Updated: Jun 22, 2018
A few years ago, on the 22nd of February, my aunt went in for a gynecologic surgery. The surgeon had recommended a minimally invasive procedure so she could be back home quickly. She discussed it with her sister - my mom and a doctor herself - and all the indications were that this would be “routine”. The surgery was completed as planned, and within a few hours my mom received a call relaying the procedure went uneventfully. Everything seemed fine and my aunt was recovering well. A couple of days later, when my aunt got up to use the restroom, she suddenly felt breathless. Before my family could fully grasp what was happening, she was in the ICU. And before long, my mom received another call, except this one had a very different tone. The message this time was that “something has happened”.
My aunt was a second mother to me. I grew up with her, spending every one of my summer breaks at her home. Because my mom had a busy clinical practice, she could never really take a summer break. My aunt ended up being the caregiver for my grandparents, other family members, and even our family dog. Somehow, she always seemed to have the energy to do it all. She was a mathematical genius and her passion for the subject was infectious. Every summer, she challenged me for many hours a day with math problems, somehow managing to make it fun. Just as my mom was our family’s primary doctor, my aunt was our family’s primary event organizer. She organized all our holidays making it enjoyable for all age groups. And she did all this so gracefully. Always ready to serve, she hesitated to bother others for her needs.
That February though, when my mom flew in, she was shocked to see the state her young sister was in. Hadn’t it been a routine procedure on a healthy woman? How had she deteriorated so quickly? All the pre-op tests she was told were normal. And the anesthesiologist had cleared her for surgery. But the lab results now seemed unbelievable, and my mom tried to seek answers to the medical questions. This surgeon had done many such surgeries safely. But from having opened up many an abdomen herself, my mom was known to say, “opening an abdomen is like opening a pandora’s box”. Had the surgeon found something in my aunt’s abdomen that wasn’t normal? My mom’s own friend, a trusted radiologist, had personally come to the hospital to perform a thorough abdominal scan. After reading it herself, she confirmed there were no perforations or apparent technical issues with the surgery. At this point, an abdominal infection was suspected. By the time her son (my cousin) made it to the hospital, she was already on a ventilator. A couple of nights later, at around 11 pm, the nurses told the family to rush to the ICU. Running down the stairs, my cousin overheard the nurses saying that it was over - my aunt was no more.
In the wee hours of the morning, my mom could hardly make sense of all that had happened. How could her own sister be dead days after a laparoscopic surgery? How many thousands of women had she personally witnessed go through such surgeries! From her own point of view, surgery had evolved so much. Operations like this had become so much safer. When she started her career, these surgeries were done with a six inch incision across the abdomen. Now, as her sister had experienced, it was a minimally invasive procedure. Using laparoscopes, the surgery could be performed through only tiny poke-hole incisions with cameras to guide their work. It was much safer with minimal blood loss and an easier recovery. It was all simple; until it wasn’t.
None of us got to say goodbye to our aunt. The surgeon later surmised that the reason for death was probably a pulmonary embolism and sepsis. He then went on to say that each case was different and that the same things he had given his other patients hadn’t worked on my aunt. He said that each human body was different. Was this no longer a “routine” or “standard” case?
Universally, anyone who hears a story like this views it as tragic; what comes next varies widely based on the individual. Some will be immediately tempted to invoke the “fragility” of human biology. Others will philosophically ascribe it to the unpredictability of life. Some others feel indignant and blame the medical providers. To me, it seemed this simply should not have happened with skilled doctors and an otherwise healthy surgical candidate. I have since spent many nights trying to understand surgical complications.
Sepsis and pulmonary embolism, I learned, are “common” and surgery increases their risk. The reported crude mortality rate after major surgery is 0.5 - 5%, and complications after inpatient operations occur in up to 25% of patients. Looking at the US trend alone, hospital mortality rates were going down significantly after non-elective surgery, but no such improvements were occurring for elective surgery patients who developed sepsis. An estimated 9 million people have post-surgical sepsis annually, and the global incidence of sepsis is on the rise. Does that mean our tragedy could be re-lived by that many families every year?
On that fateful morning, my aunt was the first of many such cases that this surgeon performed in that same operating room with that same team. How was she different? Perhaps she was at a higher risk for infection and blood clots compared to the other patients? The surgical team followed a standardized evidence-based protocol; but in speaking with leading surgeons and scouring academic journals, I found published research on many specific risk factors for each type of complication after surgery. Why wasn’t my aunt assessed for each of these known risk factors? Because this was a “routine” procedure on a “healthy” patient, were the possible risks subconsciously minimized in the minds of well-meaning doctors? Surely, armed with specific risk information for each complication type, more tailored interventions could have been pursued at the earliest sign of a complication.
According to the World Health Organization, at least half of the cases in which surgery led to harm are considered preventable.
At least half of the cases in which surgery led to harm are considered preventable .
Why then was the hustle demonstrated after the complication dramatically more than what was demonstrated before the surgery? Could the preparations have been personalized to my aunt’s risk levels? Could some optimizations have been done before the surgery to avoid the complication? If we don’t have a “before” picture of her risk for complications, we cannot make sense of the “after” results. Without risk-adjusted outcome measurements, this surgeon, the medical community and researchers could never truly learn from this tragic loss.
When any doctor uses the word “routine” now, I reflexively cringe. When they say a complication occurs only 5% of the time, I break into a sweat. No one wants to be in the 5%. When you are in the 5%, the complication happens to you 100% of the time. I am not bending the statistic, I am speaking only of the reality when viewed from the lens of the patient and their family. If complications can be prevented, is there not an imperative that we pursue it? Surgical utilization is rapidly accelerating worldwide. Our population, and hence the surgical candidates, are increasingly older and sicker, and we do more surgeries today on an outpatient basis than we do in the hospital. Investments in risk management beforesurgery then are one of the most critical levers for any healthcare system.
After my first healthcare startup, I worked at Providence Health & Services, the 3rd largest non-profit health system in the US. I was in the health plan division, where existed an urgent and strong incentive to mitigate health risks. It was here, developing health risk assessments, personalized patient engagement and digital health innovations, that it became increasingly clear to me that all healthcare is risk management.
All healthcare is risk management.
Whether it is preventing chronic diseases or planning acute care, proactively mitigating risk is required for consistent outcomes. No matter how many advancements are made in medicine, their application carries inherent risk. A health plan, however, looks at risk at an aggregate level. I didn’t want to reduce risk for “most 40-50 year old non-smoking females who were getting surgery”. I wanted to mitigate the risk for each patient like my aunt. Population health carries the allure of helping many, but I believe it is critical to focus on each specific surgery and each specific person. Getting it right individually adds up to getting it right at a population level. As I had learned first hand, each surgery is unique.
Today, for the first time in human history, errors of ineptitude have overtaken errors of ignorance as medicine’s key problem. Some of our society’s brightest minds become surgeons today. But they are human too; and limited by the same cognitive biases and misleading heuristics all of us routinely display. I wanted to empower these surgeons to do everything they possibly can to mitigate surgical risk. If every medical intervention is a risk we take, each time we must pair it with a rigorous risk mitigation strategy.
If every medical intervention is a risk we take, each time we must pair it with a rigorous risk mitigation strategy.
This is the only way we can get to 0% complications. If our medical professionals had access to all the relevant patient-specific risks at the time of their decision-making, it puts them in a position to target mitigation strategies on an individualized level to ensure better outcomes for that patient. Why then are we still discussing standardization protocols, when we understand that each patient is so different? Today, we can garner intelligence from vast amounts of personalized data. Precision medicine means every patient gets care perfectly tailored to her, even if it’s not the “standard of care” at a population level. No longer would we simply consent to the generic “5% chance of complications”.
Personalized Medicine may seem to some as a new buzzword; but to me, and our team at Ready Surgery, it simply means one safe surgery at a time; one young woman, like my aunt, at a time. Medical rigor means no family ever looks back after surgery and wonders if anything could have been done differently. That’s why I started Ready Surgery.