Complications during surgery can weigh heavily on a surgeon’s mind, which is why one consultant is trying to reduce the negative impact of mistakes and the likelihood of them happening at all. Peter Blackburn reports
Like so many surgeons Kevin Turner has found himself returning to that familiar old script when a colleague is struggling after a bad operation: ‘You’re good, bad things happen, dust yourself off and get back on the horse.’
But in 10 years as a consultant urologist Mr Turner has seen colleagues become stiffened, risk-averse, isolated and anxious, and facing family and relationship breakdown – as a result of the complications and mistakes that form a necessary but punishing part of their daily lives.
The script is no longer enough.
‘There’s a tendency to think you are directly responsible for an adverse outcome,’ Mr Turner says. ‘Surgeons have perfectionist tendencies and often think all these outcomes are their responsibility – but all procedures have risks of complications and mistakes can be made.’
And for most surgeons the stark reality is that it is simply a matter of time until the next complication or mistake. The concern for Mr Turner is how those inevitable incidents add up – and the damage done to the individual.
The Bournemouth-based surgeon says: ‘The question is: as you get longer in the tooth do you get better at taking the bullets? Is it a case of, we have seen it all before and bad things happen and we can deal with the fallout of an adverse event, or are senior surgeons even more vulnerable because they have been hit before? Is it the case that you can only take so many bullets?’
The study Healthcare Professionals as Second Victims after Adverse Events carried out in 2012 found surgeons are becoming ‘second victims’ – deeply affected emotionally or physically – by complications or mistakes in up to 40 per cent of cases.
It found that many of the surgeons report negative reactions varying from ‘anger and irritation, sadness and depression to shame and self-blame’.
Oxford professor of surgery Neil Mortensen agrees that there is a problem too long ignored.
He says: ‘The caricature of surgeons is cold-hearted brutes who don’t care but most of them care a lot.
‘Surgeons probably do have a personality type as a group – on the whole they are the kinds of people who can compartmentalise and rationalise bad things and so on, but maybe it doesn’t come out in obvious forms like suicide but shows in personal problems or divorce.
‘I think surgeons also lose their bottle and become cautious – I’ve seen many great surgeons who were once very technical and can’t take risks anymore.
‘Surgeons are becoming more risk-averse. And clearly there are situations where you need someone to be able to take a risk.’
And the demands are increasing, according to Professor Mortensen.
‘There is the volume pressure of getting the work done, there’s increasing scrutiny and the physical and emotional demands of surgery are growing. If [someone] dies you have difficult governance issues to face such as gardening leave, the GMC and sometimes it feels like it’s all a gathering storm – it’s something that’s very underestimated. It’s an area where evidence needs to be gathered.’
When mistakes are made or complications cause problems in surgery the mental pattern is well-trodden, Mr Turner says. Surgeons question what could have been done differently and guilt builds. Adverse reactions from families or colleagues can deepen problems.
It is at this point that the familiar script: ‘You’re good, bad things happen, dust yourself off and get back on the horse,’ kicks in.
‘People do fall into that script because they want to help – if they share a bad experience that can be helpful. But that script is not enough,’ Mr Turner says.
‘I have been a consultant surgeon nearly 10 years and like all of us I’ve had experiences of errors and complications and those things do affect you – I’m in a fortunate position of having had extremely supportive colleagues. Not everyone in that position does understand.’
If the script is no longer enough – and perhaps it never has been enough – support outside the traditional comfort of colleagues, family and friends might be needed. After all this is a problem not just affecting the surgeons themselves, but also potentially patient care and safety and even the sustainability of an NHS in which these talented professionals are scarce.
‘Surgeons are an incredibly expensive resource and if their performance is below par, whether because they are signed off work or at work making less good decisions that’s very expensive for everyone. I’m very interested in the personal well-being of surgeons and that has a broader impact on healthcare providers,’ Mr Turner says.
It is here where Mr Turner’s work could help. Along with a group of researchers at Bournemouth University and The Royal Bournemouth Hospital, Mr Turner has launched a survey that aims to understand the psychological impact of errors or complications for surgeons. It is hoped the survey will generate a national picture which could make a difference – to reducing negative impacts of adverse events and ensuring they are at a minimum likelihood in the first place.
Mr Turner says: ‘What the data suggests is that surgeons have a tendency to be more cautious and more risk-averse when bad things happen and potentially avoid procedures that are associated with complications. That might not be good for patient care – and ultimately that is what this is about. We don’t really know the cumulativeeffect of errors and complications.
'We hope to get a broad range of surgeons.
‘I’m interested in the feelings of isolation, loneliness, anxiety and avoidance behaviours – maybe people who drink more or exercise more to avoid facing up to what might happen.
'We’re also looking at impacts on family life, relationships and hours spent at work. We’re also of course very interested in avoiding significant acute mental health events.’
PhD student Catherine Johnson is one of the researchers involved. She says: ‘Once surgeons complete the survey, we will have a detailed idea of the ways in which they respond to complications and errors.
‘We recognise that all surgeons are different and that we cannot put every individual who opts for a career as a surgeon into the same box.
‘However, because we have the opportunity to reach tens of thousands of surgeons with our survey, we hope to gain a much more detailed understanding of the different ways in which surgeons may be affected by adverse surgical events.’
Mr Turner adds: ‘The reaction we’ve had when speaking about this and presenting this is unequivocal – this is really important, it should have been done before and we’ve had nothing other than encouragement that this is a whole area that needs to be explored.’
The survey will, in time, provide many of the answers – but what could better support for surgeons look like?
Mr Turner thinks the key is to be proactive, rather than just reactive, when asked about whether using mentors or psychological professionals could be key.
And changes to training could be vital too – with Mr Turner identifying that trainees are ‘never told what they will feel like or go through’.
Professor Mortensen has similar suggestions. He says: ‘Clearly support is something that at the moment we don’t do very well. We have a regional network of Royal College of Surgeons representatives and if somebody has a problem they can ring those up but I don’t think that system works particularly well. We have been talking about having a kind of mentoring hotline where you have a group of senior people who are a bit like Samaritans.
'Helping at a personal level needs to happen – a lot of the arrangements are cold and bureaucratic.’
Regardless of the outcomes of the survey the work can only help build a bigger picture and a platform for positive change.
As Ms Johnson says: ‘The bottom line is that surgeons who are supported through adverse events will provide better patient care in the future. That is what we are aiming to achieve through this research and why it is so important.'
Perhaps it’s time to put the script aside.
Take part in the survey
The BMA provides counselling and peer support services for doctors
It also provides dedicated support for doctors going through GMC investigations
Read Healthcare Professionals as Second Victims after Adverse Events
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