From the Journals

Patient complications affect surgeons adversely


 

FROM JAMA SURGERY

Psychological consequences of patient complications seem to be an important occupational health issue for surgeons, according to the results of an extensive literature review published in JAMA Surgery.

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Sanket Srinivasa, PhD, of North Shore Hospital, Auckland, New Zealand, and colleagues assessed studies from MEDLINE, Embase, PubMed, Web of Science, and Google Scholar that examined the consequences of complications, adverse events, or error for surgeons published up to the search date of May 1, 2018. Studies pertaining to burnout alone, studies not conducted on surgeons or surgical trainees, and review articles with no original data were excluded. This final review of consisted of nine studies (10,702 unique participants) that explored the occurrence of patient complications and their affect on surgeons’ psychological well-being and their professional and personal lives.

All of the studies indicated that surgeons were affected emotionally after patient complications, which led to adverse consequences in their professional and personal lives. The study authors identified four themes from the literature.

  • The adverse emotional influence of complications (including anxiety, guilt, sadness, shame, and interference with professional and leisure activities) after intraoperative adverse events; one study diagnosed acute traumatic stress (using valid diagnostic criteria) in one-third of their participants 1 month after a major surgical complication.
  • Coping mechanisms used by surgeons and trainees (including limited discussion with colleagues, exercise, artistic or creative outlets, alcohol and substance abuse); emotion-focused coping strategies reported included rationalization, seeking reassurance, blaming oneself or others, and dissociation with self-distraction. Other adaptive strategies used included engaging in artistic endeavors and exercise, although maladaptive strategies were also adopted by some, including alcohol and substance use disorder.
  • Institutional support mechanisms and barriers to support (including clinical conferences, discussion with mentors, and a perception that emotional distress would be perceived as a constitutional weakness). For example, surgical trainees in one study did not believe that morbidity and mortality meetings addressed the emotional needs of trainees, and respondents in another study pointed to poor institutional support with a competitive, unsympathetic surgical culture, with the morbidity and mortality meeting being regarded as accusatory and hostile without providing support.
  • The consequences of complications in future clinical practice (including changes in practice, introduction of protocols, education of staff members, and participating in root-cause analysis). Participants in several studies believed that dealing with errors and complications improved their subsequent performance, For example, 92 of 123 respondents (74.8%) in one study believed that their professional ability was not impaired after a complication, and in another study half of the surgeons did not believe they should stop operating for a brief period after an intraoperative death. “However, respondents in other studies described a combination of anxiety and shock affecting their ability to rectify the operative problem in a practical sense immediately after an intraoperative complication. Some respondents reported impairment for weeks after the incident, describing ongoing rumination, difficulties in concentration, adversely affected clinical judgment, and loss of confidence,” according to the researchers. Surgeons in another study described an initial denial and minimization of the severity of the consequence potentially delaying the necessary treatment, while some surgeons reported avoiding or stopping certain operations as well as contemplating early retirement.

“Surgeons across the studies indicated that they deal with these problems in isolation with significant personal and clinical consequences. With primum non nocere remaining a cornerstone of medical practice as applied to patients, a similar philosophy needs to be embraced by the surgical community for the betterment of health of the profession,” the researchers concluded.

The authors reported that they had no conflicts of interest.

SOURCE: Srinivasa S et al. JAMA Surg. 2019 Mar 27. doi: 10.1001/jamasurg.2018.5640.

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