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Unexpected events are a reality of life, whether in the context of medical treatment or otherwise. However, often times patients and their families seem to develop unrealistic expectations going into a procedure, believing that it is merely routine and that nothing significantly bad can happen, despite acknowledging the contrary when executing the informed consent documents. Our experience suggests that patients and their families also tend to react with more emotion when something bad occurs in a medical context than they would in some other setting. Right or wrong, this seems to be a reality. Consequently, when you find yourself in this circumstance it is appropriate to have an honest and frank discussion with the patient or her family so long as it is based upon fact rather than upon mere speculation. However, you must be cognizant of the fact that even when you have the facts, or believe that you do, you might just lend fuel to the fire if you speak before you think!! Consider the following and you will see how choosing your words carefully is an important aspect of conversing with your patients, particularly after complications have occurred.

Dr. Z, a busy surgeon, has been in practice for 30+ years and has seen it all as the saying goes. Over the years he has become somewhat vocal with respect to a number of things including the expertise of some of his younger colleagues when compared to his own; something that may be justified at times but is nevertheless seed for trouble in many instances. In October 2003 the seasoned veteran was called into an emergency involving a 65 year old woman who had experienced a vascular complication while undergoing back surgery. Apparently, a younger general surgeon perforated one of the iliacs during an anterior approach to provide exposure for the orthopedic surgeon. After quickly evaluating the situation Dr. Z attempted to repair the rent but each time he placed a suture the vessel tore. He was later quoted as likening the integrity of the iliac to "wet tissue paper" and he was of the opinion that everything done for the patient from the time he arrived was reasonable, prudent and timely. Exhausted after a lengthy fight to correct the problem, Dr. Z left the OR a bit frustrated and with a gut feeling that the problem would not have occurred in his experienced hands. Of course he did not have the benefit of a compete evaluation of the patient's vascular disease status and or the younger surgeon's full explanation of what occurred just prior to the bleed.

Shortly after finishing the surgery, Dr. Z spoke with the patient's husband and adult children in an effort to describe the circumstance and to explain what had occurred. In a blunt, Joe Friday, fashion typical of Dr. Z in later years, he used the word "sloppy" when describing the conditions in the OR.

Because of the severity of the blood loss intra-operatively the patient developed DIC and despite aggressive efforts she died later in the day. In retrospect and with the luxury of a review of the autopsy report as well as the explanation of the surgeons involved in the case, the good doctor reached the conclusion that the patient's vessels were extremely friable due to disease. He was of the opinion that the initial tear in the iliac probably occurred during movement of the vena cava which had to be "teased" off of the spine due to adhesions. He testified in deposition that this injury was likely unavoidable for that reason. Nevertheless, his comment during the immediate post-operative discussion with the family stuck in their minds; leading the family to conclude that the technique employed by the young surgeon must have been "sloppy" and must have caused the injury. After sharing this comment with an attorney, suit was filed against the general surgeon based upon his technique and against the orthopedic surgeon for failing to supervise the younger surgeon's anterior approach. While the veteran defended the young surgeon in deposition he was honest enough to own up to his comment to the family and it then became a credibility fight between the plaintiffs, who claimed that the comment was aimed at the surgeon's technique, and the veteran, who claimed that he was simply referring to the problem with the vessels and the amount of blood loss he encountered in surgery.

The above clearly demonstrates the impact that your words have upon the patients you treat and or their family members. I am not advocating that you not speak with patients and family in an honest and frank way. I believe that doing so is an important part of being a complete physician. I am, however, suggesting that you be as sensitive to what you say as you are to the patient's need for explanation and consolation following an unexpected adverse event.

Until next time, remember: Your mouth is not anatomically designed to accommodate your foot so stop trying to prove Mother Nature wrong by inserting it where it does not belong!