One of the benefits, or aberrations, depending on your point of view, of the fee-for-service model is that we surgeons are remunerated for correcting our mistakes and complications.
At first glance this seems wrong. But perspectives differ, and when a doctor has to deal with serious, undeserved complications and is self-employed he deserves to be compensated adequately. So what really is the difference between the two?
A complication may be described as an adverse event caused by pre-existing factors that were outside the doctor’s control. Patients are not the same in health, habits, immunity or healing power, and have varying susceptibility to complications. A mistake, however, assumes there was a lapse of either quality or control by the surgeon out of keeping with normal expectation.
There are many examples. During thyroidectomy, injury to the recurrent laryngeal nerve may cause permanent hoarseness. If the surgeon does not find the nerve and injures it as a result, this is a surgical mistake. If he does find it, preserves it, and the nerve loses its blood supply and a palsy results, this is a complication. If tumor invades the nerve and it has to be sectioned, this is a complication.
When an intercostal chest drain is inserted through too low an intercostal space and injures the diaphragm or liver, this is clearly a surgical mistake. If it is inserted in the normal location, and still injures the diaphragm or liver, this is a complication. If however a chest x-ray taken beforehand shows an elevated diaphragm, the complication deserves to be considered a ‘mistake.’ The doctor should have known.
A misplaced suture through the rectum during a hysterectomy, and the resulting disaster in all its complexity is a mistake more than simply a complication.
So who cares? As long as surgeons operate, complications will occur. Insurers, hospital managers, healthcare systems have highly vested interests in limiting both complications and mistakes, as do doctors. We remember these long after our successes are forgotten. So do our patients.
Malpractice lawyers are very interested in the difference. Here is an excerpt from the main webpage of a medical litigation practice:
Whether a surgical complication is the result of medical malpractice is often a complicated question. Therefore, it is critical to contact a medical malpractice attorney with the knowledge, skill, and dedication to effectively prosecute your case.
The message I get from this is that lawyers will fall over themselves to show that a complication was in fact a mistake worthy of financial retribution.
A doctor with a higher incidence of mistakes may profit from his relative lack of skill until the general population wises up to the fact and goes elsewhere. Yet surgeons who tackle more difficult surgery will have more complications and should not be penalised for dealing with them.
Is the fee-for-service principle the real problem? Should there be a global fee that covers all possibilities and eventualities? I don’t know.
There is one critical area however that clearly distinguishes the two – that of informed consent. If a patient is not warned of possible complications beforehand, any complication is in my opinion a mistake, and the surgeon should face the consequences.
And yet with surgical error, as with human error, there are still gray areas. Things go wrong. Every surgeon knows that it is simply a matter of time before the next complication or mistake. As for apportioning blame, often the only person who knows what really happened and why is the surgeon himself.
Martin Young is an otolaryngologist and founder and CEO of ConsentCare.
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