Surgical complications and their implications for surgeons' well-being
Healthcare professionals can be seriously affected when they are involved in major clinical incidents. The impact of such incidents on staff is of particular relevance to surgery, as the operating room is one of the highest-risk areas for serious complications. This qualitative study aimed to assess the personal and professional impact of surgical complications on surgeons.
This single time point study involved semistructured, individual interviews with general and vascular surgeons, consultants and senior registrars from two National Health Service organizations in London, UK.
Twenty-seven surgeons participated. Many were seriously affected by major surgical complications. Surgeons' practice was also often affected, not always in the best interest of their patients. The surgeons' reactions depended on the preventability of the complications, their personality and experience, patient outcomes and patients' reactions, as well as colleagues' reactions and the culture of the institution. Discussing complications, deconstructing the incidents and rationalizing were the most commonly quoted coping mechanisms. Institutional support was generally described as inadequate, and the participants often reported the existence of strong institutional blame cultures. Suggestions for supporting surgeons in managing the personal impact of complications included better mentoring, teamwork approaches, blame-free opportunities for the discussion of complications, and structures aimed at the human aspects of complications.
Those involved in the management of surgical services need to consider how to improve support for surgeons in the aftermath of major surgical incidents.
Presented in part to the International Society for Quality in Healthcare Conference, Hong Kong, China, September 2011, and the European Health Psychology Society Conference, Crete, Greece, September 2011
Humans make frequent errors and misjudgements in every sphere of activity, but some environments are less forgiving than others. Failures in academia, law or architecture, for instance, can mostly be remedied with an apology or a cheque. Those in medicine, or in the air, may have severe or even catastrophic consequences. This is not to say that the failures of doctors, nurses or pilots are more reprehensible, only that they bear a greater burden because their errors have greater consequences. Making an error, particularly if a patient is harmed, may therefore have profound effects on staff involved, particularly if they are seen, rightly or wrongly, as responsible for the outcome. Healthcare professionals have been called the second victims of adverse events in healthcare.
The operating theatre is one of the highest-risk areas for serious complications[3, 4], but little is known about the response of surgeons to serious complications, or how best to support staff in the aftermath of adverse events. A recent survey study of 7900 surgeons found that those who had experienced a surgical error during the past 3 months were more likely to have a lower quality of life, and increased probability of symptoms of burn-out and depression. Such effects are not only important for surgeons and their families but also for their patients, as high levels of stress can adversely affect clinical performance and patient safety[6-9].
The present study aimed to explore the impact of surgical complications on surgeons by examining how they are affected by such incidents personally and professionally, the factors that affect their reactions, how they cope with the consequences, and their perceptions of support. Surgeons were asked to discuss complications without an assumption that these were caused by medical error. This approach was adopted in order to explore the implications of a wider group of complications on surgeons' well-being (not only preventable ones) and is in line with existing definitions of surgical complications (any deviation from the normal postoperative course)[10, 11].
A single time point design was used, with in-depth, semistructured, individual interviews. Semistructured interviews were selected because they are a very flexible method of data collection leading to rich narratives that permit the researcher to analyse how the participants make sense of the topic under investigation.
Setting and participants
A purposive sampling technique was used. Individuals were eligible to participate if they were surgeons with specialization in general or vascular surgery, which is associated with high risks of serious complications, and above registrar level with at least 3 years of experience, which implied substantial exposure to major surgery.
Participants were recruited from two large teaching National Health Service (NHS) Trusts in London, UK, which provide for a large number of patients undergoing general or vascular surgery. All eligible surgeons who worked for the two hospital Trusts were sent an e-mail with information on the study and an invitation to be interviewed.
The interviews were semistructured. A standard topic guide was used, which was developed based on a comprehensive review of relevant literature[3, 5, 11, 13-21] and through consultation with surgeons, psychologists and academics in patient safety. The guide was piloted with four surgeons for comprehensibility and relevance. The final version included general topics of investigation and relevant prompts. The topics were: how surgeons are affected by complications, what factors determine their reactions, how they cope with the impact of complications, and their views on support experienced and support required (Appendix S1, supporting information).
The interviews were conducted in private, face to face, by a researcher with a background in psychology and patient safety research. They lasted 45–60 min, were audio-recorded and transcribed verbatim professionally for analysis. Participants' consent to being interviewed was recorded.
The interview transcripts were analysed in QSR NVivo qualitative analysis software, version 8 (QSR International Pty Ltd, Version 8, 2008), using interpretative phenomenological analysis (IPA). The aim of IPA is to explore how participants are making sense of their personal and social world, with a strong emphasis on the meanings that particular experiences, events or states hold for participants. An idiographic iterative approach to analysis was followed, starting from coding the detail of each transcript and slowly working up to more general categorizations and statements. The emergent themes were assessed for connections, which led to a hierarchical tree of superordinate and subordinate themes. Samples of the transcripts were coded independently by two researchers: the researcher who conducted the interviews, and a researcher with a psychology and patient safety background who had not been involved in the interviews. The coding of the two researchers was compared and discussed in detail to ensure multiple perspectives, consistency and coherence in the analysis. Tables with the number of participants that mentioned each theme were produced. These numbers should not be interpreted as prevalence data because they are not based on a structured interview schedule with a prescribed list of items. However, they offer an indication of the themes that were discussed most frequently in a semistructured interview context. The participants' personal data were deidentified to ensure anonymity and confidentiality.
A total of 27 of 41 consultants and specialist registrars in general or vascular surgery agreed to be interviewed (66 per cent response rate). Further recruitment was not considered necessary as no new themes emerged after five consecutive interviews. The majority of participants were men (22), specialized in gastrointestinal surgery (18), were consultants (17) and were employed by Trust A (15). The mean number of years of experience in their current clinical position was 7 (range 3–15).
A description of the five overarching themes and their most prevalent subthemes is presented below.
Impact of surgical complications on surgeons
All of the participants referred to at least one case where a complication affected them significantly on a personal and professional level. In the majority of cases the complication was perceived as preventable and had happened early in the participant's career. The participants described a range of effects on their lives, which were grouped under five general spheres of impact: ‘emotional’, ‘behavioural, ‘cognitive’, ‘social’ and ‘other’ impact (Table 1).
Table 1. Impact of complications on surgeons
|Crisis of confidence||8|
|Worry about reputation||8|
|Worry for the patient||6|
|Anger (at self or at seniors for inadequate supervision)||6|
|Surgical practice affected (become more cautious/risk-averse)||18|
|Increasing efforts to improve||4|
|Becoming aggressive in interactions with colleagues||4|
|Reflection on what went wrong||6|
|Loss of concentration||3|
|Interference with personal life||6|
|Relationships with colleagues enhanced||3|
|Physical reactions (feeling sick)||2|
Almost all participants (26) admitted that surgical complications affected them on an emotional level and that these effects could be long-lasting. The most common reactions were guilt, anxiety, anger, crisis of confidence, worry about reputation, and worry about the patient. Some surgeons reported ongoing rumination and difficulty in maintaining concentration. A strong sense of personal responsibility and guilt in the aftermath of complications was a frequent theme: ‘…you obviously blame that particular lapse that you had committed before and it makes you feel bad, although sometimes difficult to bring in the direct connection…But it's usually about feeling like you have personally missed something…’ (consultant general surgeon). Junior surgeons were fearful of the reaction of their superiors: ‘…quite often you think what have I done wrong, am I in trouble for this…is this an error that I've made that's unforgivable and is it going to affect people's professional opinion of me…’ (registrar in general surgery). Younger surgeons also reported feelings of anger, often against their consultants for inadequate supervision, or a crisis of confidence. Strong emotional reactions usually faded, but memories of significant complications often lasted for years: ‘…The direct emotional impact does fade. Over what period of time? Who knows because it still has an impact 5 years later. I'm sure in 20 years' time I'll still be able to remember this case and what it taught me…’ (registrar in vascular surgery).
More than two-thirds of the interviewees (18) stated that serious complications had an impact on their clinical practice. Even though complications were often seen as a learning experience, many interviewees admitted that the impact of complications was not always in the best interest of patients. The most commonly reported impact was the tendency to become more conservative and risk-averse: ‘…Well it might make me much less prone to taking any form of risk…and sometimes that's not necessarily in the best interest of the patient…and I see this behaviour in my colleagues at a consultant level and down through to the registrars and even the SHOs [senior house officers]…’ (registrar in general surgery).
Factors affecting surgeons' reactions to surgical complications
Factors that were discussed as determinants of surgeons' reactions were grouped under case-, surgeon-, patient or family-, team- and institution-related factors (Table 2). Two-thirds of participants reported that unexpected (18) and preventable (16) complications have a greater personal impact: ‘…what do most surgeons like about surgery? It's the technical aspect of it…And if by your own hand, own error and judgement someone has suffered, then of course you're going to bear that complication as a greater burden than say there was some unexpected anatomy… putting in a stitch badly that tears a vein, you're going to kick yourself for that a bit more…’ (registrar in vascular surgery). Eight interviewees also suggested that complications in elective surgery are more stressful than those in emergency operations where the expectation of death is higher.
Table 2. Factors that affect surgeons' reactions
|Expected versus unexpected complications||18|
|Preventable versus less preventable complications||16|
|Elective versus emergency surgery||8|
|Intraoperative versus postoperative complications||6|
|Life-saving versus lifestyle surgery||3|
|Self-confidence in surgical technique or decision-making||10|
|Level of responsibility on case||7|
|Other personal troubles||5|
|Management of complication||3|
|Sense of responsibility to patients||2|
|Personal expectations about outcome||2|
|Lack of insight about operative ability||1|
|Communication with patient||1|
|Patient- or family-related||21|
|Empathy with patient||9|
|Quality of patient consent||1|
|Practical support during/after surgery||4|
|Other support structures||2|
|Quality of surgical training||2|
|Competitiveness between surgeons||1|
The majority of the interviewees (21) referred to the importance of personality: ‘…I have worked with people whose complications seem like water off a duck's back…and I have worked with people who completely fall to pieces when there's a complication…the first is a defence mechanism, which may well be their character…’ (consultant general surgeon). Surgical experience was also discussed extensively (21), with many suggesting that senior surgeons are affected less owing to their greater confidence and a better track record: ‘…it's pretty common knowledge that it's the junior consultants who suffer the most at [complications]…as far as the Trust is concerned, you're appointed a consultant and the buck stops with you, but they actually haven't got the maturity to have pretty much seen everything and done everything…and I have no doubt that there is higher psychological morbidity amongst that group than amongst the wise old birds who've been there and done it all…’ (consultant general surgeon).
The severity of the outcome (17) and the patient's or their family's reactions (13) were also commonly reported determinants of a surgeon's reaction. Complications that lead to severe disability or death have the strongest emotional impact: ‘…repairing someone's aneurysm, giving them a stroke and then rendering them paraplegic it would be a terrible outcome…Death, limb loss, paralysis, they're huge and probably affect the impact of complication on your emotions…’ (registrar in vascular surgery).
Colleagues' reactions (9) and institutional factors (15) were also commonly cited. For example, one-third of the interviewees (10) discussed the existence of a blame culture as a factor that often exacerbates the burden of complications: ‘…If you feel that you're working in a blame environment … you wouldn't be performing to your optimal anyway because you're watching your back the whole time…You might feel that you want to keep things to yourself…’ (registrar in general surgery).
Institutional cultures around surgical complications
One-third of the participants (9) described institutions as endorsing a blame and punitive approach to complications: ‘…[hospital managers] march in to the ward and the immediate implication is that you've done something wrong. So I don't believe in blameless culture, that is a total fallacy…’ (registrar in general surgery). Morbidity and mortality meetings in particular were commented upon quite negatively. Some interviewees suggested that these meetings are important for learning. However, almost half of the participants (12) described them as being dominated by blame, not being supportive (9) or rigorous (9), and exacerbating the burden of complications (5): ‘…morbidity and mortality meetings are supposed to be a forum where you can have an open discussion but if anyone believes that they're only kidding themselves; everybody in that room is very defensive and aggressively pursues an angle that puts them in the best possible light and professional rivalries exist…I don't find them cathartic forums for saying that was just terrible wasn't it…’ (registrar in general surgery).
Coping with surgical complications
The interviewees used a variety of coping mechanisms in the aftermath of complications. These were grouped under two types of coping which reflect the distinction between problem-focused (directed towards changing the relationship between the demands of the situation and the resources available) and emotion-focused coping (directed towards managing the emotional consequences of the stressor) (Table 3)[24, 25].
Table 3. Surgeons' coping strategies in the aftermath of serious surgical complications
|Discussing complications with others for advice||25|
|Deconstructing complications to identify learning lessons||17|
|Ensuring that surgical skills are as good as possible||8|
|Ensuring optimal management of complications||7|
|Involving patients and families in management of complications||6|
|Using colleagues' practical help||5|
|Overinvestigating future cases||2|
|Carefully consenting future patients||2|
|Being open with patients and families||8|
|Getting on with life, carrying on||8|
|Disassociating from emotional aspects of complications||6|
|Blaming external factors||3|
The most commonly reported problem-focused coping strategies were: discussing the complications with peers for advice, deconstructing the complication to identify learning lessons and ensuring that skills are up to scratch. For example: ‘…I suppose what you do is you privately, just deconstruct it and replay it in your mind until you really thoroughly evaluate it, what the complication was, how a big a complication it is and your personal responsibility for it…You do that quite quickly even on the way home…’ (registrar in vascular surgery). The most common emotion-focused coping strategy was rationalizing by putting what happened into perspective: ‘…the stress tends to dissipate because you've put things into perspective…because if you recognize that complications happen, no matter how good a surgeon you are, then it should become part of your working life…’ (consultant general surgeon). Other common emotion-focused coping strategies were talking openly to patients as a way of finding closure, and seeking reassurance from colleagues.
Support for surgeons who are affected by surgical complications
Almost unanimously (26) participants reported that peers are the most commonly available and most sought after source of support. Discussions with colleagues happen informally and offer reassurance. Senior surgeons' support was greatly appreciated by junior surgeons. One senior consultant described an example of an informal team structure that allows young surgeons to deal with complications more effectively: ‘…We have a team of three, we do a ward round together and we bounce opinions off each other… We will happily discuss complex cases and complications of cases. And that's a very good stress reliever, especially if you're relatively junior and there's a very senior person who's probably seen it all before, that's very reassuring…’ (consultant general surgeon) (Table 4).
Table 4. Surgeons' perceptions of support in the aftermath of complications
|Loved ones (partners, family members, outside work friends)||10|
|Institution (M&M meetings, managers, administrative help with complaints)||7|
|Barriers to seeking support||17|
|Relatives/friends cannot understand||8|
|Not wanting to burden family||5|
|Suggestions for better support||26|
|Formal mentoring system||11|
|Time break after serious complications||10|
|Formal teamwork structures (operating in pairs)||8|
|Structure focused on human aspects of complications||8|
|Open opportunities for discussion of complications||7|
|Structured debriefing sessions||5|
|Peer support groups||5|
|Resources to release pressure from surgeons||3|
However, more than two-thirds of the participants (19) suggested that support from employing organizations is inadequate. Debriefing or effective mentoring in the aftermath of serious incidents was rare. Organizations typically reacted in a punitive manner and with little understanding of the wider systemic problems that can contribute to complications: ‘…I don't think the institutions have any knowledge of the difficulties that their consultants face and to my knowledge there are no mechanisms for support, at all. If a Surgeon mucks up the Trust's response is to suspend them…’ (consultant general surgeon).
The majority of the participants suggested that support for surgeons in the aftermath of serious complications needs to be improved. The need for a better mentoring system was discussed extensively (11): ‘…it's very good to have someone a little more senior that if you have a problem you can say, “What am I going to do?” or “What happens next?” That's very, very unofficial and it would be nice if it could be made more structured in the Health Service…’ (consultant general surgeon). Other suggestions included a time break after major complications, teamwork structures (operating in pairs), structures aimed at the human aspects of complications (facilitating communication with patients when things go wrong), and confidential psychological services (with mixed views about their acceptance within the surgical community).
Surgeons can be affected by serious complications and the implications of this impact concern all parties: surgeons themselves, their colleagues, patients and the wider organization. Emotional reactions range from guilt and crisis of confidence, to anger and worry about a career. Even though the intense emotional impact fades progressively, there are certain cases that surgeons recollect many years later. These findings reflect earlier studies of major railway accidents, which show that the psychological well-being of drivers who are involved in serious accidents that cause major injuries or death is significantly impaired in the short term, whereas a smaller number continue to experience significant distress in the longer term. Longitudinal quantitative designs could elucidate the degree, types and duration of the psychological impact of surgical complications on surgeons.
Serious complications also often make surgeons more conservative or risk-averse in the management of patients, which can be detrimental for patient care. This finding is in agreement with an early study on house officers' medical mistakes. The authors of that study found that the participants reported increased use of vigilant behaviours in the aftermath of their mistakes, such as paying more attention to detail, personally confirming case-related data and trusting others' judgement less. The potential implications of this effect for the quality and safety of surgical care warrant further investigation.
‘Knowing that you've caused something by your own hand’ was reported as a particularly painful experience. A sense of direct responsibility over the care that surgeons provide possibly makes the experience of surgical adverse events more personal than in other medical specialties. In a study of burn-out and medical errors in surgeons, Shanafelt and colleagues found that over 70 per cent of the participants attributed errors to individual rather system-level factors. This heightened sense of personal responsibility may place surgeons at risk of severe distress after their involvement in major surgical complications, as self-criticism is a significant predictor of depression in clinicians[29-31].
Surgeons are typically regarded as more tough-minded than other healthcare professionals and there is indeed some evidence that this is the case. The present study found, however, that there is a considerable variation in both the nature and severity of reactions to complications, with some surgeons being much more affected than others. This is explained in part, but by no means completely, by seniority and experience. Personality may also play a role, but the development and use of coping strategies might well be the critical factors, as suggested by the literature on coping with stressful life events. Experienced surgeons may react less strongly to complications in the first place but, importantly, may also have more effective ways of dealing with those reactions. Junior surgeons, on the other hand, are less confident clinically and also more worried about the implications of complications for their careers; therefore, the impact of serious complications on younger surgeons is particularly critical.
Another common theme was that institutions often endorse a blame culture and a punitive approach to complications, both within the wider organization and seemingly from professional colleagues. Criticism was particularly directed at morbidity and mortality meetings, which were said to be dominated by a blame and cover-up culture. As Orlander and co-workers point out in their overview of morbidity and mortality meetings: ‘if the style of the conference is unduly blunt and criticism is directed towards individual persons rather than towards procedures and patterns of decision making, then participants may fear public humiliation and the result may be aversive conditioning rather than the forthright evaluation of poor medical practices and outcomes’. Lack of institutional support and negative reactions from colleagues have featured as important barriers of healthcare professionals' effective coping in the aftermath of medical errors.
Surgeons, as other healthcare professionals, regard support from their peers as particularly critical, and informal relationships and networks provide important sources of advice and support[20, 21, 34]. The study findings suggest that surgeons also see value in more formal arrangements aimed at supporting them after serious incidents, and also in training them to manage these events. Common suggestions included more effective mentorship for young surgeons, open opportunities for the discussion of complications, and formal teamwork approaches in the management of complicated cases (operating in pairs). When serious complications occur, breaks from operating and structured debriefing were also suggested.
The study findings therefore suggest that surgeons at any stage could benefit from structures aimed at facilitating coping with serious complications. The following initiatives could be considered:
Surgical training: Surgical training could place more emphasis on the challenges of surgical complications. Early guidance on the potential personal, institutional and patient/family reactions to surgical complications, as well as on the availability of support, may be particularly helpful for young surgeons and may prevent symptoms of severe psychological distress.
Mentoring: A better mentoring system was the most commonly suggested type of support for surgeons in the aftermath of major complications.
Mortality and morbidity meetings: These need urgent review to consider how to re-establish them as educational forums rather opportunities for personal rivalries and blame passing.
Teamwork: Teamwork approaches in the management of complex cases with joint working could facilitate coping and prevent reactive decision-making.
Psychological interventions: Researchers from North America have developed a toolkit to help healthcare organizations implement support programmes for clinicians suffering from the emotional impact of errors and adverse events. Structures with a psychological focus may also be of value for surgeons who are seriously affected in the aftermath of major complications.
There are certain limitations that need to be considered in the interpretation of these findings. First, very junior surgeons were excluded from the sample, which restricted the ability to extract the experiences of this group. Surgeons are often affected by major complications that happen early in their careers, and interviews with very junior trainees would be informative. Moreover, the participants were recruited from two large UK NHS Trusts. Surgeons who work in smaller hospitals, or different healthcare systems, may report different experiences. Finally, the lack of a control group restricted the ability to examine the extent to which surgeons' experiences are different from those of other healthcare professionals. Nevertheless, published literature on healthcare professionals' experiences of adverse events has allowed the present findings to be cross-checked against existing research data.
It is worth noting there is evidence that surgeons suffer particularly from high levels of burn-out, and that their well-being and quality of patient care may be affected by a range of factors. Such factors include demographic (sex, family status), personal (alcoholism, conflicts between personal life and work, use of wellness promotion practices), or wider work-related influences (hours worked per week, work location, institution)[35-37]. Future quantitative studies should try to identify the psychological impact of serious surgical adverse events on surgeons in the context of the wider influences that seem to affect their (or indeed other healthcare professionals') psychosocial well-being.
The authors thank the participants of this study, and R. Davis for her contribution to the analysis of interview transcripts. This work was supported by funding from the Health Foundation. The Imperial Centre for Patient Safety and Service Quality is funded by the UK National Institute for Health Research.
Disclosure: The authors declare no conflict of interest.