Surgeons, Trainees Experience Distress After Medical Errors

Surgeons and surgical trainees almost universally experienced significant distress after adverse patient events, but female trainees and those with a minority racial or ethnic background disproportionately experienced negative emotions and self-doubt, a single-site, mixed-methods study found.

Of the trainees, 82.8% said they were involved in at least one recent adverse event. Most reported embarrassment (84.8%), rumination (82.1%) and fear of attempting future procedures (64.4%), while over a third (35.9%) considered quitting, Sara Ginzberg, MD, of the University of Pennsylvania Health System in Philadelphia, and co-authors reported in JAMA Network Open.

Female or minority racial or ethnic background trainees consistently responded “yes” at higher rates than male or non-Hispanic white trainees to questions about negative personal impacts of adverse events. Female trainees also reported higher rates of physical symptoms than male trainees, including difficulty sleeping (38.2% vs 16.7%) and loss of appetite (38.2% vs 9.5%).

“Given 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,” the researchers wrote.

Though medical errors are frequent, clinicians who unintentionally harm a patient may avoid certain patients and cases in the future, and may be more likely to leave their practices or direct patient care, previous studies have shown.

Little research has investigated the varying reactions of surgeons and surgical trainees to errors, or the role of gender, race, and ethnicity in these reactions.

“There is a productive larger conversation developing around clinician workforce challenges that goes beyond the impact of involvement in adverse events,” like burnout and moral injury, said James Hoffman, PharmD, of St. Jude Children’s Research Hospital, in Memphis, Tennessee, who was not involved in the study. “However, it is useful to tightly focus on understanding clinicians’ experiences with adverse events as there are still specific things to learn about experiences with adverse events. This research provides deep insights on the experiences of surgeons that should be useful to planning interventions.”

Researchers utilized a 37-question survey for surgical trainees because of concerns about trainee work schedules, and conducted qualitative interviews with faculty. The survey included questions about race, ethnicity, and gender.

Trainees from seven surgical programs in the same health system — cardiothoracic surgery, general surgery, orthopedic surgery, otorhinolaryngology, plastic surgery, urology, and vascular surgery — were invited to complete surveys at educational conferences between September and November of 2022; 93 completed them. Surveys were adapted from the Second Victim Experience and Support Tool, removing questions irrelevant to the trainee population and adding new questions, with majority agreement of an expert panel.

Semi-structured interviews with 23 surgical faculty from four departments were conducted one-on-one via email recruitment. They took place between June and September of 2022, either by video conference or in the faculty member’s office. Researchers purposively included participation from both genders, and a variety of subspecialties and experience. An interview guide with themes from the survey was developed by consensus among the study team.

Of the trainees, 52.7% were male, 64.5% were in third postgraduate year or higher, 24.7% were Asian or Pacific Islander, 6.5% were Black, 54.8% were white, 14% were Hispanic or Latinx, and 8.6% were another race. Of the faculty members, 56.5% were male and median years in practice was 11.

The greatest gender difference was in response to the statement, “My experience makes me wonder if I am not really a good healthcare provider” (91.2% of female vs 64.3% of male trainees).

The largest disparity between racial and ethnic groups was in response to, “After my experience, I became afraid to attempt difficult or high-risk procedures” (86.1% minority race or ethnicity vs 47.4% of non-Hispanic white trainees).

The most desired form of support following an incident was the chance to discuss the incident with an attending physician (97.4% of trainees). Faculty described feelings of guilt and shame, a loss of confidence, and distraction after adverse incidents. Though most said talking to peers and senior colleagues was useful, some said they would not reach out in the first place. Several suggested having a departmental point person to debrief with.

As one surgeon said in an interview, “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?'”

“To cope, both trainees and faculty rely on support from peer and senior colleagues,” wrote Ginzberg and colleagues. “More formal support mechanisms at all levels may help decrease stigma and restore confidence.”

“With regard to formalizing support in the immediate aftermath of adverse patient events, programs could consider providing standard outreach to all trainees involved in in-hospital deaths and perhaps even to all trainees who submit complications that qualify as Clavien-Dindo grades IIIb or higher (i.e., intervention under general anesthesia, life threatening complication requiring intensive care management, or death) for morbidity and mortality review,” they continued.

Only 5.3% of trainees had used formal institutional resources to cope with adverse events (like free counseling sessions), although nearly a third expressed a strong desire for an employee-sponsored counseling program. No faculty, meanwhile, discussed using professional mental health support services, and most were unfamiliar, and skeptical of, formal institutional resources.

Researchers were limited by their small sample size, from a single academic institution in the U.S., and potential survey nonresponse bias. They also did not ask faculty questions about race and gender to preserve anonymity.

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