Learning From Post-Op Complications In Residency

I have been told, “If you aren’t seeing complications, then you aren’t doing surgery.” It is an unfortunate inevitability but something that we all must learn to deal with. Residency centers around surgery. We show up, assist on a case and then move on to the next. More often than not, we are not present during the preoperative workup, surgical decision making or the postoperative care. We also rarely ever see the actual consequences of the complications that arise.

In residency, one of the first surgeries I assisted on was a derotational arthroplasty of a fifth digit. When the procedure was done, I felt happy with the bone cuts, the suturing and with the derotation we were able to achieve with the skin ellipse. After we finished and before we bandaged the foot, the attending looks at the toe and says, “Well, it is a little floppy but I am sure it will be just fine.” He was not worried. He felt the procedure went well and felt the patient would be extremely happy with the result. However, I had a different opinion.

I have set a high standard for myself during residency. I did not get this far in my education just to phone it in during my surgical training. During the drive home from the hospital, I went over every step of the procedure to see what I could have done better and to learn how I could make sure the complication did not happen again. This was my first complication. In the postoperative period, my attending was adamant that the patient was happy but that didn’t change the fact that I was not.

This was a very valuable lesson. Not everything goes right all the time. Since then I have been a part of other procedures that have had complications in the postoperative period. Recently one of our attendings performed a first ray procedure in which the patient began changing dressings and picking at and removing her own sutures during the first weeks of the postoperative period. Her incision dehisced and she ended up with subsequent infections. Not only was this a learning opportunity for dealing with post-op complications and infection, but it was a good practice management lesson.

I had always assumed that nothing in the postoperative period was billable. However, I recently learned that if the patient is not progressing at a reasonable pace, or has unforeseen complications (i.e., self-inflicted dehiscence), then you may begin billing for those wound debridements and office visits, provided you have appropriately documented the issues as well as attached the appropriate modifier. In this case, you need a 24 modifier for an unrelated evaluation and management (E/M) in the postoperative period, or a 79 modifier for any debridements/procedures in the postoperative period. These are very important modifiers to know as they may allow you to be reimbursed for performing extensive wound care and management beyond what was normally expected in the postoperative period.

Complications happen to everyone. After being able to be a part of some surgeries with complications, I would say it is extremely important to have some experience early on. That way, when you are on your own, you have an idea of how to conduct yourself and manage the patients.