On a recent flight back from Europe I had a most unsettling but thought provoking experience when I watched the Oscar-winning foreign movie “Amour.”
You may ask why this film had such a profound effect. It was because it aroused an emotion I had submerged for many years – the sense of dread that I might cause severe harm to a patient with my surgery.
Now, for those of you who haven’t seen it yet, don’t worry — I am not going to give away the whole story, so no spoiler alert is necessary. The premise of this extraordinary film revolves around an elderly French couple. The wife is a retired piano teacher who undergoes a carotid endarterectomy following a TIA. When she returns from hospital, her right side is paralyzed, but she can still speak. From then on we watch the gradual decline of this lovely woman and the consequences her stroke has on their lives. Her loss of self, her struggles to complete the basics of life, and even the ability to hold and read a book. Her loving and dedicated husband struggles with his own dwindling abilities to care for her, to help her bathe, and to eat.
Her daughter asks the husband what happened. He replies in a defeated but matter of fact tone … “The surgery was unsuccessful. You know, it’s that 5% thing.”
That 5% thing! Our journals are full of similar statistics about the bad things that can happen to our patients and we use these statistics all the time. We reassure our patients that in our hands the stroke rate or the amputation rate or the mortality rate is 5%, or 1%, or whatever percent. Sometimes we do it with a sense of pride. Sometimes we discuss these statistics to avoid a malpractice suit. Sometimes we don’t even know for a fact what our statistics are. But most of the time we give out this information glibly. There is little thought for what it will mean to our patients if they are the unlucky one who suffers the event we describe with these percentages.
So what makes us forget that our actions that can have such life changing outcomes? I believe there are many reasons. Perhaps the most common would be confidence in our technical skills, past excellent results and the rarity of the complications. But having been reminded by the film “Amour” I think it is because we do not see our patients living their daily lives when afflicted by a life changing complication.
We don’t go into their homes and watch them try to feed themselves with one hand. We don’t place a diaper on the bedridden lying in a bed saturated with urine. We don’t see the husband struggling to take care of his now handicapped spouse. What about some of our interventional colleagues? Do they come to the operating room to watch us try to save the life or limb of a patient after one of their procedures went amiss? How many of us go to the rehab hospital to check on our newly paralyzed patient? How many of us visit the dialysis unit and sit for three hours with our patient who is now in renal failure? How many of us are there when our patient is learning to walk again with an artificial leg? How many of us attend the funeral of a patient that succumbed following an unsuccessful procedure?
Of course we don’t. It’s not that we are heartless or uncaring, but our lives are complicated and enormously stressful and time is precious. So we continue with our busy schedule, trying to do the best we can while our patients become yet another statistic.
But then, what if we did spend time with our unfortunate outcomes? Would we become so emotionally handicapped ourselves that we could not continue doing our necessary interventions? Would we become so scarred that we could never again lift a knife or insert a catheter?
I believe that would be the case because after the film I turned to my wife and said “I don’t want to do this anymore. I don’t want to be the cause of such misery.” Fortunately she replied that I “should remember all the people I had saved from such a fate” — the 95%! And then the reassuring platitude that if I couldn’t save the patient then who could?
As we flew on, I had time to ruminate, and my misgivings diminished. For it is a fact that as vascular surgeons we are well aware of the extraordinary responsibility that we shoulder when patients hand us their bodies. We know what the disease will do to our patients if we do not intervene, and we also know when we should leave the patient alone. We are aware of the magnitude of a decision to perform surgery or an endovascular procedure, and we are aware of our own abilities.
So even though we are not infallible we can still continue to strive for the 95% and pray that we are not the cause of “that 5% thing.”