The emotional toll of surgical complications on urologic surgeons

Amy N. Luckenbaugh, MD

Luckenbaugh is an assistant professor of urology at Vanderbilt University Medical Center in Nashville, Tennessee.

Every surgeon, no matter how big or small the surgery they perform, will experience a surgical complication. As a specialty, we analyze the reasons for surgical complications religiously in morbidity and mortality conferences, categorizing the etiology of the complication—error in technical skill, error in judgment, or nature of disease. Invariably, the etiology of complication is often a combination of these factors. What we generally do not discuss at morbidity and mortality conferences is the impact of a complication on the surgeon.

There remains a paucity of research examining the impact of a complication on urologists. Urologic oncologists are likely to experience some of the most serious patient complications, including mortality, simply based on the complexity of the surgeries they perform. A survey in the United Kingdom that included 445 surgeons evaluated the impact of surgical complications or errors on surgeon well-being and overall health. The majority of surgeons surveyed (79.1%) cited an elective surgical complication, rather than an emergency surgery complication, as the event impacting them more severely. The surgeries we as urologic oncologists perform are often elective rather than emergent. Elective surgeries that result in an error or complication may be more susceptible to triggering an emotional response in surgeons. Overall, 48.3% of the survey respondents reported increased anxiety following a complication or error. Additionally, 42.5% reported sleep disturbances, 32.1% experienced increased anger or irritability, 11.7% reported increased depression, and 10.6% reported increased substance use.¹ Importantly, those who reported a surgical error (ie, something attributable to a decision or technical error by the surgeon) were more likely to experience increased anxiety, sleep disturbance, and substance use compared with those experiencing a complication.

To any surgeon who has experienced a complication, these results are unsurprising, but it is critically important to our field to provide both quantitative and qualitative data demonstrating the impact of complications on urologists. It is our duty to educate the field, including the more senior members of our society, on the importance of caring for each other after a complication. There continues to be a group who views discussing the emotional toll of a complication as a weakness. Even as I write this, I have a sliver of hesitation, knowing there are influential people who consider this a sign of inferiority or weakness. We must work to change that attitude. Discussing the emotional impact of complications with colleagues is a strength, and it is likely to help the surgeon recover from the event. If we cannot change the attitude toward the individual surgeon experiencing a complication, there is greater societal reason to change the attitude or to at least develop support programs. Second-victim programs help to prevent a third victim—our health care system. It is well established that surgeons who experience complications or errors are more likely to experience posttraumatic stress disorder and require professional and pharmacologic support. If we do not provide this support, we are at risk for losing surgeons from our workforce.

After experiencing an adverse event, surgeons were most likely to speak to a colleague (83%) about the event, with 58% speaking to their partner or friends. The majority of participants in the survey did not solicit formal support services.¹ Based on the survey results, it is clear that a peer-support system is an excellent option to support surgeons and trainees following an adverse surgical event. Although there are many second-victim programs that exist, including at Kaiser Permanente, Nationwide Children’s Hospital, and the University of Missouri, one of the most published on is a program in place at Massachusetts General Hospital (MGH).

The peer-support program at MGH was created through a 5-step process. Perhaps the most critical part of the process was the selection of the peer supporters. Surgical trainees and staff nominated individuals who they felt most comfortable reaching out to for support. One to 2 surgeons from each surgical division and residency class were selected. These surgeons were trained on how to provide support. Subsequently, at each morbidity and mortality conference (or by word of mouth), major adverse events were identified. Impacted surgeons were paired with a peer supporter. The peer supporter reached out to the surgeon, and the surgeon was able to opt out if they were not interested in the support. After creation of the program, its participants were surveyed. The majority of surgeons (81%) accepted the peer support meeting, and of those who accepted 80% were likely to recommend the program to their colleagues.² One potential limitation in urology is the size of urology departments, which tend to be smaller than the average size of a general surgery department. That being said, this may lend itself to a closer bond among its faculty and may allow for a program like this to work seamlessly.

There are 2 critically important parts to this program. First is peer selection of supporters. Surgeons must both trust and respect the peer supporters for the program to maximize its impact. Second, this is an opt-out program. It does not rely on the victim to solicit support. Instead, the peer supporter approaches the second victim to offer support. Many surgeons are simply too prideful to seek support on their own, and the opt-out strategy likely improves participation and broadens the impact of the program.

Complications and surgical errors are bound to happen, no matter how big or small the surgery. It is important as a field that we recognize the potential emotional impact of surgical adverse events. Discussing these is not a weakness; in fact, it is a strength. Normalizing negative emotions after a surgical complication may help trainees, junior faculty, and perhaps even senior faculty move through their own grief following a surgical adverse event.

REFERENCES

1. Turner K, Bolderston H, Thomas K, Greville-Harris M, Withers C, McDougall S. Impact of adverse events on surgeons. Br J Surg. 2022;109(4):308-310. doi:10.1093/bjs/znab447

2. El Hechi MW, Bohnen JD, Westfal M. Design and impact of a novel surgery-specific second victim peer support program. J Am Coll Surg. 2020;230(6)926-930. doi:10.1016/j.jamcollsurg.2019.10.015