The orthopaedic ostrich: surgeons’ responses to complications

Deepa Bose

Deepa Bose is a Consultant in orthopaedic trauma and limb reconstruction at the Queen Elizabeth Hospital Birmingham. She is Vice Chair of the Specialist Advisory Committee for Trauma & Orthopaedics, and the lead for CESR application reviews. She has also contributed to the revision of the curriculum. She holds an MSc in Medical Education and is a member of the Academy of Medical Educators.

This article is an abridged version of the winning entry for the 2021 Robert Jones essay competition.

Science does not, ostrich-like, bury its head amidst perils and difficulties. It tries to see everything exactly as everything is.

– Garrett P. Serviss

Complications are an inevitable part of surgery. It is said that if a surgeon has no complications he or she is either lying or not operating.

Surgeons respond in different ways to post-operative complications; denial, anger, despair and acceptance. These are perfectly understandable if one considers the surgeon as a craftsman. Any craftsman is wont to take criticism of his or her creation personally. It is this perceived apportion of blame which can result in surgeons “burying their head in the sand”, as ostriches are said to do, when complications occur.

What is a surgical complication?

History as well as life itself is complicated - neither life nor history is an enterprise for those who seek simplicity and consistency.

– Jared Diamond (Collapse: How Societies Choose to Fail or Succeed)

What constitutes a surgical complication? Whilst there is a broad understanding that it refers to an adverse event, there is no consensus, although many attempts have been made at a definition. Dindo and Clavien1 propose the definition “any deviation from the ideal post-operative course that is not inherent in the procedure and does not comprise a failure to cure.” They divide negative outcomes after surgery into 1) Sequelae (a natural result of surgery, for example a scar); 2) Failure to cure (the purpose of the surgical intervention was not achieved) and 3) True complications. Other authors have adapted this to different surgical specialties, including orthopaedics2 .

Visser et al.3 highlight the wide variation in and subjective nature of what surgeons report as complications. Interestingly, Woodfield et al.4 found that when patients reported complications themselves, there was a rate of over 40%, and that many of these, although clearly of significance to the patient, would not have otherwise been identified.

The notion of a surgical complication is closely linked to medical negligence in the minds of the general public and medical practitioners alike. Negligence, however, has a very specific definition whereby a duty of care must have been owed and the breach of which resulted in harm to the patient. This association in the minds of patients and surgeons is difficult to escape, and goes some way to understanding the reticence in acknowledging a complication.

Surgeons’ responses to complications

Every surgeon carries within himself a small cemetery, where from time to time he goes to pray—a place of bitterness and regret, where he must look for an explanation for his failures.

– René Leriche

There are numerous documented accounts of the negative impact complications have on surgeons’ wellbeing, and therefore on patient care5,6 . These authors found that emotional reactions range from anger and guilt to performance anxiety and fears about one’s surgical career. Furthermore, although the intensity of such feelings dims with time, there are a few cases that haunt surgeons for many years; this is the basis of the quote above by French surgeon René Leriche, a popular one amongst surgeons. Wu7 has coined the term “the second victim” for the physician affected by an adverse event, although some think this is insensitive to patients. It is important to recognise that all responses described above are natural – there are no right or wrong emotions.

Although adverse events are visited upon all medical specialties indiscriminately, there is something very personal to the surgeon when it comes to a post-operative complication. Surgery is often referred to as a ‘craft’ speciality; this conveys the concept that surgery requires more than just sound scientific principles, and that the ‘expertise’ so avidly sought and so dearly won by trainees is to be found at the sweet intersection of manual dexterity, anatomical knowledge, delicate handiwork and creativity. When a post-operative complication occurs, there is a sense that one has caused the event “by one’s own hands”. These feelings of failure, guilt and frustration are the seeds of our emotional reactions to adverse surgical events.

Surgeons are traditionally regarded as possessing a certain personality; emotionally tough, confident, high achievers. One may be forgiven for thinking, therefore, that surgeons should be well equipped to deal with setbacks. Nothing could be further from the truth. The ‘flip side’ of the so-called ‘surgical personality’, if this can be said to exist, consists of some very negative characteristics; perfectionism, workaholic, poor delegators and poorly able to prioritise tasks. These can lead to an unhealthy response when things do not go according to plan. Surgeons are taught and encouraged to take responsibility for their patients. Consultants ‘carry the can’, ‘the buck stops’ with them; all these are viewed as necessary qualities, but they merely add to emotional stress when things go wrong. It is well known that medical practitioners in general are prone to burnout and mental health problems. The rate of burnout is especially high amongst surgeons, and Money8 emphasises the contributory role of high stakes human outcomes in this.

Turning the tide; healthy responses to complications

You people with hearts, have something to guide you, and need never do wrong; but I have no heart, and so I must be very careful.

– Tin Man (The Wizard of Oz)

Several years ago I attended an event organised by the excellent Surgery and Emotion project, run under the auspices of the Royal College of Surgeons of England. It was enlightening and fun. I found the members of the public to be highly insightful. Twice I was asked what support there was for surgeons when things go wrong. Having been in this unenviable position myself, I responded “Not very much, actually.” They were both taken aback; they had naturally assumed that such an important service would be readily available to us.

So how do we cope with complications? Head down to the local for a pint with a friend? Speak to a mentor? Analyse endlessly? Adopt risk-averse behaviour? Accept disproportionate blame or shrug off any responsibility? There are as many coping mechanisms as there are surgeons. Pinto et al.6 report that discussion, deconstruction and rationalisation (putting things into perspective) werethe most common responses. These are very positive measures, and result in the emotional and professional growth of the surgeon. Unsurprisingly, there are also negative coping mechanisms such as alcohol and substance abuse. These can heighten feelings of depression, guilt and shame, and ultimately result in predictable problems on a professional and personal level.

The question we must now ask ourselves is how to manage the aftermath of surgical complications in a way which is both supportive and conducive to growth. It is noteworthy that this very important aspect of surgery is not usually addressed in surgical curricula. We, like our friend the ostrich, tend to bury our heads in the hope that the emotions will eventually pass, but this is a most unhealthy strategy.

Peer support, mentorship and a team structure which encourages open and frank discussions have all been mentioned as vital in helping surgeons to deal with their emotions after an adverse event. Making this a normal part of practice represents an acknowledgement that complications are not unusual, are emotionally challenging for the best surgeon, and that seeking support is not a sign of weakness.

Dorsey and Ritzer9 have coined a marvellous phrase called “the McDonaldization of medicine” for the application of corporate values such as efficiency, calculability, predictability and control to the practice of medicine. These institutional values often result in a ‘blame’ culture when things go wrong. Several authors point out that lip service is paid to a supportive environment, but the reality is that surgeons are often made to feel that they are solely responsible for adverse events. A non-adversarial governance culture is essential in allowing surgeons and patients to benefit from the valuable lessons to be learnt from unintended outcomes.

Fear of litigation and malpractice is known to be a factor in the negative impact on surgeons after a post-operative complication. A no-fault compensation system for surgical complications would foster a blame-free environment, and a better surgeon-patient relationship.

What lies ahead?

There is no separation of mind and emotions; emotions, thinking, and learning are all linked.

– Eric Jensen

Recently we are seeing the emergence of not just an awareness of the negative impact of complications on surgeons, but the necessary tools to combat this. The Royal College of Surgeons of England have released ‘Supporting Surgeons after Adverse Events’10 . In this they stress the role of a ‘first responder’ whose primary role is to focus on the surgeon’s wellbeing.

It is also vital to consider how we prepare our trainees to deal with surgical complications, and with the emotional fallout of these.

Finally it seems, we are lifting our heads from the sand.

Disclaimer

The author is aware that ostriches do not actually bury their heads in the sand!

References

References can be found online at: www.boa.ac.uk/publications/JTO.