about possible complications if they know what it is the patients fear the most or consider a major problem. Surgeons can also tell patients how likely it is that each complication might occur to help prepare them for surgery and formulate their own expectations about what might happen.
The authors conclude by saying that they will continue working with this concept. They will make some additional changes in their research method and improve the design of future studies. They will also improve the validity of their assessment tool to judge complications for use in other studies as well. Building consensus in the literature around the concept of perioperative and postoperative complications will be the final outcome of their work.
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References:
John K. Ratliff, MD et al. Complications in Spinal Surgery: Comparative Survey of Spine Surgeons and Patients Who Underwent Spinal Surgery. In Journal of Neurosurgery: Spine. Vol. 10. No. 6. Pp. 578-584.
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