Abstract
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There were three reasons in the last few years why I chose this topic for today:
• The first reason: A colleague—gynecologist and obstetrician, 63 years old, and two years until his retirement. During a sailing trip, he was sitting next to me on the ship's side and told me that he could not handle the situation with complications anymore—not the technical problem solving, but the psychological pressure especially after complications with newborns. • The second reason: My own experience when I got under mental pressure because of the economic impact of surgical complications in a private hospital even when complications were in the normal range. • The third reason: The title in the January 2014 Bulletin of the American College of Surgeons: Dealing with Surgical Complications [1].
To clarify my thoughts, I may start with an imaginary case—a well-known situation of an intra-abdominal infection.
Case
A 75-year-old male with diabetes mellitus, known smoker, and renal insufficiency arrived in the emergency department, pale, almost blue-faced, with an enormously distended abdomen—so to speak, near death. He went to the operating room after compensation in the intensive care unit (ICU). He had had a contrast-enhanced computed tomography (CT) scan demonstarting a sigmoid cancer with a free perforation, contrast medium and free fluid in the lower quadrants.
The patient had a Hartmann procedure, lavage of the peritoneal cavity, and resection of the tumor. A good decision; no time-consuming operation. The anesthesologists and colleagues from intensive care did a good job post-operatively and during the night. The next day, the patient was transformed into a rosy-cheeked man with normal appearance who smiled two days later from his bed in the ICU. A patient's metamorphosis from near death to life.
You as the surgeon saved his life—spectacular, great drama.You feel good, you are the best, the best that could happen about the patient. Enthusiasm, but not hubris. Never in doubt about your decision, confidence in what you did, ego boost. We all know these feelings. You may realize that I exaggerate, but do I really?
What makes a surgeon, male or female, good?
I am trying to define my view of the surgeon's ethos and principles before proceeding with the case. The emotional and valuable attitudes of surgeons differ from other medical specialties. The surgical ethos resembles more that of a pilot.
Possible attributes are:
• Authenticity • Courage • Self-confidence and belief in your own power—not flamboyant self-confidence, no prima donna like • Judgment and intuition based on knowledge, experience, training, technical skills, including new techniques • Ability to concentrate • Kant categorical imperative: Act only according to that maxim whereby you can, at the same time, will that it should become a universal law [2].
The golden rule in its positive form is: Treat your patients as you wish to be treated. My personal translation of that maxim is: Treat your patients as you wish your family members to be treated as an individual patient appreciation.
Surgeon's principles in our daily work
1. Responsibility and leadership
It is always my problem because I am the captain of the ship. That includes the responsiblity for the well-being and life of our patients they entrust to us. Making a wrong decision is no act of God or others; it was my decision, and I have to take care of it.
2. Situation awareness and decison making
3. Teamwork and communication skills
4. Constant reflection of our own doing
5. Mental training
Do every dissection, every anastomosis, and every important operative step in your imagination before you enter the operating room, but before doing mental preparation, slow down [3].
6. Gentleness, not speed, is the cardinal surgical virtue
“I can do this operation in only 30 minutes.” You can booast about how quick you are, but speed is second to gentleness. Careful technique and avoidance of bleeding is the maxim.
“The surgeon should have the eye of an eagle, the heart of the lion, and the hand of a woman,” as Harvey Cushing, MD, FACS, paraphrased a maxim from the 15th century [4].
“Thanks to women in surgery. Tissue (and women) are delicate; handle them carefully.”
7. Esthetic. What looks good will be as good as the esthetic surgeon's self-esteem.
That Makes A Good Surgeon !
But even with all these attributes, virtues, and principles, you can face a potential complication with every decision made or every action taken. Every day, every patient, every risk involves a potential tragedy.
Back to my imaginary case
A few days later on your morning ICU round, you see your patient with all his co-morbidities back on the ventilator because of an aspiration during the night. Late in the afternoon, he becomes septic with multiple organ dysfunction syndrome and dies the next day.
We all share common experiences with severe complications: The feeling of guilt and shame when facing the family and team members.
“1% mortality represents 100% for the family who lost the patient.” J.C. Goligher.
“I killed a patient,” which is not really the truth as we know, but how terrible do I feel, how long do I feel terrible, when will I be able to do the same operation after this case? These are severe questions with an impact on our mental toughness.
Surgical complications have an impact on the patient and his or her family as the first victim but also on the surgeon and the team as the second victims. The term “second victim” was first described in 2000 [5], and a definition exists since 2009 [6]. The prevalence of second victims after an adverse event varies from 10.4% up to 43.3% [5].
Common reactions can be emotional, cognitive, and behavioral. Second victims may feel anxiety, fear, guilt, or anger, may experience deterioration of work and personal life leading to depression, burnout, pharmaceutical or alcohol consumption. All these can have an impact on patients, colleagues, and self [7].
There are a lot of confusing synonyms and no clear definitions with respect to first or second victims: Complication, fault, error, failure, mistake, malpractice, and adverse events. A patient safety committee of St. Luke's identified three levels of undesired outcome that may clarify the situation:
1. Error 2. Treatment failure 3. Adverse event [8].
It is not my topic today to discuss the legal bearings of cases when malpractice or treatment failure lead to patient lawsuits or the threats of such suits. I would like to concentrate on adverse events independent from the juridical consequences.
An adverse event is any untoward medical occurrence in a patient administered an operation or therapy that does not necessarily have a causal relationship with this treatment. An adverse event can therefore be any unfavorable and unintended sign, symptom, or disease temporally associated with the operation or therapy [9]. Based on our experience, we have been witnesses to a hugh variety of adverse events intra- and post-operatively.
Two recently published articles focused especially on intra-operative adverse events and their consequences for the patient and the surgeon—the first and the second victim [10,11]. In the first article, the American College of Surgeon surveyed intra-operative adverse events such as bowel laceration covered with one stitch or vessel injuries and their impact on clinical outcome. More than 9000 cases were included, and 2% (n = 183) had an intra-operative adverse event (iAE) leading to increased 30-day morbidity and death, prolonged hospital stay, and were associated with severe complications such as organ-space surgical site infections, sepsis, pneumonia, and failure to wean from the ventilator [10]. The iAEs have a great impact on the first victim, the patient.
The second article examined the psychological impact of intra-operative adverse events [11]. A 29-item questionnaire was developed, and a survey was performed in three major Harvard teaching hospitals. One hundred twenty-six surgeons answered, most of whom (83%) performed more than 150 procedures per year. During the last year, 32% of these experienced surgeons recalled one iAE, 39% recalled two to five iAEs, and 9% recalled more than six iAEs.
The emotional impact of iAEs on the second victim was significant, with 84% of respondents reporting a combination of anxiety (66%), guilt (60%), sadness (52%), shame/embarrassment (42%), and anger (29%). Colleagues constituted the most helpful support system (42%) rather than friends or family; a few surgeons needed psychological therapy/counseling.
For reporting, 26% preferred not to see their individual iAE rates, and 38% wanted it reported in comparison with their colleagues' rate. Morbidity and death conferences are preferred as the formal process to report, but a great number of surgeons fear blame and damage of reputation. Quality and safety systems are more focused on blaming surgeons than solving safety issues, which makes a difficult emotional time even worse. Other barriers to report iAEs were fear of litigation (50%), lack of a standardized reporting system (49%), and absence of a clear iAE definition (48%).
We cannot operate without compromising our patients and dealing with uneventful and unexpected complications. We must consider this to move forward while at the same time taking care of our patients.
How can we deal with the psychological and emotional impact of uneventful adverse events? What makes a good surgeon mentally tough?
The following 13 FBI Principles of Mental Toughness might be helpful to give some practical tips for surgeons. The principles have been summarized as the personal experience of a female FBI agent working undercover [12]. For me, these experiences are comparable to our situation in surgical procedures to push through difficult and even painful situations.
Principle #1: Self-awareness
A survey in Belgium revealed the following:
1. The psychological impact for healthcare workers is higher when the degree of harm for the patient is more severe. 2. Impact is lower among more optimistic professionals. 3. Impact decreased significantly over time [13].
Become aware of your emotions with complications and learn to control them, instead of letting them control you.
Principle #2: Awareness of Others
An increased awareness of your own feelings and behavior helps you to better understand the emotions of others. Be transparent with the patient, the family, your colleagues, and yourself.
Principle #3: Communication
Transparency is the keyword. Discussing complications with your colleagues serves as a basis for lessons in how to prevent and compensate for adverse events and to deal with all the emotions. A blame culture, however, increases the psychological impact [13].
Principle #4: Resilience
Resilient people are mentally tough because they take responsibility for their actions and do not start blaming others for their situation.
Principle #5: Authenticity
Be transparent with yourself, analyize your actions, develop preventing strategies, and forgive yourself to come to peace to be able to provide quality care to the next patient after a complication. Reflect on errors with a little “book,” or on the computer, or institutionally with application of an “aviation black box principle” as performed in Pediatric Cardiac Surgery in St. Louis [14]. Integrate your experiences into your everyday life. “After stapling the ureter once during rectal resection, check, double-check, or even triple-check the anatomy before dividing. ”
Principle #6: Confidence
One story in the 2014 Bulletin (1) described this principle: A surgical resident met a patient after he ligated the common bile duct during cholecystectomy. The patient had to stay for weeks in the hospital, and after the operation, the resident entered the room, head held low, no eye contact, obviously no self-confidence. The patient put his hand on the shoulder of his doctor and told him: “Doc, you are my surgeon, but we can't go through this together if you have already given up.”
Self-confidence with positive enthusiasm, a smile, eye contact, and slowly and clearly speaking demostrates your self-confidence, and the patient feels more comfortable.
Principle #7: No Self-Limiting Beliefs
Negative thoughts are unavoidably associated with complications and adverse events. “You can't stop a bird from landing on your head, but you can keep it from building a nest” (Martin Luther). By changing the way you think about self-limiting beliefs and other obstacles, you can reset your brain in a way that it works for you and not against you.
Principle #8: Willpower
The capacity to say “No” to the call of temptation is called willpower. Intention is the “will” in willpower. It is the power to stay on task or return to it until the work is done. Surgeons need willpower to find the energy, motivation, and enthusiasm to keep going even when they are confronted with a complication.
Principle #9: Grit
Grit means the perseverance and passion to achieve long-term goals. People with grit do not let short – grit plays a more important role than anything else for achieving your goal, your vision. “Grit is like a muscle. It needs to be worked to grow and develop. If you haven't pushed yourself in small ways, of course you'll not be successful to deal with all kinds of unplanned adverse events.”
Principle #10: Positive Thinking
The physical and mental benefits of positive thinking have been demonstrated by multiple studies. Positive thinking can give you more confidence, improve your mood, and even reduce stress.
Principle #11: Growth Mindset
A growth mindset believes that intelligence, especially emotional intelligence, and personality can be developed.
Principle #12: Gratitude
Gratitude is one of the most important emotions we can cultivate. We should be thankful for what we have every day.
During my time as a fourth-year student at Tufts University in Boston, I met a hand surgeon from New York. His slogan was: “We are surgeons. We have fun.” The daily care of patients, thinking about a new problem and anew about an old one, the unpredictability and ever changing novelty of events as well as the pleasure of working with hands and the brain, that is fun.
Principle #13: Mastery
Hard work by focusing on practice, your willpower, persistence, and training will lead to personal mastery.
Every surgeon has those faces or names from patients with special complications or death engraved in his or her memory, and they stay with us for the duration of our career.
“Mortui Vivos Docent”
Mostly, we are dealing with ourselves to come to peace, and the 13 principles for mental toughness may help, but sometimes support from coaching to therapy is necessary. Even intra-operative adverse events affect the surgeon.
Obviously, there is no standard for how to deal with second victim problems. Addressing mental problems requires leadership support and a culture of safety. Such a culture includes concepts of reporting like the RISE (resilience in stressful events) program, which was implemented at Johns Hopkins as a second victim peer support program [15].
Do not suffer in silence!
A focus has to be set on this problem to offer a structured course of action in case of minor or major complications and emotional problems. Programs should allow healthcare providers to cope with their emotional stress by obtaining support in an confidential and a non-judgmental environment.