Articles

Complication Is Inevitable, but Suffering is Optional-Psychological Aspects of Dealing with Complications in Surgery Hau D Le, Justyna M Wolinska et al. Eur J Pediatr Surg. 2023 Jun;33(3):181-190. Epub 2023 Mar 22.

Surgical complications have been defined as “any deviation from the ideal postoperative course that is not inherent in the intervention and does not comprise a failure to cure”[1] In the USA, multifaceted efforts to improve safety and reduce adverse events have resulted in reducing overall rates of death associated with surgery from 1.5 to 0.8% and inpatient complications from 11 to 7%[2][3]. Globally, 310 million major surgeries are performed annually and it is estimated that 1–4% of these patients will die, up to 15% will have serious postoperative morbidity, and 5–15% will be readmitted within 30 days[4]. The notion that a surgical complication is an inevitable part of a surgeon’s career has led to a famous aphorism: “the reason you haven’t had a complication is you haven’t operated long enough”.

In general, surgeons view complications as personal failures. After a complication, it is common for a surgeon to experience a complex emotional, physical, and psychologic response. The second victim syndrome[5] (SVS) is defined as the health worker who ? experiences an error and is traumatized by the event. This trauma can manifest psychologically (shame, guilt, anxiety, grief, and depression), cognitively (compassion dissatisfaction, burnout, secondary traumatic stress), and/or physically (insomnia, irritability, fatigue). The degree of support from one’s peers, institutions, and networks often influence the impact of the complication on the surgeon.

This excellent review contributes to the accumulating literature documenting best practices and preparation concerning both an individual and system approach to surgical complications. The review explores the internal and external factors which impact the severity of one’s response to an adverse event. The paper then expands the discussion exploring how to improve the psychologic outcomes of Second Victims. Again, both external and internal factors are explored. Externally, there is a call for having a well organized and defined SUPPORTING NETWORK in place. This includes peers, especially senior and highly respected surgeons willing to discuss their own complications and associated emotional struggles. Additionally, the concepts of promoting compassion, empathy, and confidentiality are re-enforced. A novel part of the discussion is the observation that “surgeon’s have some degree of control over their patients’ psychologic responses and outcomes after complications”. The information presented discussed how surgeons are not generally well versed in matters of communication, especially news about a complication. Transparency and honesty are stressed. Additionally noted is that unprepared or poorly delivered information concerning a complication can further exacerbate the negative impact on all parties. And the converse is also true – patient’s exhibiting acceptance of a sub-optimal outcome can provide relief for the surgeon. The authors conclude that all of us will, at some time, be in the position of a second victim or of a supporting peer. We must normalize the expected individual responses to complications and must strive to provide a robust empathetic institutional support system that is ideally proactive. Familiarizing ourselves with best practice strategies to mitigate adverse outcomes in the arenas of emotional, psychologic, and physical well-being will be crucial in “choosing not to suffer”.

Trends in Surgeon Burnout in the US and Canada: Systematic Review and Meta-Regression Analysis[6]. Etheridge JC, et al. J Am Coll Surg. 2023 Jan 1;236(1):253-265. Epub 2022 Dec 15.

Burnout is described as a syndrome characterized by exhaustion, cynicism, and reduced self efficacy (person’s belief in their ability to complete a task or achieve a goal). Burnout is further defined in the context of 3 key dimensions that drive a syndrome that develops in response to chronic stressors: emotional exhaustion, depersonalization, and feeling incompetent (or lacking self-confidence). The consequences of burnout are numerous and include: negative affect on patient care, increased absenteeism (and presenteeism), decreased productivity, increased errors, and decreased satisfaction. Depending on the study, burnout in surgeons is estimated at 35-50% in attending surgeons and up to 70% in trainees. Addressing burnout is not only a practical necessity, it is a moral imperative.6 The ACS and ACGME (amongst others) have issued calls to action and implemented programs to mitigate burnout. Data on burnout trajectory (or how has burnout changed over time) for surgeons is lacking.

This metanalysis represents 103 studies with over 63,000 surgeons from 1996-2021. Forty-one percent met criteria for burnout. Trainees had a higher incidence than faculty (46% vs 36%). The authors conclude that there is no evidence for the claim of rising burnout. Instead, increased awareness of surgeon burnout may lead to perceptions of a growing epidemic. Indeed, there was consistent suggestion in the analysis that components of burnout, especially emotional exhaustion, are on the decline. The authors are careful to state that surgeon burnout remains worrisome, and at the current rate of decline it would require “several decades” for the US to reach European burnout rates (< 19%). Importantly, the authors stress that “Burnout is not simply a failure of resilience at the individual level, it stems from mismatch between job demands and available resources”.

Addressing Surgeon Burnout Through a Multi-level Approach: A National Call to Action[7]. Golisch KB, et al. Curr Trauma Rep. 2023 Jan 17;1-12. Online ahead of print.

Surgeons have one of the highest rates of burnout in medicine (42%). Although some studies suggest a stagnant or declining rate of surgeon burnout, others do not and the US Surgeon General recently released a report sounding an alarm on health care worker burnout. As the root causes of burnout are multi-factorial and complex, the authors advocate for a novel conceptual model to address burnout at the individual, institutional, and national level.

This paper is a “Call to Action” to mitigate surgeon burnout and presents a comprehensive overview of burnout, including key factors and effects. By analyzing 35 recent papers (2017-2022) the authors develop a strategy to classify and implement solutions to improve well-being using a 3-layer approach. At the individual level; emotional intelligence, mindfulness, and resilience is taught. At the institutional level; initiative, mentoring, and support is stressed. Finally, nationally, policies, opportunities, and leadership are discussed. Each of these areas has an easily digestible 2-3 paragraph section with informative and meaningful content for those wishing to further explore.

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