Three weeks ago, I went to see my surgeon, the ob/gyn who performed my hysterectomy last fall. The last time I had seen her was in January, the day my complication was diagnosed. In my mind, though, she had been present throughout my various procedures and recovery, even after the urologists took over my care and our only continued connection was through what I sent to her. I had talked with her once after the urologists placed my drains, and after that, emailed (my preference, a consequence of my lifelong terror of the phone). I had sent her my article during those first weeks, and she emailed back that it described her own experience. Time had separated us more by the time of my visit, but I kept her up to date with plans and surgery reports.
We had become entangled by concern as I worried as much over her experience as my own. So to the extent that my meeting with her last month was a conclusion, I was sad to see her go, and I felt unaccountably lonely that day. This long, shared experience, that wasn’t really shared but perhaps co-imagined, had made me want to cling to that connection. But yet, what to do with it? And the awkward: she is not my colleague; we are not friends.
And yet, as I spoke with her, I found myself wanting to ask questions like a colleague/ mentor/ teacher/ friend more than as a patient. What did you see, what did you do, what (if anything) have you changed? And to explain what I had surmised, technically: that my injury was subtle and would have been hard to detect at the time of surgery, my ureter at first patent, then after 20 days blocked, then, soon after, ruptured. That my best guess is a devascularization injury to the ureter that caused it to deteriorate slowly. That, at the end of surgery before closing, everything might have looked normal.
Long before I had my surgery, I knew that she was a low volume surgery provider. I know the data: that, statistically, lower volume surgeons have higher complication rates. I knew it before my own surgery and thought but didn’t seek to make a change. I probably could have asked to go to the large referral hospital in the same town– I certainly could have withstood the awkwardness of the request. Perhaps I partly thought that the odds were still (and ever) in my favor, as they were. Statistical risks don’t get you far as an individual. I liked her hands.
Why would high-volume surgeons have lower complication rates than low-volume surgeons? Partly it may be the development of the manual, physical skill of surgery. Practicing a fine motor task leads to greater skill, and perhaps in this case the more you practice the greater the skill. But I think also that there is an accumulation of knowledge about anomalies and an abundance and diversity of feedback as one does surgery more often.
In some surgeries and for some complications, the feedback is immediate. This fast feedback enhances learning because the error and the consequence are memorable and easy to connect. These complications may be painful or scary or intense in the moment, but the connection between cause and effect is never in question.
In my case, the feedback was long delayed. By the time I had my ureter reimplantation surgery, suture from the original surgery had dissolved, scar tissue had formed, and the original injury was completely obscured. Even worse, the only way that my surgeon knew about my progress and the only way she saw my surgery report was that I sent these things to her. Otherwise she would have had no follow-up or feedback at all after the complication had been recognized. Without my efforts, her knowledge of my complication would have been limited to the findings on the day of its discovery.
This lack of feedback feels perverse. It is the consequence of privacy laws and complicated, diverse, and poorly interconnected systems in medical care. But it is not the way to support doctors or to improve the quality of care they provide.
Atul Gawande describes the need for a more robust feedback loop in medical care in this Freakonomics Podcast episode (and talks about how immediate feedback interventions– like the use of anesthesia in surgery–catch on much more quickly than delayed-feedback ones — like antisepsis).
I wish I could end this post with some brilliant solution to this lack of feedback, but for now, I only have the observation. I suspect the problem is less prevalent in veterinary care both because of less emphasis on privacy (no HIPAA for pets), and because of less complexity and specialization in the systems of care. I’d like to think that Atul Gawande is right when he says in this podcast that we’re in the MS DOS phase of medical information systems, and that at some point in the future, systems will be integrated enough to provide medical providers with the feedback they need.
As for me, other than being determined to climb bigger mountains than my current fitness level would indicate, I am doing well. My incisions are all healed and my various tubing has all been removed. Other than follow-up with occasional ultrasound exams, I’m done with this whole process of complication and repair.
I’ll end with a few more pictures from my hike last week on Mt. Cube (scroll back up to the beginning of this post to see the panoramic view from the mountaintop).
Magnificent post, Sarah. Your graceful and engaging writing style, your intimate sharing, your exquisite photos, all of it is magnificent. Thank you for this wonderful thread. While I’m now – newly! – fully retired, my muscle memory lives on and is aroused by your words. As is my intellectual property, which I hope to continue to share..
Thank you Joan, and congratulations on your retirement!
I’d like to think communication is better in veterinary medicine, but I’m not sure it is. In our specialty hospital, information is only conveyed to the referring veterinarian and not other vets who may have played a role in patient care. If clients self-refer, there is no feedback to any veterinarians. Even within our own clinic, there isn’t an automated system for giving feedback to diagnostic services like radiology, pathology, and clinical pathology about whether the final outcome validated their findings. Likewise, quality issues are not communicated. For example, I have to bring my own cat back for ultrasound-guided liver aspirates 3 times because the initial aspirates were of poor quality. The radiologist never would have known there was a technique problem if I didn’t tell them.
I agree Julie, I don’t think our communication is necessarily better. The bigger and more complex a system (healthcare, including animal) becomes, the more difficult it seems to be to manage communication within it. It would seem like an integrated system like a referral hospital would have a leg up on those of us in independent practices (who also don’t necessarily communicate with each other well), but the complexity of the system seems to counteract the benefits.