Surgeon and Surgical Trainee Experiences After Adverse Patient Events

Key Points Question How are surgeons and surgical trainees affected by adverse patient events, and what coping mechanisms are used? Findings This mixed-methods study surveyed 93 surgical trainees and interviewed 23 faculty and found that surgeons and trainees frequently grapple with the personal impact of adverse events. Trainees who identified as female and/or from a minority racial or ethnic background more frequently reported negative psychological consequences, and surgeons described opportunities to reduce stigma and improve support mechanisms. Meaning These findings suggest that the negative personal impact of adverse events is underrecognized but nearly universal in surgery; more formal structures to restore surgeon and trainee well-being are warranted and may be particularly helpful for underrepresented groups.


Introduction
Medical errors are estimated to be the third most common cause of death in the US, with more than 250 000 deaths attributable to medical errors annually. 1,2Nearly all physicians report having made at least 1 error during their career. 3Despite the frequency of medical errors, it can be very disturbing for physicians to realize that they have unintentionally harmed a patient. 4eaning These findings suggest that the negative personal impact of adverse events is underrecognized but nearly universal in surgery; more formal structures to restore surgeon and trainee well-being are warranted and may be particularly helpful for underrepresented groups.

Key Points
In 2000, Wu 5 described the experience of health care professionals who made a mistake that negatively affected a patient.7][8][9] Moreover, this negative personal reaction may trigger a vicious cycle of depression, burnout, and future errors. 10,11Ultimately, clinicians who have been involved in errors may avoid certain types of patients and cases and be more likely to leave their practices or leave direct patient care altogether. 3,4,12,13ven the invasive nature of surgical work, the perfectionist culture in surgery, and the frequency of malpractice claims relative to other specialties, surgeons may have unique reactions and needs in the aftermath of adverse events. 14,157][18][19] Therefore, in this mixed-methods study, we sought to (1) better characterize the perceived impact of adverse patient events on surgeons and surgical trainees, with attention to potential differences related to surgeon demographics; (2) describe current coping mechanisms; and (3) identify potential opportunities for institutions to help restore surgeon well-being and promote optimal functioning in the wake of such events.

Methods
This study was designed to capture the experiences of both surgical trainees and faculty with adverse patient events.Given pragmatic concerns about surgical trainees' work schedules, a survey was used, whereas qualitative interviews were used to assess faculty experiences to elicit maximal depth and nuance in this sensitive subject matter.This study followed the Consensus-Based Checklist for Reporting of Survey Studies (CROSS) 20 and Consolidated Criteria for Reporting Qualitative Research (COREQ) 21 guidelines and was deemed exempt by the institutional review board of the University of Pennsylvania because it involved survey and interview procedures and the data were maintained and reported in a deidentified fashion.

Definition
We defined adverse patient events as both overt errors and unanticipated complications.The rationale for this broad definition is that the distinction between these 2 types of events is often blurred, and the psychological effects on the involved clinician are often similar.

Part A: Trainee Survey
A cross-sectional survey was administered to surgical trainees at a single academic institution.3][24][25] The instrument was reviewed by an expert panel via email correspondence.Six questions irrelevant to the surgical trainee population were removed, and 13 new questions were developed by majority agreement.Questions regarding the forms of support used in the aftermath of adverse events, such as free counseling sessions offered through the Employee Assistance Program, were added to inform potential future interventions.Demographic questions, including self-reported gender identity, race, and ethnicity, were added so that the study team could assess for associations between these characteristics and the personal impact of adverse patient events.The adapted survey instrument included 37 questions (eAppendix 1 in Supplement 1).
Trainees enrolled in 7 surgical programs offered by our health system (cardiothoracic surgery, general surgery, orthopedic surgery, otorhinolaryngology, plastic surgery, urology, and vascular surgery) were invited to complete the survey using a secure, web-based tool during educational conferences between September and November 2022. 26The first page of the survey was composed of information about the study and institutional review board approval, including a statement that Survey data were reported using descriptive statistics.Responses that used a 5-point rating scale were dichotomized as no ("not at all") vs yes ("a little," "somewhat," "quite a bit," or "a lot") to perform comparisons between subgroups using χ 2 tests and Cohen d statistics. 27Incomplete surveys were excluded.Incomplete surveys were excluded; however, if a participant responded to at least 1 part of a multipart question, their survey was retained for analysis.

Part B: Faculty Interviews
One-on-one semistructured interviews were conducted with surgical faculty from 4 departments at the same institution.Surgeons were purposively recruited via email, ensuring participation from both genders, a breadth of subspecialties, and multiple levels of experience.An applied thematic analysis approach was used. 28On the basis of review of the literature as well as preliminary assessment of the transcripts, an initial codebook was developed by consensus of the study team.Eight transcripts were coded independently (S.G., J.G., J.P., and J.S.), and then coders met to adjudicate disagreements (minimum Cohen κ coefficient of 0.8).Subsequently, 15 transcripts were coded by consensus between pairs of coders.The codebook was iteratively refined as additional transcripts were assessed.Codes were organized into themes within each of the study domains by coder consensus.No additional interviews were scheduled after the coders agreed that thematic saturation had been reached.

Statistical Analysis
Statistical analyses were performed using Stata, version 17.0 (StataCorp LLC), and qualitative analysis was conducted using NVivo, version 20.7.1 (QSR International).We used χ 2 tests with effect sizes to compare survey responses between subgroups of trainees.A 2-sided P < .05 was considered statistically significant.

Results
Part A: Trainee Survey

Disparities by Gender and Racial and Ethnic Background
When stratified by gender, questions describing the negative personal impact of adverse patient events consistently received more yes responses from female trainees compared with male trainees When stratified by race and ethnicity, trainees who identified as having a minority racial or ethnic background responded yes at higher rates than non-Hispanic White trainees on all but 2 questions (Table 2).The largest difference between groups was elicited in response to the statement, "After my experience, I became afraid to attempt difficult or high-risk procedures" (31 of 36 trainees with a minority race or ethnicity [86.1%] vs 18 of 38 non-Hispanic White trainees [47.4%],P < .001;effect size = 0.89; 95% CI, 0.40-1.36).

Current and Desired Forms of Support
When asked about sources of support used in the wake of adverse events, trainees most commonly

Part B: Faculty Interviews
Of 29 faculty invited to participate, 23 (79.3%) accepted and completed interviews.Participants had been in practice of a median (IQR) of 11.0 (7.5-20.0)years; 13 (56.5%)identified as male and 10 (43.5%) as female.We did not collect data on age, race, or ethnicity from participating faculty due to concerns about preserving anonymity in this small, single-institution study.No faculty interviewees declined to answer any of the interview questions; therefore, no interview data were missing.Several themes emerged within each of the 3 study domains and built on the results from the trainee survey.

Personal Impact of Adverse Patient Events
All interviewees described at least 1 adverse event that was especially challenging from a personal standpoint.Many of the described events shared common characteristics that made them particularly salient: (1) the event was unexpected, (2) there was a lack of a clear explanation for what happened, and (3) the event led to significant harm to the patient.Mirroring the survey responses, most interviewees described feelings of embarrassment, guilt, shame, and self-doubt after these events.Many discussed being distracted by thoughts of the event both at work and at home, and some talked about how the complication took on an outsized role in their mind compared with other cases and activities.In contrast to the results from the trainee survey, few surgeons reported physical manifestations of their experiences with adverse events.However, adding another dimension beyond the trainee survey results, surgeons discussed how these events can have a lasting impact over time, both personally and professionally.Interviewees described how memories of the event tended to resurface indefinitely, and how they experienced a period of increased vigilance that only dissipated months to years later.Finally, several surgeons discussed how being involved in malpractice litigation perpetuated the emotional impact of the adverse event due to the associated isolation, delay in closure, and questioning of professionalism.Representative quotations from this domain are included in Table 2.

Coping Strategies
Several themes emerged from interviewees' discussion of their coping strategies, paralleling the responses at the trainee level (Table 3).Most interviewees had identified 1 or a few trusted colleagues, typically in the same subspecialty, to whom they could turn for perspective and reassurance.Early-and middle-career interviewees discussed the value of reviewing complications with senior mentors.Several interviewees emphasized that in order to access peer support, they had to actively seek it out.Some surgeons described feeling comfortable sharing details of cases with their peers, yet others stated that they were reluctant to reach out.
Several additional coping mechanisms were discussed.A few interviewees described compartmentalization as their primary means of coping.Many surgeons spoke about receiving support from their spouses, but the degree of relief associated with spousal support varied depending on the spouse's experience with the field of surgery.Some interviewees discussed turning to hobbies, such as exercise and fishing.A few mentioned reviewing notes of gratitude from other patients who had had a positive outcome.A few also mentioned using alcohol as a coping mechanism, although no surgeons discussed overuse or use of other substances.Notably, none of the interviewees discussed using professional mental health support services; in fact, several surgeons explicitly eschewed the idea of such services.

Current and Suggested Institutional Support Systems
Echoing the small percentage of trainees who reported using formal institutional resources, most faculty were unfamiliar with-and skeptical of-such resources.Those who did name formal resources mentioned the Department of Psychiatry and an online wellness platform accessible by all health system employees.Several interviewees noted that a morbidity and mortality conference does not serve as a support mechanism for dealing with the personal impact of adverse events.Onus is on the surgeon to reach out "There are definitely senior people that are available for you to talk to, but it is up to the individual surgeon to seek out these people." "I have colleagues who probably have experienced the same thing, and I guess I could have easily talked to them, but I just didn't.Because…you don't want to burden other people with your stresses, especially when they may be experiencing the same stresses themselves." "[My friend] published this piece about how distraught [she had] been over a patient event.I called and was like, '…You didn't call me!' And she was like, 'I was so deep into the badness that I literally was afraid to even call you.'"

Compartmentalization
Effective for some "For me, personally, if I have something, I tend to kind of deal with it and not reach out.""It's just easier to function that way sometimes, when you sort of pack things away, and still be focused on something else." Insufficient for others "If you don't talk to other people about it, it just eats away at you." "You can't just put it inside.Some people can, but you've got to talk about it, because it's just gonna be something you're gonna face for your whole career."

Other strategies
Spousal support "My husband is a great support, and we often talk about what's going on at my job, but he's not in medicine, so there's only so much true empathizing." Reflection on positive outcomes "I actually have saved some files of screenshots of very nice reviews that patients-as much as I hate that I'm being rated like a restaurant-I have saved some of them that are meaningful and kind.I will reread those to try and find a perspective." Hobbies "I like to fly fish.So, it's a getaway.I usually do it by myself, away from people and things.And so, it's like a very sort of mindful, very relaxing sort of thing." Eschewing of mental health services "I did not feel like I needed professional help or anything like that." "I've never pursued any kind of psychological, psychiatric support, although people have told me to."In describing the informal culture in their departments with regard to the personal impact of adverse events, surgeons were divided by specialty.Some described a sense of camaraderie and nonjudgment within their department; interestingly, most of these interviewees had trained at the study institution.Conversely, other surgeons described a culture of stigma, where faculty do not tend to discuss complications with each other for fear of reputational damage.

JAMA Network Open | Surgery
Most interviewees felt that more institutional support for faculty dealing with adverse patient events would be beneficial.Several interviewees spoke about the need for destigmatization.
Additionally, many surgeons thought that having a designated point person for debriefing of adverse events would be helpful, but there was uncertainty about what type of individual would be best for that role.Suggestions included a senior faculty member with patient safety experience, an emeritus faculty member, and a trained therapist.
Similarly, most surgeons thought that there should be more explicit support for trainees regarding the issue of adverse patient events.Several interviewees discussed the importance of debriefing complications with trainees, but some noted that this process may need to be performed by a third party when the involved faculty member is unable to engage due to his or her personal involvement.Furthermore, surgeons observed that developing a process for coping with adverse events requires time and experience, and several suggested that training programs should take a more active role in setting expectations and helping trainees learn to deal with the personal impact.
The themes and quotations from this domain are summarized in Table 4.

Discussion
In this mixed-methods study at an academic medical center, we found that most surgical trainees had been involved in at least 1 recent adverse event and subsequently experienced a negative personal impact.Despite low statistical power, female trainees and those from racial and ethnic minorities consistently reported negative consequences at a higher rate than male and non-Hispanic White trainees.Although only about half of trainees received support from colleagues after adverse events, nearly all who had been negatively impacted by an adverse patient event desired an opportunity to debrief with an attending or trusted senior resident.These findings were echoed in the themes that emerged from the faculty interviews.Surgeons universally described distress associated with adverse events and discussed how these cases often had a lasting personal impact.Surgeons differed in their perceptions of the institutional culture around adverse events by department; some described a culture of stigma, whereas others described a supportive and nonjudgmental culture.All agreed that departments and training programs could do more to help individuals manage the negative personal consequences of adverse events.
Our findings regarding the emotional and cognitive impact of adverse events on surgeons and trainees build on the existing literature.Two survey studies demonstrated that surgeons frequently experience negative emotions, such as anxiety (48%-66%) and anger (29%-32%), as well as guilt (60%) and embarrassment (42%), in the wake of complications. 30,31Similarly, 2 qualitative studies found that surgeons commonly experienced guilt, self-doubt, and rumination. 16,17One survey study of surgeons and trainees found that 36% met criteria for clinically concerning traumatic stress after a major complication. 32wever, no prior studies have attempted to identify whether trainees or surgeons experience adverse events differently based on gender, race, or ethnicity.The differences we observed in surgical trainees' reactions to adverse events by gender and racial or ethnic background is an important finding for the surgical workforce.4][35][36][37] Thus, it is possible that the disproportionate burden of negative emotions and self-doubt experienced by female trainees and those from minority racial and ethnic backgrounds in the aftermath of adverse patient events represents a key contributor to the observed differences in attrition.
One of the major themes that emerged from the faculty interviews was the value of affirmation from colleagues, a concept that has been identified in previous work. 30,38,39However, the ability to access peers and mentors for support may differ by background.Because women and individuals of races and ethnicities other than non-Hispanic White have been historically underrepresented in surgical specialties, they may have fewer close social connections and trusted mentors with whom they identify and to whom they can turn for validation. 40Prior work in the medical student population has found that Black students enjoy less social support and less frequently identify with the stereotype of a surgeon. 41,42Similarly, female surgical trainees have been found to have higher rates of imposter syndrome than male trainees. 43,44Taken together, these findings suggest that formalizing mechanisms to provide peer support in the wake of adverse events may be particularly beneficial for surgeons and trainees from underrepresented groups.
Currently, our institution offers a web-based platform to support the mental health of all employees.Resources offered through the platform include podcasts, group mindfulness sessions, opportunities to schedule free appointments with resilience coaches and/or counselors from the Employee Assistance Program, and more.Although the platform does not track usage by role to "My network would not be within my department.And perhaps some of that is because I would have concerns about potential retribution or-not retribution, but I don't want it accounted for.Or, as much as people talk about things being confidential, I would have a fear it wasn't." Less problematic for faculty who trained at same institution "I think our division…is very supportive.I suspect that part of that is because I trained here, so I have some established relationships." "I am fortunate to know and trust my colleagues because I had already been a member of the department for 9 years.…Icould very easily see how that might be difficult if I entered a brand-new space without those established and trusted relationships."

Suggestions for faculty support
Destigmatization "We need to be more open about discussing these things.And I think that openness will be the first step.…Wehave to develop a mindset that it's okay to talk about these things." "What you want is a culture of understanding.…Ifyour name is up on the M&M board multiple weeks in a row, that you're not gonna get the reputation as the attending that's always causing problems." Point person for debriefing "Having maybe 1 designated person who is familiar with safety events and talking to risk management.…Having a go-to person would probably be helpful.…Itsort of normalizes and kind of destigmatizes the fact that everybody makes errors." "I've heard of some departments having even a departmental therapist.…I'mnot sure that exists.It sounds like it should.I feel like too often in our training within our field, we're so caught up on the technical, on the medical side of things, that we forget to also look at the clinician themselves and say…if their mind isn't straight, how do you expect them to function at the highest level?" "That might be a really good role for someone at the emeritus level."

Suggestions for trainee support
Event-specific outreach "If you have a complication, I think it's important that you talk to your resident afterwards.…Maybethat's not done enough." "I've had to remind myself to reach out and be like, 'Hey, that was a tough case.'…ButI don't always feel like I'm the most qualified to help them cope because I'm already kind of struggling with it myself.I don't have a great solution for what could be done.Maybe it's alerting the program director like, hey, this happened, could you maybe just check in with them over the course of the week and see how they're doing." "I think that's a very important role for the program directors.…Notmandatory, but they should at least be offered…a debriefing.Let's just sit down and talk about this in a nonjudgmental way.I think that would be very important for the trainees." Formal instruction "But I do think that having something more formal for trainees is more important because they have not yet had a chance to develop their own system for dealing with these issues."

Findings
How are surgeons and surgical trainees affected by adverse patient events, and what coping mechanisms are used?This mixed-methods study surveyed 93 surgical trainees and interviewed 23 faculty and found that surgeons and trainees frequently grapple with the personal impact of adverse events.Trainees who identified as female and/or from a minority racial or ethnic background more frequently reported negative psychological consequences, and surgeons described opportunities to reduce stigma and improve support mechanisms.

Table 1 . 29 JAMA Network Open | Surgery Surgeon
and Surgical Trainee Experiences After Patient Adverse Events Most participants (77 [82.8%]) reported they had been involved in at least 1 adverse patient event in the past year, and 21 participants (22.6%) were involved in 5 or more events.Most trainees experienced negative emotional and cognitive consequences after involvement in adverse events.For example, 67 of 79 trainees (84.8%) endorsed feeling embarrassed, and 64 of 78 trainees (82.1%) reported rumination.Although a smaller proportion of trainees reported physical symptoms, such as trouble sleeping (20 of 78 trainees [25.6%]), many endorsed feelings of self-doubt; 65 of 78 trainees (83.3%) experienced feelings of inadequacy regarding their patient care abilities, 51 of 78 trainees (65.4%) reported feeling afraid to attempt future procedures, and 28 of 78 trainees(35.9%) (14.0%) identified as having a Hispanic or Latinx ethnicity.Most reported being married (37 trainees [39.8%]) or in a committed relationship (29 trainees[31.2%]).These demographic characteristics of respondents approximated the national surgical trainee population and are summarized in had thought about quitting training.The proportions of respondents who answered yes to each question are given in Table2.
"I'm checking my phone all the time.And I'm thinking about what's going on and calling the residents and they're calling me and I'm trying to help my kids with homework and I'm thinking about my patient and I'm trying to sit and have dinner with them and hear about their day and I'm thinking about my patient.""I think that can really affect your confidence, your ability to keep going and progressing and wanting to do the field.…Inall honesty, I would not have gone into this field if I had to do it again."Abbreviation: NA, not applicable.a Denominators differ for some statements because some participants did not answer all items.P leaning on friends and family (69 of 78 trainees[8.5%]) and informal support from colleagues in the department (52 of 77 trainees [67.5%]).Only 4of 77 trainees (5.3%) had used formal institutional resources, such as the free counseling sessions, and 2 of 76 trainees (2.6%) had taken a "mental health day."Whenpresented with potential options for support after an adverse event, trainees expressed the most interest in opportunities to discuss the case with an attending physician (76 of 78 respondents [97.4%]) or trusted senior trainee (73 of 78 respondents [94.8%]).Additionally, despite the low rate of current use, 23 of 78 respondents (29.5%) expressed a strong desire ("quite a bit" or "a lot") for an employer-sponsored counseling program.The ability to take time off was strongly desired by 18 of 78 trainees (23.1%), and having a private space to recover was strongly desired by 29 of 78 trainees (37.2%).

Table 3 .
Themes, Subthemes, and Representative Quotations From Domain 2 (Coping Strategies) "She's just my compatriot in this.She's kind of the same stage in her career.She does exactly what I do, professionally.And so, we are able to talk to each other.""AndIgota lot of positive reinforcement from colleagues saying I'm not so sure I would have done anything different than what you did."Senior mentor"My usual way of coping with it was to go to my senior partner, and I think of it as carrying my albatross into his office and laying it at his feet.…Therewasnothing that I would have done that he hasn't done too.And just having that kind of person was extremely helpful to me, especially in my earlier years of practice, just being able to confess and share our shortcomings and be human.It's kind of like a one-on-one M&M [morbidity and mortality review], and I thought it was very therapeutic.""Iwent to talk to [Dr.X].I said, listen, I need your help with this case.He says, you know what?You get back on the saddle.This happens.We'll take care of it.Let's fix it together.That kind of relationship is worth its weight in gold.And I think if a junior attending doesn't have that kind of mentorship, it's probably lonely as hell." Surgeon and Surgical Trainee Experiences After Patient Adverse Events JAMA Network Open.2024;7(6):e2414329.doi:10.1001/jamanetworkopen.2024.14329(Reprinted) June 3, 2024 7/14 Downloaded from jamanetwork.comby guest on 06/07/2024

Table 4 .
Themes, Subthemes, and Representative Quotations From Domain 3 (Current and Suggested Institutional Support Systems) "Is there support within our department or division?I don't know.That's a great question.No one ever talks about it.""There'snoformalmechanismforus to discuss it outside M&M….The obsession in M&M is, how could you have prevented it, rather than…how is the team handling that?So, yeah, I would say effectively zero from a formal standpoint."Skepticism"So,thereareresourcesthat people can tap into.Whether they choose to do so or not is really an individual thing.""Ihaveneverutilized it.I don't even know if a resource like that exists.I'm not sure many would use it."StigmaProblematicfor some "People don't talk to each other about these sorts of things.They just-whether it's complications or even things like, when you're young attending, the first time you get sued-people just don't talk about it.It's like a dirty little secret or something." When you are a medical professional and you're putting yourself in harm's way emotionally, you need to be taught how to deal with that."