Extremely frequent, virtually always occurs
Very frequent, very commonly occurs
Moderately frequent, commonly occurs
Relatively frequent, usually doesn’t occur
Relatively infrequent, uncommonly occurs
Very rare, very uncommonly occurs
Extremely rare, exceedingly uncommonly occurs
Medical importance or significance: major, minor, inconsequential
Patient importance: debilitating, disabling, inconvenient, annoying
Legal importance: direct negligence, potential negligence, possible association, unassociated
Disability: permanent, partially recoverable, transient (recoverable)
Extent: complete, partial
Significance of Complications
The context and perspective of the individual who is viewing the complication, risk, or consequence of surgery is the key factor in determining the significance of a complication. Perhaps surprisingly, the actual degree of incapacity, inconvenience, or severity of the complication itself is not, of itself, always the prime factor in making a complication significant for a patient. Grading of the significance of any complication or consequence of surgery or the relative risk of these is a potentially complex issue and is highly dependent on the person or perspective from which the judgment is made. The reason for the surgery is another key factor; for example, cancer patients are often most concerned about survival.
Frequently the patient, the surgeon, the lawyer, and the health system will demonstrate differing views on the significance of a particular complication. Additionally, it is not unusual for the precise view of a complication to alter over time. As the patient and surgeon gradually adapt to any incapacity or become accustomed to the results of a complication, the “severity” of the complication may “lessen” over time. Conversely, a complication may become longer term or increase in severity with time, leading to increasing irritation or incapacity producing increasing dissatisfaction.
A very frequent complication may be viewed as expected and if minor may not be significant but should usually be mentioned to the patient. An unsightly scar may be viewed as inconsequential by the surgeon or general practitioner but may be the most disappointing outcome of an operation for the patient or patient’s partner. Conversely, the surgeon may regard the breast reconstruction as near technically perfect, but the patient may be disappointed with the outcome. A major intra-abdominal anastomotic leak and infection may be regarded as very serious, devastating, and technically imperfect by the surgeon but not recalled or considered a major event by the patient after recovery, due to sedation and ICU care. Some complications are important in the perioperative period but pale into insignificance when the patient is well again. Some long-term relatively minor complications are annoying or irritating for the patient, while these may be considered minor and inconsequential for the surgeon. Some of these “minor” irritating long-term complications, for example, neural injury resulting in parasthesia or anesthesia, may torment the patient and come to the attention of the lawyer and courts, sometimes involving the surgeon, hospital, and indemnity insurance companies in protracted, time-consuming, and costly litigation. This is especially the case with failure to inform the patient of that risk and when poor communication has occurred.
Legal Considerations and Significance
The principal objective of legal counsel is to address the case for an association between the complication experienced and the surgery performed, what was told to the patient during consent, and the degree of disability suffered. The main burden of proof is to establish whether the surgeon was negligent in their duty of care, including performance of the surgical procedure, and that the patient has suffered loss. The difficulty is that legal significance does not always equate with medical significance in relation to a specific complication. Some cases are more clear-cut – for example, the amputation of the wrong limb or removal of the incorrect kidney.
The economic significance may be viewed very differently from the perspectives of the:
Patient (e.g., loss of time, work, income, mental health, enjoyment, life)
Surgeon (e.g., loss of competence, professional standing, prestige, referrals, mental health, credentialing, income, registration)
Family (e.g., loss of health or life of spouse, parent, grandparent, child)
Lawyer (e.g., gain in fees, loss of case, winning of case, prestige, business)
Hospital (e.g., loss of standing, money, insurance, patients, accreditation)
Health system (e.g., loss of standing, money, insurance, patients, media profile)
Community (e.g., loss of employee, money, volunteer, family member, friend, contributor)
The spiraling cost of healthcare has engendered a firm focus upon the way medicine is practiced and the manner in which hospitals are managed. The cost of adverse events is displayed at multiple levels within the health system, and only a proportion of these costs are able to be quantified adequately at the economic level. Many of the true “costs” are hidden, transparent, or unquantifiable in strict economic terms – examples are psychological consequences, loss of enjoyment, low-level impairment, and loss of confidence in the medical and health systems. For example, the cost of postoperative surgical infection, with prolonged hospital stay and/or readmission to hospital, constitutes a major burden for the health sector, both for governments and, where present, for the private health industry. Any reduction in the frequency or magnitude of surgical complications, through measures to prevent or recognize these earlier, will be expected to show a significant impact on direct hospital costs and the indirect costs incurred through litigation and insurance. The importance of cost and economic factors in surgical care and complication avoidance (where possible) is only likely to increase.