Dr. Bagrodia on tools, resources for surgeons following surgical complications

In this interview, Aditya Bagrodia, MD, FACS, walks through key elements of the paper, “Complications and Surgeon Health: Resources for individuals and institutions.” Bagrodia is a genitourinary urologic oncologist at the University of California, San Diego.

This transcription has been edited for clarity.

Aditya Bagrodia, MD, FACS

Could you provide an overview of this paper?

I'd like to start out by giving credit to Scott Eggener, MD, who invited me to share my thoughts on a panel in December 2022. The panel was really focused on the emotional toll of surgical complications. And that panel was really the impetus for urologic oncology putting together a collection of papers, focusing on various elements of this incredibly important and underrecognized phenomenon. It's one of those things where when you talk to a surgeon, as soon as they hear about it, hear it verbalized, it's so glaringly obvious, that, due to the nature of what we do, when things don't go well or perfectly, we take on a lot. As surgeons specifically, we feel a direct responsibility for a patient not having a great outcome. So, Scott really brought that to the forefront in many ways, I would say, to our community within oncology and within urology more broadly. It's still somewhat in its infancy and in the medical literature, as I see it. So, that's a little bit of the stage.

This paper specifically starts out with one of my colleagues who I've gotten to know really well—he's the chief of urologic oncology at Tata Memorial Hospital, Gagan Prakash, MBBS––just sharing his thoughts, walking through a complication that he had, not from the, "what could I have done differently," [perspective] but just, "how did this affect me?" Then, we run through some of the initiatives to make sure people aren't going through their careers getting blindsided when they feel really bad after a complication. There are a lot of different ways to think about this. Our own individual response, how are we feeling? What are we thinking? What can be done at a departmental level, institutional level? How can we support our colleagues? And within professional societies. So, broadly, this paper increases awareness, and then talks a little bit about some of the tools that any given person can utilize or implement.

Your paper touches on the importance of educational initiatives for mid-career surgeons. Could you elaborate on why this specific career stage might be particularly vulnerable?

I think there are a couple of reasons. One starts out with most people in the mid-career state were never educated on [or] made aware of complications during their training, whether that was medical school, residency, fellowship, or early career. That's one element. I mean, the first time I participated in something like this, it was like, "Oh, my gosh. This is resonating on so many different levels." You're also coming off the heels of early career, and in those early phases where you're getting your hands wet and learning how things go, I feel like you're particularly vulnerable. If you come out of that without any support, heading into the next phase of career could be trying. Then, if you look at the literature, when they talk about complications and the impact, it's almost like a bimodal, 2-part distribution where you're most susceptible in early career––[which] makes a lot of sense––and then later in your career, as you may be questioning your continued ability to practice your trade well. So, starting to think about these things in mid-career can help you for that second, third phase of your career, as it were.

You and your colleagues also propose utilizing Morbidity and Mortality (M&M) conferences for peer support and learning from near misses. Could you describe some specific ways that these conferences can be structured to achieve these goals?

Fortunately, I think most institutions are moving away from a shark-in-the-water approach to Morbidity and Mortality conferences toward, “how do we think about systems and processes to improve outcomes?” Those are generally, in my experience, focused on what are the patient-specific factors? What are the system-specific factors? And what are the surgeon considerations that could have been modified––management considerations? M&M is a pretty fertile area to start these conversations. If somebody has, let's just call it a big complication or a bad complication, [you could have] a buddy system where somebody would check in on any given person that has a complication. Not to run through the details of the complication, but more, how are you doing? How are you coping with this? Make it a little bit more proactive instead of leaving it up to surgeons who, most of the time, won't reach out for help. I think that can be one obvious thing, again, moving away from vindictive M&M.

Sometimes, almost changing it to periods of positivity, where you think about some of the good that we do for patients. That's not often front and center. We don't sit around patting ourselves on the back, for better or for worse. Also, intentionally discussing how people are coping. Part of the M&M series could be the impact on us. That's a morbidity of any given complication. So, those are just a couple [of examples]: try to keep it supportive, try to make it a comfortable and safe environment for people to speak openly, don't make it vindictive or negative or nasty. Having these buddy systems and creating a safe space for people to talk about how they're doing are ways to start.

Your paper also mentions acceptance and commitment therapy as a tool for promoting surgeon well-being. Can you explain how this might be helpful for surgeons dealing with the emotional burden of complications?

I'm not a psychologist or a psychiatrist or a psychoanalyst, but basically, acceptance and commitment therapy focus on trying to stop avoiding struggling with inner emotions, and accepting them as appropriate or normal responses to any given scenario. For us, when you have a complication, and you're feeling sad and anxious and depressed and everything that comes along with it, the first thing is, "Okay, this is normal." In some ways, it's like a trauma that you've been through. Complications come in all different ways, shapes, and sizes. But if you have something fairly traumatic happen to you—an on-table death, a pediatric young, healthy patient dying, something like that—you really feel terrible. I mean, terrible is the most euphemistic way to put it. For me, it's anxiety, guilt, depression, self-loathing—these are words that you hear all the time. And just to acknowledge that, "yes, this really awful, profound thing happened, and it's normal for me to feel all these really raw and tough emotions." That's like phase 1. So, these researchers in the UK, led by Kevin Turner, actually did a study where trainees received education on acceptance and commitment therapy [ACT]. Suffice to say that resilience assessments, self-compassion, less anxiety and depression, were all seen in the trainees that received ACT, or acceptance and commitment therapy. So, to boil it down, it's accepting what has taken place—these emotions in the context of a complication are normal, and that they're not bad. They're not something we need to shy away from, sweep under the rug. We can percolate on them a bit, allow those feelings to take place, and move forward.

I appreciate you sharing that experience. You and your colleagues also advocate for integrating resources from organizations like the AUA and the AMA; could you highlight some of the specific resources offered by these organizations?

It's really exciting to see so many different individuals, groups, and institutions, taking interest in and raising awareness and education [for this]. I'll give a couple of examples. The American Medical Association has a really wonderful downloadable resource to facilitate conversations about physician well-being after adverse events. If you go to the AMA and look up steps forward, it's got a slide deck that anybody could download, and it's intended to be shared with the department community.

I was really excited this past year at the AUA 2024 [because] we had a course on strategies and taking care of ourselves after complications. Polina Reyblat, MD, talked about peer support services. Phillip Pierorazio, MD, talked about the immediate aftermath and physiology of our body after a stressful event like a complication. Casey Seideman, MD, talked about things from the trainee perspective. And then Kathleen Kobashi, MD, FACS, shared some really nice data and insight from surveys done through the AUA. Last year, there was a there was a plenary talk by Scott Eggener. Those are AUA-level examples.

I'm really excited to work with Gina Badalato, MD, and Lindsey Hampson, MD, MAS. We're doing some things with the Intern Academy. One of the things I have interest in is education. And with BackTable, we're putting together a couple of episodes for trainees on how to start thinking about complications and their impact. So, there are more and more conversations happening. It's beginning to get normalized, which I think is the first phase. And then, depending on any given department or institution’s resources, we've seen really amazing, well-supported peer support programs. The [International] College of Surgeons has standards and guidance on supporting surgeons after adverse events. So, there are great resource to educate oneself and educate one's peers that are out there, and those are just a few.

This paper focused on urologists, but do you believe these strategies could be applicable to other surgical specialties as well?

1,000%. I mean, it's doctors, it's surgeons, it's physicians, it's surgical subspecialists. No one's immune. My wife's a pediatrician, and if one of the kids she's taking care of isn't doing well, we all kind of carry that in some way. This is a part of our commonality. And honestly, it's not just physicians; it's the whole health care team who comes to work to take care of other people. When things don't go well, it's really, really tough. This is something where I feel like in many things, urology is a bit ahead of the curve. But to be sure, there are things we can learn from our other colleagues in medicine, in surgery, and in other subspecialties.

Is there anything else that you wanted to add?

It sounds so cliche, but if you are going to be a surgeon, nearly certainly, complications are going to happen. And those complications are really, really hard to process. We go into medicine to take care of people and to help them, and when that doesn't transpire, it's a very tough reality. I would just tell anybody listening that you're not alone. There's a whole community out there that wants to support you and help you get through any given situation, make sense of it, and come out of it impacted but able to perform in a meaningful way. I'd like to thank you all, Hannah and Urology Times, for highlighting this. I don't think people can hear it enough. And again, you're not alone. People want to help. Talk to somebody at the very least, because even something so simple can help make meaning out of a tough situation to comprehend.