Author + information
- Marwan Badri, MBChB∗ ()
- ↵∗Reprint requests and correspondence:
Dr. Marwan Badri, Lankenau Medical Center, Lankenau Institute of Medical Research, 100 Lancaster Avenue, Wynnewood, Pennsylvania 19096.
For centuries, “primum non nocere,” or “first, do no harm,” has been one of the main bioethical principles taught to medical students around the world. However, almost all interventions undertaken by healthcare professionals are accompanied by some potential for harm. Even a simple procedure like phlebotomy causes needle-stick pain, which can be perceived as harm. These interventions are nevertheless justified, because the anticipated benefits are greater than the harm caused. This balance is reversed when complications occur, which are not uncommon in a high-risk specialty like cardiology.
Over the past few decades, cardiologists have achieved marked procedural advancements in the way cardiovascular diseases are treated. These have led to significant improvement in patient survival and decreased morbidity. Unfortunately, these procedures come at the cost of potential complications. Although the major complications of most commonly performed cardiovascular procedures are rare, they do happen. As a result, invasive cardiac procedures have been shown to cause stress to the performing physician, which is more pronounced in early career cardiologists (1). This stress may go so far as to negatively impact the psychological state of the performing physician (2). Physicians that experience these effects after adverse events have been called “second victims,” considering patients are the first victims (3). If unaddressed, these types of stressors can lead to physician burnout and increased risk of future mistakes, particularly among trainees (4). Although any procedure-performing physician can be affected, interventional cardiologists are likely more prone to this phenomenon when considering the complications of primary percutaneous coronary intervention, where operators’ specific interventions are recorded. During primary percutaneous coronary intervention, an operator’s procedure time is vital for patient outcomes and is also used as a performance measure, which can further increase their stress levels.
Witnessing procedural complications during fellowship has critical impact on fellows’ career choices, as well as their tendencies to refer patients to certain procedures as opposed to managing them conservatively. This is a vital part of training, where we gain perspective on the real risks and benefits of available interventions. Nevertheless, these experiences can lead to misconceptions if anecdotal cases are not viewed in the context of the known overall benefit of certain procedures.
Since deciding to pursue a career in interventional cardiology, I frequently thought about procedural complications and their implications. Witnessing cases where cardiac catheterization is complicated by retroperitoneal hemorrhage, stroke, or coronary dissection, I imagined myself being the responsible physician and thought of how I would react. I envisioned explaining to a patient and their family that despite our best efforts, a complication occurred that resulted in his or her suffering. Similar to any other fellow or cardiologist, I would be distraught when the main outcome of a procedure is a complication rather than success, even if that complication is a known possibility that was previously explained to the patient and family.
During fellowship, I have observed how my mentors handle complications, and I have learned a few lessons that may be helpful in managing adverse procedural outcomes:
1. The risk of complications reinforces the importance of judging the appropriateness of a procedure beforehand. It is by far easier to manage an adverse event of a strongly indicated procedure than that of one performed on less firm ground.
2. Concise yet comprehensive informed consents explain the physicians’ realistic expectations and concerns, as well as reflect the depth of their experience, making them more trustworthy to patients. Carefully obtained informed consents can therefore ameliorate negative reactions when complications occur.
3. It is important for us to remember that we perform procedures with the intention of benefiting patients. Although this may seem intuitive, most physicians feel guilty when complications happen (some to the degree of requiring professional help ).
4. When a physician suspects a complication, he or she should make all of the necessary effort to either rule it out or confirm and manage it. In other words, quoting one of my mentors: “A physician should never shy away from a complication.” Early recognition of complications allows their management to start before their adverse effects progress. Moreover, ruling out complications with appropriate testing provides reassurance to patients, the procedure-performing physician, and other members of the healthcare team.
5. Importantly, physicians should be forthcoming with their patients and patients’ families when a complication occurs. Full disclosure of the details of adverse events to patients is considered an ethical requirement according to the American Medical Association’s Code of Medical Ethics (6). Communicating the specific details of the adverse event and explaining the steps taken to manage it usually goes a long way in strengthening the physician-patient relationship and increasing the patients’ trust in their physicians. Additionally, disclosure of mistakes to patients decreases the likelihood of future litigation (7).
6. Self-critique is an important part of the constructive process that allows physicians to evaluate their practice to explore possible weaknesses and should, therefore, be performed when complications occur. It is vital that this process is differentiated from self-blame, which can only lead to lower self-confidence. When potential weaknesses are identified, discussion with senior cardiologists can be useful to make effective practice modifications that may avert future complications.
7. Physicians should routinely explore new procedural techniques that may lower the risk of complications of their interventions. An example is the transition from femoral to radial arterial access for coronary catheterization and the associated decline in risk of vascular complications. Although such practice changes may not be simple, they are achievable with the appropriate training and gradual adoption of techniques that have the potential to improve patient care.
8. When a colleague is involved in an adverse event, consider offering peer support, which can help restore his or her confidence (8), particularly by providing examples of similar complications and how you managed it.
9. When physicians experience a post-complication psychological consequence, they should seek support from their close friends, family members, or even professional help if needed to return to doing what they do best—take care of patients.
Although it is vital to take procedural complications into consideration when considering an invasive subspecialty, they should not be the primary determinant of a fellow’s future career. Medicine is not a perfect science and complications are inevitable, but the vast majority of procedures result in the intended favorable outcomes. A physician with strong procedural skills should allow patients to benefit from these skills, as procedures will continue to be a fundamental part of contemporary cardiovascular care.
- American College of Cardiology Foundation
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- ↵American Medical Association. AMA Code of Medical Ethics: opinion 8.12—patient information. 1994. Available at: http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion812.page? Accessed August 24, 2014.
- van Pelt F.