Dr William Higgins on Surgical Complications

H. William Higgins II, MD, MBE, FAAD, is a Mohs micrographic surgeon in Philadelphia, PA. He is an assistant professor of Dermatology at the University of Pennsylvania and lab director at the Pennsylvania Hospital Mohs surgery unit. He joined The Dermatologist to offer insights into his session, “Surgical Complications” presented at the AAD Summer Meeting.

Can you tell us a bit about the Summer AAD presentation, “Surgical Complications”?
People in the dermatologic surgery community go to meetings for two reasons.

One, to learn how to execute techniques well, and second, to learn how to manage situations where things don't go well. Our session covers the latter.

Studies have shown that physicians attend meetings to talk to their colleagues about complications, about cases that didn't go well, and about dealing with burnout, which is a hot topic issue.

Our session showcased top-tier speakers who covered a broad range of topics that are applicable to people in all levels of experience. This includes people fresh out of fellowship, seasoned dermatologic surgeons, academic clinicians, and private practice clinicians.

They review case-based examples of complications, the evidence on how to manage those complications, and how they treated their own surgical complications.

How could shared decision-making and patient education help reduce postsurgical complications?
Shared decision-making is so impactful for what we do for patients every day. Prior to the procedure, the conversation we have includes getting to know the patient, getting to know their social situation, who they live with, their activity level, and how capable they are of taking care of a wound after surgery.

Taking a moment before engaging in a surgery to learn about an individual and their expectations for the procedure is essential. Reviewing their cosmetic outcome, the functional outcome, and coming up with a shared decision all help to minimize complications and increase patient satisfaction.

Eg, there may be scenarios where a patient might benefit from a less invasive procedure. Going through the different treatment options with the patient, giving them the different treatment cure rates, and discussing the potential adverse events that go along with each procedure helps the patient to feel engaged. It shows how much we care and helps us decide together on right path for treatment.

What are some simple prevention techniques that derm surgeons can use to help avoid complications?
Staying up to date, going to meetings, speaking with colleagues, and being humble about it when it happens.

As far as preventative techniques, knowing the anatomy of the site you're working on, knowing the comorbidities of that patient that might put them at higher infection risk, higher bleeding risk, or higher risk of pain associated with the site. We factor all of these factors in when deciding how to treat them and how to reconstruct them afterwards. That will help you minimize adverse events and minimize complications.

Are there any other thoughts on surgical complications or dermatology in general that you would like to share with your peers and colleagues?
We're very fortunate that our complication rate is very low for dermatological surgeries.

The rate of infection is usually 2% or lower. The rate of bleeding is roughly 1%¹, based on one paper that was published.

That low complication rate is because we take our time to learn the literature and to practice evidence-based medicine.

For those starting out in dermatologic surgery, it's very important to have a good mentor. There's nothing that trumps experience, so having a mentor that you could bounce things off of is extremely helpful.

Having humility, and an ability to talk about your complications is how you're going to learn more.

Complications happen. We tend to beat ourselves up over them and lose sleep about them. We care a lot about our patients. It’s helpful to develop a growth mindset about these things. When an adverse event happens, having the mindset that it's not a failure. How can we learn from this episode and what can we do to treat the complication? Our session discusses how we can use these complications as a learning opportunity so that we can do things better in the future.

Reference
Syed S, Adams BB, Liao W, Pipitone M, Gloster H. A prospective assessment of bleeding and international normalized ratio in warfarin-anticoagulated patients having cutaneous surgery. J Am Acad Dermatol. 2004; doi:10.1016/j.jaad.2004.07.058