Our Writing Contest

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A Lesson in Humility and Forgiveness

by Richard T. Bosshardt, MD, FACS

We are pleased to present this award winning article by Richard T. Bosshardt, MD, FACS, who received the grand prize in our writing contest. Dr. Bosshardt is a board certified plastic surgeon practicing in Tavares, Florida.

We look forward to publishing the two remaining winning entries in future issues.

In 17 years of private practice, I have been named in three malpractice suits. You’ll just have to take my word for it when I say that not one was truly malpractice. Two involved adverse outcomes, and although I felt both were defensible, I chose to settle rather than go to court. I was dropped from the third suit because it was clear, even to a very aggressive plaintiff’s attorney, that I was not culpable. This story, however, is about the time I wasn’t sued.

The patient was a middle-aged woman on whom I had performed successful carpal tunnel surgery years earlier. Now, the problem was her right ring finger, which was tender over the proximal interphalangeal (PIP) joint, and she felt something “catching” or “snapping” when she flexed it. Her examination was normal except for the impression that something was getting hung up as she flexed the finger. I felt that, for reasons that were unclear, part of her extensor mechanism over the joint might be slipping laterally as she flexed the finger. The x-rays were normal. I recommended surgical exploration and repair.

I had not encountered this problem before, and therefore, prior to surgery, I reviewed my finger anatomy, especially that of the extensor mechanism. On the morning of surgery, I carefully checked the finger in the preoperative holding area to verify that the problem had not changed. In the operating room, I put on my 3.5x surgical loupes, as was my practice for all hand cases, and went out to scrub, as I had done hundreds of times before. Reentering the room, I approached the table, where the arm had been prepared and draped by the circulating nurse. Sitting down and peering through the loupes, I grasped the finger and carefully marked out a gently curving incision over the PIP joint. After exsanguinating the arm and inflating the pneumatic tourniquet, I incised and reflected the skin, and began to explore the extensor mechanism, which looked surprisingly normal.

At this point, Mike, the circulating nurse, approached the table and looked over my shoulder. “I thought we were doing the ring finger…,” he noted, the sentence left hanging. I felt a cold chill. As the implication of his comment became clear, I suddenly felt, quite literally, nauseated. I looked around the telescopic lenses of my loupes and verified that I was indeed operating on the wrong finger—the long finger, as it turned out. It was one of those situations from which there is no graceful recovery. Neither was there a hole in that OR big enough for me to crawl into. With a sigh that could probably be heard far down the hall, I carefully closed the incision and, after regaining my composure, proceeded to explore the correct finger. I found a small bony spur that was snagging the edge of the extensor tendon and trimmed it away. Her problem was solved but mine was just beginning.

After settling the patient in the recovery room, I had to go out and face her husband. Fortunately, their pastor was with him. Doubtless, his presence served as a buffer and softened the husband’s reaction at my unwelcome news. I apologized, explained what had happened, and reassured him that, beyond the small scar, there should be no ill effects to the long finger. Although upset, he reacted graciously; probably more so than I might have, had I been in his shoes. When I explained the situation to the patient later, she was so kind and understanding that she just made me feel even worse, though I wouldn’t have thought this possible.

Reflecting on events, it became clear what had happened. The involved finger did not show any external abnormalities. Since it was not marked in any way, the tunnel vision induced by the loupes allowed me to grasp the wrong finger. My chagrin at this gross error was all the more painful as I really had no excuse for it. I was not in a hurry, had not been distracted in any way, and had even taken extra precautions to prepare for the case, including my immediate preoperative reexamination. Before this case, I would not have imagined that this scenario was possible. I was shocked at how easily this happened.

Although the patient and her husband took the news well, the incident sent shock waves through the hospital. Meetings were held with hospital administrators, operating room staff, and the chief of surgery. As a result, the hospital’s protocol for identifying the site of surgery was completely revamped, especially as it pertained to extremity surgery.

The state board of medicine initiated a full-blown investigation of the event to determine what action needed to be taken. I wrote out a summary of the events, as accurately as possible, along with my assessment of how this happened. Because of potential licensure issues, I retained an attorney to represent me before the board and was informed that the best I could hope for was a “Letter of Concern.” As he explained it, this would be tantamount to the board saying “go, and sin no more.” So long as I had no further incidents, after a couple of years, the letter would be removed from my file at the board of medicine. Much to my relief, this was, in fact, what happened.

So, in all this, what about the patient and her husband? As I had expected and fervently hoped, she did well and had no further problems with either finger. We discussed my “faux pas” in my office at length, and the husband stated that he had been very angry at first, but after reflecting a bit and talking it over with his wife, he realized that mistakes happen. The fact that I had owned up to it immediately and without excuses went a long way toward allowing him to accept this as an unfortunate, but sometimes unavoidable, aspect of medicine. The patient herself never expressed any displeasure or consternation and did not seem to lose any confidence in me. The possibility of litigation never even came up. It was a very humbling experience and a demonstration of patients’ amazing capacity for forgiveness when their physicians prove all too human.

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