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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].
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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.