‘Participation helps with processing’

What is it like for doctors when something goes wrong during an operation?

“A complication never gets used. I have colleagues who lose sleep over it. Luckily I sleep well, but it stays in my mind for a long time. Patients also notice this in me. A patient who had something gone wrong during surgery said to me, “How sad for you!” And that while I had caused the complication. She saw that it affected me too. I think this applies to a lot of doctors.”

What do doctors normally do when a complication occurs?

“In most surgical departments of hospitals, there are regular consultations about patients where something has not gone completely as desired. Doctors and nurses briefly discuss any complications that have arisen since the previous discussion. The main goal of these consultations is that healthcare providers learn from them, so that complications occur less often in the future.”

What did you change in the first place?

“During my training I worked in an Australian hospital for several years. I’ve been through a lot of complication meetings there. These were much more extensive than in the Netherlands. When I returned to Nijmegen, I quickly thought: these discussions should be better here. Step by step, we have implemented improvements in the Gynecological Oncology Department. We no longer discuss all the complications briefly, but one or two in depth. We also look up additional information in the scientific literature and ask other medical specialists for advice. In addition, for each complication we indicate which points we need to improve. This comes in a report, which we also send to the patient. Three months later, we contact the patient and explain the progress of the areas for improvement. And we have been doing something extra for about five years now: we also invite patients ourselves for a meeting in which we treat their own complication.”

Why did you start doing that?

“I got the idea five years ago from a patient I had surgery. Something had really gone wrong during the operation. As a result, she had many additional complaints and had to go under the knife again. I told her: ‘We are going to map this out and discuss it extensively.’ She said she would like to be at the complication meeting. My first thought was, why not? It fits in with the principle that doctors and patients have an equal relationship. Unfortunately, I couldn’t manage it yet for this patient. Employees of the hospital’s legal department, as well as doctors, were concerned that the patient would make an official complaint or claim for compensation. But not much later it worked and we had the first complication meeting with the patient present.”

What went wrong with that operation?

“This patient underwent surgery for cervical cancer. In this operation, the ureter is completely exposed. The woman developed a blood clot just above the vagina a few days later. To relieve this, the vagina was opened slightly with forceps, so that the blood could run out. The ureter was damaged. A few days later she came back to me: she had a stomachache and her stomach was getting bigger. We found that the ureter was damaged when defecating the blood clot and urine was flowing into the abdomen. The woman underwent a second operation to reattach the ureter into the bladder. This is an example of an unwanted event with quite serious consequences, because this patient had to undergo another major operation. Complications may also be less severe, but this one was serious.”

How did the discussion with the patient go?

“I found it very exciting. It is quite difficult to tell, in front of everyone: this did not go well. I also wondered whether it was good for the patient to be told in such detail exactly what had gone wrong. I didn’t want it to bother her. I also think that all healthcare providers found it exciting whether this way of discussing would not lead to additional claims for compensation and official complaints. We discuss openly and a colleague can say, for example: why didn’t you approach it this way or that way? That includes the patient.”

How was it for the patient himself?

“I heard afterwards from the woman with the damaged ureter that she felt safe during the meeting. I hear from some other patients that they found it exciting. We do our best to reduce their nerves. A nurse from the outpatient clinic explains what the intention is to do before the consultation and takes care of the patient afterwards. They may bring one person along for support, for example a friend or partner. We also never sit there with a white coat on. During the consultation, a doctor presents the history of the complication and then we discuss it as healthcare providers. The first few discussions was the search for the right words. You don’t want to leave any of the medical content behind and at the same time you want the patient to understand. So I couldn’t use difficult medical terms. We now have quite a bit of experience with these discussions. We ask the patient whether she has any additions to the complication discussion and whether she has suggestions for improvement. Sometimes that yields surprising insights.”

What kind of insights?

“The insight that patients’ experiences are sometimes completely different from what doctors think about it. A good example is the patient with the damaged ureter. Something else went wrong with her: the surgical wound became inflamed and burst open. I didn’t mind that much, but the patient thought the open wound was worse than the damaged ureter for which she had to have a second surgery. This has given me a lot of insight. It shows that some things that doctors don’t consider serious, do need improvement.”

Finally, how does it help patients?

“The discussion with patients is often also enlightening for them. They see that we take such an undesirable event seriously and want to learn from it. I think for most patients it also helps with processing. The patient with the damaged ureter put it this way: ‘The complication discussion felt like a coping process. I can now continue.’”

Petra Zusterzeel (49) has been working as a gynecological oncologist and researcher at Radboudumc in Nijmegen since 2010. There she operates on women with cancer of their ovaries, uterus, cervix or labia. During her education she worked for several years in a hospital in Australia. There she experienced that the discussion of complications was better than in the Netherlands. Back in her motherland, she started to work to improve this.

Tip

Did something go wrong during your operation? You will not be invited to the complication meeting any time soon; that doesn’t happen often. But you can always write a letter with your experience about what went wrong and ask if this can be included in the discussion.

This article previously appeared in Plus Magazine July/August 2022. Want to subscribe to the magazine? You can do that in an instant!