For both physicians and patients, surgical complications can be profoundly difficult to navigate. While most surgeries go well and recovery follows expectations, a percentage of patients will experience an unexpected and sometimes severe, even life-threatening complication.
In the modern age of medicine, corporations and health insurance companies exert enormous influence over care. The doctor has become a “provider,” the patient a “consumer,” and the vital physician-patient relationship has been cheapened by bureaucracy and risk management that forces us into transactional interactions. When that relationship begins to feel akin to placing a takeout order complete with google reviews, navigating complications can be even harder for everyone involved.
Over the years, I have remembered every patient who experienced a serious unexpected complication, partly because they happen so rarely, but also because they stay with me emotionally long after. When one of my patients had a stroke in the early postoperative phase over the Christmas holiday, I stepped away from my family’s celebration to walk alone, calling my father, also a physician, to break down in a way I couldn’t in front of my husband and children. I could not stop thinking about her family: huddled around an ICU bed over the holidays, absorbing the reality that she would never be the same. Years later, I still think about her often and every single Christmas. Complications are always hardest for patients and their families. But they leave a permanent mark on physicians as well.
Another of my patients was initially too high-risk for surgery. We spent two years working alongside his primary care physician to optimize his health until he finally qualified, only for him to suffer a massive heart attack a few days after his procedure. For days I turned it over in my mind, wondering what I could have done differently, grieving that he never got to enjoy the joint replacement he had worked so hard to receive. Sometimes, though, I accept there is no way to predict a negative outcome. No way to know that despite every precaution and clearance, a patient will still experience an acute event that profoundly changes or ends their life.
One of the hardest parts of any complication is sitting with the anger and grief that families and patients understandably feel, while simultaneously putting myself through the same torture internally, questioning my decisions, my skill, my dedication. Hindsight makes second-guessing effortless. Even when risks can be anticipated and reduced, it can still feel surprising even shocking for family. One patient who I think of often with mild early dementia needed a hip replacement and, together with his family, decided to proceed. We had a detailed conversation about the risks of anesthesia for patients with cognitive decline: the potential for delirium and the possibility of permanent worsening. We all understood what we were weighing. But when his dementia did worsen, not just acutely, but permanently, his family was devastated, and certain they had never truly understood the risks. It can be nearly impossible to hold onto nuanced conversations about risk and benefit when no one ever truly believes they will be the one percent. I questioned myself for a long time. Could I have explained the risks more clearly? Should I have simply declined to operate? I still don’t know for certain. I wish there were an alternate dimension where I could see the other outcome.
No matter how many patients embrace me in the hallway, send photographs of themselves living fully again, or tell me I changed their lives, I will always remember the few whose outcomes I couldn’t control. The few who were changed, not for the better. The few whose families are grieving. And the losses will always weigh more heavily than the victories. I suspect they always will. It keeps us careful, vigilant, and is part of the work of being a surgeon.
Then, mercifully, there are the families who respond with such grace that they restore my resolve and give me the courage to keep doing difficult surgeries and making hard decisions. One patient I was particularly fond of was quite elderly, miserable from hip arthritis so severe he could no longer walk. His heart condition made surgery high-risk. After lengthy, honest conversations, we decided together to proceed. He had an uneventful early recovery but succumbed to heart failure a few weeks later. While I was quietly wishing we had chosen otherwise, his widow reached out to tell me how grateful they were that he had been able to make that choice and enjoy his new hip, even briefly. She understood that he had not wanted to live in pain and immobility, and that for him, the chance to try had been worth any outcome. Her grace was a gift I did not expect and have not forgotten.
Sadly, not every story holds that kind of peace. When outcomes are devastating, it is natural to look for somewhere to place blame and the surgeon is the obvious and sometimes rightful target. If there is one thing I would want patients and families to know, it is this: we are harder on ourselves than anyone else could possibly be. The moral injury that accompanies a serious complication can be almost debilitating, reaching into our personal lives and health in ways that are rarely visible from the outside. Learning to compartmentalize, to remain whole enough to show up fully for the next patient is a necessary and difficult skill. But some days, the impulse is simply to lay down the scalpel and walk away.
A mentor once told me, “If you don’t like complications, don’t operate.” There has never been a truer statement. Even the most skilled surgeon in the world has faced devastating complications and loss. There is no way to avoid it entirely. But we must return every day, knowing we will sometimes fall short. The work is to remember the ninety-nine percent, and to hold those moments of connection and recovery close enough that we have the strength to absorb whatever the next unexpected outcome asks of us.