Influence of external assessment on quality and safety in surgery: a qualitative study of surgeons' perspectives

INTRODUCTION

Transparency about the occurrence of adverse events has been a decades-long governmental priority, defining external feedback to healthcare providers as a key measure to improve the services and reduce the number of adverse events. This study aimed to explore surgeons' experiences of assessment by external bodies, with a focus on its impact on transparency, reporting and learning from serious adverse events. External bodies were defined as external inspection, police internal investigation, systems of patient injury compensation and media.

METHODS

Based on a qualitative study design, 15 surgeons were recruited from four Norwegian university hospitals and examined with individual semi-structured interviews. Data were analysed by deductive content analysis.

RESULTS

Four overarching themes were identified, related to influence of external inspection, police investigation, patient injury compensation and media publicity, (re)presented by three categories: (1) sense of criminalisation and reinforcement of guilt, being treated as suspects, (2) lack of knowledge and competence among external bodies causing and reinforcing a sense of clashing cultures between the 'medical and the outside world' with minor influence on quality improvement and (3) involving external bodies could stimulate awareness about internal issues of quality and safety, depending on relevant competence, knowledge and communication skills.

CONCLUSIONS AND IMPLICATIONS

This study found that external assessment might generate criminalisation and scapegoating, reinforcing the sense of having medical perspectives on one hand and external regulatory perspectives on the other, which might hinder efforts to improve quality and safety. External bodies could, however, inspire useful adjustment of internal routines and procedures. The study implies that the variety and interconnections between external bodies may expose the surgeons to challenging pressure. Further studies are required to investigate these challenges to quality and safety in surgery.

Learning from experience: a qualitative study of surgeons' perspectives on reporting and dealing with serious adverse events

INTRODUCTION

In surgery, serious adverse events have effects on the patient journey, the patient outcome and may constitute a burden to the surgeon involved. This study aims to investigate facilitators and barriers to transparency around, reporting of and learning from serious adverse events among surgeons.

METHODS

Based on a qualitative study design, we recruited 15 surgeons (4 females and 11 males) with 4 different surgical subspecialties from four Norwegian university hospitals. The participants underwent individual semistructured interviews and data were analysed according to principles of inductive qualitative content analysis.

RESULTS AND DISCUSSION

We identified four overarching themes. All surgeons reported having experienced serious adverse events, describing these as part of 'the nature of surgery'. Most surgeons reported that established strategies failed to combine facilitation of learning with taking care of the involved surgeons. Transparency about serious adverse events was by some felt as an extra burden, fearing that openness on technical-related errors could affect their future career negatively. Positive implications of transparency were linked with factors such as minimising the surgeon's feeling of personal burden with positive impact on individual and collective learning. A lack of facilitation of individual and structural transparency factors could entail 'collateral damage'. Our participants suggested that both the younger generation of surgeons in general, and the increasing number of women in surgical professions, might contribute to 'maturing' the culture of transparency.

CONCLUSION AND IMPLICATIONS

This study suggests that transparency associated with serious adverse events is hampered by concerns at both personal and professional levels among surgeons. These results emphasise the importance of improved systemic learning and the need for structural changes; it is crucial to increase the focus on education and training curriculums and offer advice on coping strategies and establish arenas for safe discussions after serious adverse events.

The Impact of Patient Deaths on General Surgeons’ Psychosocial Well-Being and Surgical Practices

Background

Patient deaths are an unavoidable occurrence in surgical practice. Although these events have negative effects on patients and their families, they can also have a profound adverse impact on surgeons who are unprepared for these deep emotional experiences. This study aims to investigate the impact of patient deaths on general surgeons’ psychosocial well-being and surgical practices.

Methods

A national cross-sectional survey of a 30-item questionnaire was conducted. The survey evaluated the surgeons’ demographics, professional and practice characteristics, and the impact of patient deaths on their emotional well-being, professional career, and social life.

Results

Four hundred eighty participants completed the survey. One-third of the participants reported that patient deaths affected their emotional well-being, 23.3% reported that patient deaths affected their social life, and 34.2% reported that patient deaths affected their professional career. Surgeons who reported suffering from the emotional impact of death exhibited no differences in terms of place of practice, academic title, surgical experience, work hours, or annual surgical volume. Middle-aged surgeons (p = 0.004), females (p = 0.041), and surgeons who reported feeling burned out (p < 0.001) were more likely to be affected by patient loss. Feelings of sadness, worry, and stress were most reported. A total of 18.1% of the participants indicated that they considered taking a break after patient death, and 11.9% thought they would abandon their surgical career.

Conclusions

The findings of this study suggest that patient death affects surgeons’ psychosocial well-being and surgical practices. Greater awareness and effort are required at the personal, institutional, and organizational level to provide effective support, helping surgeons to cope with the emotional burden of patient deaths.

The psychosocial impact of surgical complications on the operating surgeon: A scoping review

Background and Aim

Surgical complications are common, and their management is an integral part of surgical care. The impact on the surgeon, the “second victim” is significant, particularly in terms of psychological health. The aim of this review is to describe the nature of psychosocial consequences of surgical complications on the surgeons involved.

Method

Following scoping review protocols, we set out to identify the evidence-base for psychosocial consequences on the operating surgeon, predominantly general surgeons, following surgical complications.

Results

This scoping review identified 19 articles, mainly survey and interview based (n = 8), with all but one article from first world countries. Seven articles reported on negative emotions or depressive behavioural responses. All original studies reported on difficulty in coping (37.5%), and a range of behaviours. There was little evidence for support structures or active interventions to aid the surgeon post complication.

Conclusions

The review suggests that the psychosocial impact, following a complication, is variable but affects every surgeon irrespective of the level of impact on the patient. The main variables differentiating impact are severity, and outcome of the complication and seniority of the surgeon. Reported emotions and behaviours were generally negative and persist across the surgeon's journey towards recovery. Surgeons who manage stress well exhibit largely constructive behaviours and actively work to recover. Identification of variables underpinning complications, and affected surgeons is paramount, as is the provision of services to support recovery. Efforts should be made to proactively prevent complications, via education, awareness and to formalise support processes.

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Surgical complications negatively impact the operating surgeon (the second victim).

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Negative emotions and behaviours manifested may persist throughout surgeon’s career.

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Surgeons’ reaction can negatively influence social and professional relationships.

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Range of factors affect coping and recovery, and the support sought tend not to focus on psychosocial aspects of coping.

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Need to develop management resources for surgeons to manage the psychosocial impact.

Is there a standard reaction of surgeons to surgical complications? Study on an interesting historical case

The surgeon has been recognised as the "second victim" of a surgical complication and the long term psychological impact of a surgical adverse event has been demonstrated. However, the immediate and early psychological response to a surgical complication has not been properly investigated. In this manuscript we analyse a well-known historical case of a surgical complication and discuss the early reaction of the surgeon. Sir Anthony Eden, UK Prime Minister in the '50s, underwent a cholecystectomy for gallstones, but the operation complicated with a biliary fistula causing jaundice and sepsis. The reaction of the surgeon followed a precise three-stage pattern that can be identified in almost every case of surgical complication. Initially he denied the complication, with a simplistic attitude, but subsequently he felt overwhelmed by the environmental pressure and gave up. The early psychological response of a surgeon to a surgical complication usually follows the three phases of "denial", "desperation" and "action or get-away". In the denial phase the surgeon tries to reassure him or herself by diminishing the real burden of the complication and to demonstrate self-confidence. After few days, when it is evident that the complication is more severe than expected, the surgeon changes completely his or her attitude and becomes more and more depressed and anxious. The reaction to phase 2 will determine the subsequent phase 3, where the surgeon would choose between a positive and proactive attitude or getting-away, thus disengaging from the complicated patient. Acknowledging these three phases would help team leaders and colleagues to recognise the need for a supportive, friendly and blame-free environment and to act timely to help the surgeon to overcome the negative impact on his or her personality and career.

Stress and Burnout in Training; Requiem for the Surgical Dream

OBJECTIVE

Burnout among trainee doctors is common with as many as two-thirds reporting poor health. This study aimed to assess burnout in a cohort of UK core and higher general surgical trainees.

DESIGN

The Maslach Burnout Inventory for Medical Personnel was distributed to 158 surgical trainees to evaluate emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA). High EE (≥27) and DP (≥10), low PA (≤33) scores were taken to indicate burnout.

SETTING

A single UK (Wales) Deanery.

PARTICIPANTS

One hundred responses were received; 65 core surgical trainees, 31 Higher Surgical Trainees (HST), and 4 not specified.

RESULTS

Median EE, DP, and PA scores were 22.0 (range 2-50), 7.5 (0-25), and 36.0 (19-47), respectively. High burnout by domain was: EE (n = 33), DP (n = 39), PA (n = 34), with 59% of trainees demonstrating burnout in ≥1 one domain, with strong interdomain correlation (EE:DP r = 0.351, p < 0.001; EE:PA r = -0.455, p < 0.001; DP:PA r = -0.446, p < 0.001). Female gender (p = 0.020), core surgical training grade (p = 0.012), and being childless (p = 0.033) were independently associated with higher levels of EE; whereas HST grade (p = 0.007), age >30 years (p = 0.010), married/partner status (p = 0.001), and parenthood (p = 0.015), were associated with lower levels of burnout with regard to DP. Binary logistic regression revealed lower burnout in all domains to be associated with HST status (hazard ratio 0.116, 95% confidence interval 0.014-0.980, p = 0.048) and male gender (hazard ratio 4.365, (1.246-15.293), p = 0.021).

CONCLUSIONS

Burnout among surgical trainees was common in at least 1 Maslach Burnout Inventory domain. Urgent counter measures are required to protect the health and wellbeing of trainees at risk, which ought to be associated with commensurate improvement in patient safety.