ORIGINAL REPORTS
How Surgical Trainees Handle Catastrophic Errors: A Qualitative Study James A. Balogun, MD,* Alexa N. Bramall, MD, PhD,* and Mark Bernstein, BSc, MD, MHSc (Bioethics), FRCSC† Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada; and †Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada *
OBJECTIVE: Surgical trainees are often subject to the
negative consequences of medical error, and it is therefore important to determine how trainees cope with error and to find ways of supporting trainees when catastrophic events occur. This article examines how trainees interpret catastrophic surgical outcomes and ways to provide support for trainees who have experienced catastrophic events. DESIGN: Totally 23 semistructured interviews were conducted with surgical trainees. Interviews were conducted in English and subjected to modified thematic analysis. SETTING: A tertiary care hospital in Toronto, Canada. PARTICIPANTS: Interviews were completed with 23
surgery residents. Potential participants were recruited through communications via the Department of Surgery and volunteered to take part in the study. RESULTS: Totally 5 themes emerged: (1) catastrophic
errors usually represent system deficiencies; (2) catastrophic events provide lessons for future practice; (3) many trainees did not feel comfortable speaking with the surgical staff; (4) counseling services should be offered to help a subset of trainees; and (5) the culture of surgery may act as a barrier to trainees seeking help. CONCLUSIONS: This study demonstrates the impor-
tance of providing support for the emotional needs of surgical trainees who have experienced catastrophic surgical errors and the continued need for mentoring by staff C 2015 Association of Program surgeons. ( J Surg ]:]]]-]]]. J Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: medical error, surgical education, qualitative
study, trainee support COMPETENCIES: Systems Based Practice, Interpersonal
Skills and Communication Correspondence: Inquiries to Mark Bernstein, BSc, MD, MHSc (Bioethics), FRCSC, Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada; e-mail: [email protected]
INTRODUCTION Interest in medical errors rose significantly following the 1999 Institute of Medicine report, which stated that up to 100,000 deaths in the United States may have resulted from medical errors, making it the eighth leading cause of death.1 This expectedly led to increased calls for improved patient safety from both the medical community and the general population.2-4 However, medical errors are still common despite concerted efforts at preventing them.2,4-7 Most of these errors are described as preventable, some are regarded as inevitable, and approximately 1% to 3% of medical errors results in adverse effects.3,4,8,9 A medical error can occur at any stage of patient’s care and is defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Medical errors include errors in technique, judgment, drug administration, delays in the operating room, diagnostic errors, incomplete hospital record keeping, and many more.2 Errors that result in injury are referred to as preventable adverse events1 and can be termed catastrophic when they result in serious harm or death. Such errors include the rare but devastating wrong-side or wrong-level surgery.10,11 When medical errors occur, attention is understandably and appropriately focused on the patient and their relatives, described as the first victims.12-14 The involved health care providers are described as the second victims, and usually receive little or no attention regarding how to cope with the emotional stress to which they are subjected from the error.7,12,13 There are only a few studies that have attempted to look at the responses of physicians to the occurrence of medical errors2,3,12,15,16 and even fewer studies have evaluated the response of trainee physicians to medical errors with most of these focused on trainees in internal medicine, family medicine, and emergency medicine.7,9,17,18 There is no study that has evaluated the responses of surgical trainees to medical errors as a homogenous group. This group is unique in that a large part of their training is technical in nature, putting them at risk of technical errors (in addition
Journal of Surgical Education & 2015 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2015.05.003
1
to the risk of other type of errors), which have been found to constitute approximately 15% to 28% of errors recorded in surgical patients, a patient subset that is documented to be more prone to medical errors compared with other patient subsets.2-4 This study aims to understand the responses and coping strategies of surgical trainees to catastrophic events resulting from medical errors and to recommend appropriate supports for them, given the possible profound implications of these events to the health and future practice of these trainees.
METHODS Study Design Qualitative semistructured interviews were conducted with surgical trainees in the Department of Surgery, University of Toronto. Semistructured interviews are distinct from structured interviews because the interviews are open, allowing interviewees to explore a broader range of topics instead of restricting answers to a standard set of questions. The trainees were at different levels of training ranging from first year (postgraduate year 1) residency to postresidency clinical fellowships. Data Collection, Sample Size, and Analysis Totally 23 semistructured, open-ended interviews were conducted with resident trainees or postresidency clinical fellows in the Department of Surgery at the University of Toronto. Interviews were conducted by J.A.B. Potential participants were informed of the study either by word of mouth or through email exchanges within the Department of Surgery. Self-selected participants were informed of the objectives of the study, expectations in terms of publication, and the use of quotations from transcripts, and any risks or benefits that might be incurred by participants in the study. Written informed consent was then obtained. There were no specific exclusion criteria. Although interviews were based on an interview guide (Appendix 1), questions were open ended so that themes could be more fully explored. Totally 23 interviews were completed, a number that is sufficient to achieve data saturation, a qualitative research concept to describe the point at which no new themes arise during successive interviews.19 All interviews were conducted in English. Interviews were audio recorded and demographic data including surgical specialty, level of training, age, sex, ethnicity, religion, and marital status were collected (Table 1). Audio transcripts were generated and analyzed using NVivo10 software. The transcripts of the audio files were analyzed by open and axial coding, which breaks down information into common ideas and groups the data according to overarching themes,19 and analyzed by the authors. 2
Research Ethics All data gathered for this study were kept strictly confidential. The audiotapes and anonymous transcriptions were kept in a secure location. Participation in the study was completely voluntary. The study was approved by the University Health Network Research Ethics Board.
RESULTS Demographic Characteristics The participants’ demographic data are represented in Table 1. There were 14 residents and 9 postresidency clinical fellows. Neurosurgery and general surgery trainees constituted approximately 87% of the participants. The male:female ratio was 2.3:1. The age range was 27 to 38 with a mean age of 32 years. Our cohort had equal representation of single and married individuals. The participants were from varied ethnic and religious backgrounds. The themes are presented, with illustrative quotes in italics. Catastrophic Errors Often Represent System Deficiencies Rather Than Individual Errors Many participants thought that catastrophic errors usually result from a summation of mistakes within a flawed system rather than isolated individual error. One of the major barriers cited to preventing catastrophic error is the hierarchical nature of medicine, which often creates an TABLE 1. Demographic Characteristics of Participants Characteristic
Category
Value
Age (y)
Mean Range Male Female Neurological surgery General surgery Orthopedic surgery Vascular surgery ENT Resident year 2 Resident year 3 Resident year 4 Resident year 5 Clinical fellow Married Single Christian Jewish Muslim Atheist Unidentified White Asian Arabic Other
32 27-38 16 7 12 8 1 1 1 1 8 3 2 9 11 12 10 3 3 2 5 12 4 3 4
Sex Specialty
Level of training
Marital status Religion
Ethnicity
Journal of Surgical Education Volume ]/Number ] ] 2015
environment wherein trainees feel reluctant to question authority. Hierarchy is very strict here, and speaking up is not something I’ve seen commonly done. I think that’s dangerous and I think when you see something heading towards an adverse event, no matter who the staff or fellow is at the table, it doesn’t make a difference. You have to speak up and that as a culture has to be learned because the person who’s leading the operation might not be 100% perfect. Other examples of system deficiencies included: (i) time limitations in an environment where trainees often feel overworked, especially in the early years of training; (ii) communication gaps created by large care teams; and (iii) existing pressures to discharge patients instead of admitting to hospital for further management. The concept of error as a summation of multiple events is illustrated in the following quote: I think that nothing happens because of one mistake. It’s always a complete chain of things going on. If you can interrupt at one point, you might still have an adverse outcome, and you might still have a problem, but you won’t have the disaster. Things can go wrong but you’ve got to recognize when things are going the wrong way and try to interrupt that chain. Although Trainees Felt a Broad Array of Emotions When Catastrophic Errors Occurred, These Mistakes Served As Important Lessons for Future Practice Participants felt many different emotions because of exposure to catastrophic errors, including anger, frustration, guilt, self-doubt, sadness, and shock. However, when asked how the experience of catastrophic error would affect their future career decisions and practice, most trainees found that exposure to error forced them to become more thorough and proactive physicians. Moreover, the experience of catastrophic error, though oftentimes profoundly negative, did not have any effect on future career decisions.
experiences. Although mortality and morbidity meetings can serve as avenues to learn from others’ experiences, there was unanimous agreement that mortality and morbidity meeting rounds do not address the emotional needs of trainees. The following quote describes the sequence of emotions that a neurosurgery resident felt after experiencing a catastrophic event: The first thing is probably a bit of shock, and horror. That’s quickly replaced by some sort of sadness and depression to some extent … this patient trusted me and my team to do something and we betrayed that trust. So I think for me that’s the path of emotions that I follow: initial shock and horror followed by a sadness and depression followed by a component of guilt and then self-doubt. Although Trainees Highly Valued Mentoring Relationships With Senior Staff, Many Trainees did not Feel Comfortable Approaching Their Supervisors When Catastrophic Events Occurred Most participants felt that support following a catastrophic error is best received from someone in the same surgical discipline who can better understand the context of such errors. However, it was also important to trainees that the individual be neither judgmental nor paternalistic. Although many trainees consulted family and friends to help overcome the emotional sequelae of catastrophic outcomes, some trainees also discussed the event with a staff member or senior mentor who was not directly involved in the case. Unlike more senior residents and fellows, junior residents often had not developed close relationships with senior staff and therefore did not consult them as often for advice. Moreover, trainees were often concerned that staff would view these errors as a negative reflection of the trainee’s competence. Debriefing discussions generally focused on the academic and educational, rather than the emotional aspects of the event.
Every time a complication develops it just makes you think more and plan more for next time. It just means more reflection. So whenever I face a complication or unexpected outcome, I try to reflect more on the cases to see what I could have done differently.
Anyone who ever experiences severe adverse outcome needs to have someone to be able to talk to who’s not going to judge their professional integrity and who’s not going to point at them and say it’s your fault the patient has died. Sure the patient is dead or doing poorly and it’s partly your fault, but that’s because it’s your job and your duty to do something. You can’t be blamed for things and if you don’t have anyone to talk to in a blame free environment then it can get very distressing.
Participants coped with the negative emotions resulting from the experience of catastrophic errors in many ways, including discussions with friends, family, and senior mentors. Some participants gravitated toward artistic endeavors or physical activity for emotional relief. Most of the participants also channeled their emotional energy into helping others; however, junior residents cope with their own negative
Counseling Services Should be Offered to Help a Subset of Trainees Who Might Benefit From These Services Overall, experiences of catastrophic outcome elicited a plentitude of emotional responses, which were highly varied and individual. Moreover, coping mechanisms of trainees dealing with the emotional repercussions of catastrophic
Journal of Surgical Education Volume ]/Number ] ] 2015
3
outcomes ranged from repression, rationalization, selfeffacing humor, and stoicism to “just moving on”. There were no common themes identified among participants based on self-identified sex, religion, or race. A number of the trainees spoke to their fellow trainees about the cases in order to compare their own experiences to the experiences of others at a similar level of training. Other trainees felt an obligation to speak directly with the patients’ family members following a catastrophic event, which sometimes brought emotional relief. Although some trainees therefore found effective ways of coping, others felt like they lacked the proper support to deal with their emotions. Interestingly, many participants admitted that they were unaware of existing resources at the University and within the Department of Surgery, suggesting that existing resources should be advertised more widely. Junior trainees may be especially vulnerable as they likely have not developed mechanisms for coping with catastrophic errors owing to their relative inexperience. Nonetheless, junior trainees also felt less responsible when catastrophic events occurred owing to their less senior position in the medical hierarchy: Now that I’m going to be a senior, if things go badly I’m going to feel a lot more personally culpable than I did as a junior resident. The following quote describes the experience of a junior trainee in neurosurgery: For sure one thing I feel when really terrible things happen and you’re in the hospital and you’re totally by yourself and you feel very alone, very isolated. And there were a bunch of times I felt like I’m too young for this, like life has not prepared me, like this is the job of grown adults to be experiencing these terrible things. This is a lot to be shouldering with very little life experience to back you up. So I think you age very very quickly in this specialty. Overall, most participants indicated that counseling resources, though not used by all trainees, would be beneficial to some to help cope with catastrophic events. A formal debriefing process may also be helpful, as indicated in the following quote: I compare it to my knowledge of other industries. When you have critical incidents in the aviation industry or in the police force they actually have trained psychologists that help debrief … you have a formal debrief and figure out what went wrong, what was random … I think in medicine the tragedies are no more or less horrible than what these other professions encounter but we don’t have formalized processes in terms of the debriefing. 4
The Culture of Surgery, Which Often Equates Emotional Vulnerability With Personal Weakness, is a Significant Barrier to Trainees Seeking Help Almost all surgical trainees thought that the act of seeking help for emotional reasons is often perceived as a sign of personal weakness, an attitude that reflects the general culture of surgery. It was also noted that there is often little benefit to admitting to error as this is often viewed as a flaw in one’s character or ability. I think the staff who is the team leader needs to create an environment where mistakes are not viewed as problems with someone’s character. Mistakes happen because you’re a doctor in training and everyone has made a mistake at some point.
DISCUSSION This study set out to investigate the response of surgical trainees to catastrophic errors and to evaluate the need for a support system to help trainees cope when catastrophic events occur. A number of findings emerged from the study. First, catastrophic errors were rarely caused by individual error. Second, catastrophic events provided important lessons for future practice. Third, many trainees did not feel comfortable seeking support from staff owing to the perception of error as a reflection of personal weakness or clinical incompetence. Fourth, coping mechanisms among trainees were varied, and many trainees expressed interest in expanding services to include counseling and formal debriefing sessions. Fifth, the perception of emotional vulnerability as weakness is fairly common in surgery and can be a significant barrier to trainees seeking help. The hierarchical nature of medicine and especially surgery was cited as a major barrier to trainees’ expression of potentially critical or contradictory opinions. If an error was observed in the operating room, trainees often felt restrained from drawing attention to the error as junior members of the team. Although it may be beneficial to create an environment that is more conducive to the expression of divergent opinions, trainees should also be reminded that they have the right and duty to speak up if they believe that an action may compromise patient care. The hierarchical nature of surgery also means that staff surgeons, who are generally at the top of the hierarchy, should initiate discussions when catastrophic events occur. Moreover, staff surgeons should be more open to discussing their own errors so that trainees feel less isolated and can appreciate that being fallible is not unique to him or her.4,6,20 Many participants felt that the introduction of medical errors as a topic of discussion into the residency training curriculum guided by staff surgeons would be very helpful to prepare trainees to deal with future catastrophic events. A similar proposal in an earlier study concluded that faculty within teaching institutions should be instrumental Journal of Surgical Education Volume ]/Number ] ] 2015
in the process of shifting the culture from one of blame to one of continuous improvement.21 The emotional response of trainees to catastrophic error was highly individualized as people generally respond to emotional distress in different ways.3,12,17,22,23 In general, in addition to the severity of the catastrophic event, catastrophic outcomes were more poignant to the individual if (1) the patient was admitted for an elective procedure; (2) the patient was without deficits upon admission to hospital; and (3) the physician had developed some sort of personal relationship with the patient or the patient’s family. Most participants dealt with catastrophic error by discussing their feelings with family members or significant others. However, most participants also wanted support from their direct supervisors. Unconditional support for fellow physicians is essential, particularly for trainees.7,20,24 Despite the fact that most trainees thought that it would be best to speak with a staff member who could identify with their experience, most of the participants were reluctant to consult a staff surgeon for advice. Importantly, trainees wanted to discuss the event with someone who would be nonjudgmental, and not interpret the error as a deficiency in the trainee. It is important therefore for staff surgeons to engage trainees in an objective and impartial manner when catastrophic events occur, and engage trainees in the first place. Moreover, to encourage these interactions, there should be increased mentoring opportunities with staff surgeons so that trainees feel more comfortable approaching staff for advice when the need arises. Although none of the trainees reported that the emotional consequences of experiencing catastrophic events were debilitating, there were instances of intense distress more common among junior trainees. Furthermore, psychological distress has been shown to influence future work performance and may contribute to further medical error.25 Consequently, it is pertinent to address ways of supporting the emotional needs of trainees to avoid the development of dysfunctional coping mechanisms26 and to prevent burnout, depression, and the loss of empathy, which may result from repeated exposure to medical errors.7 Although there was some skepticism about trainees’ predisposition to the use of professional counseling or psychological support services due to a fear of stigmatization, there was a general consensus that these services should be provided and advertised to trainees. A similar approach involving psychiatrists has been suggested by others.23
addressed in surgical training curriculums. First, communication between senior surgeons and surgical trainees is critical and has implications for patient safety.27 Senior surgeons should remain cognizant of the possible psychological effects of trainee’s exposure to catastrophic error, and discussions surrounding the sources of error and strategies for preventing similar mistakes should be initiated by senior surgeons outside morbidity and mortality rounds. Second, counseling services may be beneficial to a subset of surgical trainees, and should be accessible to individuals needing additional support. Finally, programs should try to foster an atmosphere devoid of fear and intimidation in which the admission of error is not regarded as a character flaw and emotions are not regarded as personal weaknesses but rather a natural human response to an unexpected and sometimes tragic situation. Above all, the importance of trustworthy mentoring relationships between staff surgeons and trainees should not be underestimated. Study Limitations We interviewed a small number of trainees (23) from a large academic Department of Surgery in a country with a predominantly socialized health care system. The results of this work may therefore not be generalized to surgical trainees in other universities and other countries. It is also of note that 8 of the 9 clinical fellows finished postgraduate training outside Canada and therefore may have different experiences of catastrophic outcomes. However, the interviewees included clinical fellows who completed postgraduate surgical training outside Canada. The study also included a large number of neurosurgical trainees, although there were also representatives from many other surgical disciplines, including ENT and vascular surgery.
ACKNOWLEDGMENTS The authors would like to thank the Greg Wilkins-Barrick Chair in International Surgery for the outstanding and ongoing support. We would also like to thank all the trainees who participated in the research study for their time and contributions.
REFERENCES 1. Kohn L, Corrigan J, Donaldson M. To Err is Human:
CONCLUSIONS Our study brings to the forefront the need for the recognition of surgical trainees as important second victims in catastrophic errors. This is the first study to our knowledge that addresses this group of individuals. Our findings establish a number of ways that medical error and the effects of error on resident education can be Journal of Surgical Education Volume ]/Number ] ] 2015
Building a Safer Health System—Institute of Medicine. Washington: National Academy Press; 1999. 2. Bosma E, Veen EJ, Roukema JA. Incidence, nature and
impact of error in surgery. Br J Surg. 2011;98:1654-1659. 3. Penson RT, Svendsen SS, Chabner BA, Lynch TJ Jr,
Levinson W. Medical mistakes: a workshop on personal perspectives. Oncologist. 2001;6:92-99. 5
4. Stone S, Bernstein M. Prospective error recording in
16. Oreskovich MR, Kaups KL, Balch CM, et al. Preva-
surgery: an analysis of 1108 elective neurosurgical cases. Neurosurgery. 2007;60:1075-1080 [discussion 1080-1072].
lence of alcohol use disorders among american surgeons. Arch Surg. 2012;147:168-174.
5. Bernstein M, Herbert PC, Etchells E. Patient safety
in neurosurgery. Detection of errors, prevention of errors, and disclosure of errors. Neurosurg Q. 2003;13: 125-137.
17. Engel KG, Rosenthal M, Sutcliffe KM. Residents’
responses to medical error: coping, learning, and change. Acad Med. 2006;81:86-93. 18. Hobgood C, Hevia A, Tamayo-Sarver JH, Weiner B,
associated with prospectively recording them. J Neurosurg. 2014;121:297-304.
Riviello R. The influence of the causes and contexts of medical errors on emergency medicine residents’ responses to their errors: an exploration. Acad Med. 2005; 80:758-764.
7. West CP, Huschka MM, Novotny PJ, et al. Associ-
19. Strauss A, Corbin J. Basics of Qualitative Research:
ation of perceived medical errors with resident distress and empathy: a prospective longitudinal study. J Am Med Assoc. 2006;296:1071-1078.
Grounded Theory Procedures and Techniques. Beverly Hills: Sage Publications Inc; 1990.
6. Oremakinde AA, Bernstein M. A reduction in errors is
8. Bostrom J, Yacoub A, Schramm J. Prospective collec-
20. Kaldjian LC, Forman-Hoffman VL, Jones EW,
tion and analysis of error data in a neurosurgical clinic. Clin Neurol Neurosurg. 2010;112:314-319.
Wu BJ, Levi BH, Rosenthal GE. Do faculty and resident physicians discuss their medical errors? J Med Ethics. 2008;34:717-722.
9. Christensen JF, Levinson W, Dunn PM. The heart of
21. Goldberg RM, Kuhn G, Andrew LB, Thomas HA Jr.
darkness: the impact of perceived mistakes on physicians. J Gen Intern Med. 1992;7:424-431.
Coping with medical mistakes and errors in judgment. Ann Emerg Med. 2002;39:287-292.
10. Bernstein M. Wrong-side surgery: systems for preven-
22. Crook ED, Stellini M, Levine D, Wiese W, Douglas S.
tion. Can J Surg. 2003;46:144-146. 11. Cohen FL, Mendelsohn D, Bernstein M. Wrong-site
craniotomy: analysis of 35 cases and systems for prevention. J Neurosurg. 2010;113:461-473. 12. Wears RL, Wu AW. Dealing with failure: the after-
Medical errors and the trainee: ethical concerns. Am J Med Sci. 2004;327:33-37. 23. Pitt E, Rosenthal MM, Gay TL, Lewton E. Mental
health services for residents: more important than ever. Acad Med. 2004;79:840-844.
math of errors and adverse events. Ann Emerg Med. 2002;39:344-346.
24. Newman MC. The emotional impact of mistakes on
13. Wu AW. Medical error: the second victim. The doctor
25. Ishak WW, Lederer S, Mandili C, et al. Burnout
who makes the mistake needs help too. Br Med J. 2000;320:726-727.
during residency training: a literature review. J Grad Med Educ. 2009;1:236-242.
14. Bernstein M, Potvin D, Martin DK. A qualitative
26. Smith ML, Forster HP. Morally managing medical
study of attitudes toward error in patients facing brain tumour surgery. Can J Neurol Sci. 2004;31:208-212. 15. Knifed E, July J, Bernstein M. Neurosurgery patients’
feelings about the role of residents in their care: a qualitative case study. J Neurosurg. 2008;108:287-291.
family physicians. Arch Fam Med. 1996;5:71-75.
mistakes. Camb Q Healthc Ethics. 2000;9:38-53. 27. Barzallo Salazar MJ, Minkoff H, Bayya J, et al.
Influence of surgeon behavior on trainee willingness to speak up: a randomized controlled trial. J Am Coll Surg. 2014;219:1001-1007.
SUPPLEMENTARY DATA Supplementary data associated with this article can be found in the online version at doi:10.1016/j.jsurg.2015.05.003.
6
Journal of Surgical Education Volume ]/Number ] ] 2015
How Surgical Trainees Handle Catastrophic Errors: A Qualitative Study James A. Balogun, MD,* Alexa N. Bramall, MD, PhD,* and Mark Bernstein, BSc, MD, MHSc (Bioethics), FRCSC† Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada; and †Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada *
OBJECTIVE: Surgical trainees are often subject to the
negative consequences of medical error, and it is therefore important to determine how trainees cope with error and to find ways of supporting trainees when catastrophic events occur. This article examines how trainees interpret catastrophic surgical outcomes and ways to provide support for trainees who have experienced catastrophic events. DESIGN: Totally 23 semistructured interviews were conducted with surgical trainees. Interviews were conducted in English and subjected to modified thematic analysis. SETTING: A tertiary care hospital in Toronto, Canada. PARTICIPANTS: Interviews were completed with 23
surgery residents. Potential participants were recruited through communications via the Department of Surgery and volunteered to take part in the study. RESULTS: Totally 5 themes emerged: (1) catastrophic
errors usually represent system deficiencies; (2) catastrophic events provide lessons for future practice; (3) many trainees did not feel comfortable speaking with the surgical staff; (4) counseling services should be offered to help a subset of trainees; and (5) the culture of surgery may act as a barrier to trainees seeking help. CONCLUSIONS: This study demonstrates the impor-
tance of providing support for the emotional needs of surgical trainees who have experienced catastrophic surgical errors and the continued need for mentoring by staff C 2015 Association of Program surgeons. ( J Surg ]:]]]-]]]. J Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS: medical error, surgical education, qualitative
study, trainee support COMPETENCIES: Systems Based Practice, Interpersonal
Skills and Communication Correspondence: Inquiries to Mark Bernstein, BSc, MD, MHSc (Bioethics), FRCSC, Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada; e-mail: [email protected]
INTRODUCTION Interest in medical errors rose significantly following the 1999 Institute of Medicine report, which stated that up to 100,000 deaths in the United States may have resulted from medical errors, making it the eighth leading cause of death.1 This expectedly led to increased calls for improved patient safety from both the medical community and the general population.2-4 However, medical errors are still common despite concerted efforts at preventing them.2,4-7 Most of these errors are described as preventable, some are regarded as inevitable, and approximately 1% to 3% of medical errors results in adverse effects.3,4,8,9 A medical error can occur at any stage of patient’s care and is defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Medical errors include errors in technique, judgment, drug administration, delays in the operating room, diagnostic errors, incomplete hospital record keeping, and many more.2 Errors that result in injury are referred to as preventable adverse events1 and can be termed catastrophic when they result in serious harm or death. Such errors include the rare but devastating wrong-side or wrong-level surgery.10,11 When medical errors occur, attention is understandably and appropriately focused on the patient and their relatives, described as the first victims.12-14 The involved health care providers are described as the second victims, and usually receive little or no attention regarding how to cope with the emotional stress to which they are subjected from the error.7,12,13 There are only a few studies that have attempted to look at the responses of physicians to the occurrence of medical errors2,3,12,15,16 and even fewer studies have evaluated the response of trainee physicians to medical errors with most of these focused on trainees in internal medicine, family medicine, and emergency medicine.7,9,17,18 There is no study that has evaluated the responses of surgical trainees to medical errors as a homogenous group. This group is unique in that a large part of their training is technical in nature, putting them at risk of technical errors (in addition
Journal of Surgical Education & 2015 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2015.05.003
1
to the risk of other type of errors), which have been found to constitute approximately 15% to 28% of errors recorded in surgical patients, a patient subset that is documented to be more prone to medical errors compared with other patient subsets.2-4 This study aims to understand the responses and coping strategies of surgical trainees to catastrophic events resulting from medical errors and to recommend appropriate supports for them, given the possible profound implications of these events to the health and future practice of these trainees.
METHODS Study Design Qualitative semistructured interviews were conducted with surgical trainees in the Department of Surgery, University of Toronto. Semistructured interviews are distinct from structured interviews because the interviews are open, allowing interviewees to explore a broader range of topics instead of restricting answers to a standard set of questions. The trainees were at different levels of training ranging from first year (postgraduate year 1) residency to postresidency clinical fellowships. Data Collection, Sample Size, and Analysis Totally 23 semistructured, open-ended interviews were conducted with resident trainees or postresidency clinical fellows in the Department of Surgery at the University of Toronto. Interviews were conducted by J.A.B. Potential participants were informed of the study either by word of mouth or through email exchanges within the Department of Surgery. Self-selected participants were informed of the objectives of the study, expectations in terms of publication, and the use of quotations from transcripts, and any risks or benefits that might be incurred by participants in the study. Written informed consent was then obtained. There were no specific exclusion criteria. Although interviews were based on an interview guide (Appendix 1), questions were open ended so that themes could be more fully explored. Totally 23 interviews were completed, a number that is sufficient to achieve data saturation, a qualitative research concept to describe the point at which no new themes arise during successive interviews.19 All interviews were conducted in English. Interviews were audio recorded and demographic data including surgical specialty, level of training, age, sex, ethnicity, religion, and marital status were collected (Table 1). Audio transcripts were generated and analyzed using NVivo10 software. The transcripts of the audio files were analyzed by open and axial coding, which breaks down information into common ideas and groups the data according to overarching themes,19 and analyzed by the authors. 2
Research Ethics All data gathered for this study were kept strictly confidential. The audiotapes and anonymous transcriptions were kept in a secure location. Participation in the study was completely voluntary. The study was approved by the University Health Network Research Ethics Board.
RESULTS Demographic Characteristics The participants’ demographic data are represented in Table 1. There were 14 residents and 9 postresidency clinical fellows. Neurosurgery and general surgery trainees constituted approximately 87% of the participants. The male:female ratio was 2.3:1. The age range was 27 to 38 with a mean age of 32 years. Our cohort had equal representation of single and married individuals. The participants were from varied ethnic and religious backgrounds. The themes are presented, with illustrative quotes in italics. Catastrophic Errors Often Represent System Deficiencies Rather Than Individual Errors Many participants thought that catastrophic errors usually result from a summation of mistakes within a flawed system rather than isolated individual error. One of the major barriers cited to preventing catastrophic error is the hierarchical nature of medicine, which often creates an TABLE 1. Demographic Characteristics of Participants Characteristic
Category
Value
Age (y)
Mean Range Male Female Neurological surgery General surgery Orthopedic surgery Vascular surgery ENT Resident year 2 Resident year 3 Resident year 4 Resident year 5 Clinical fellow Married Single Christian Jewish Muslim Atheist Unidentified White Asian Arabic Other
32 27-38 16 7 12 8 1 1 1 1 8 3 2 9 11 12 10 3 3 2 5 12 4 3 4
Sex Specialty
Level of training
Marital status Religion
Ethnicity
Journal of Surgical Education Volume ]/Number ] ] 2015
environment wherein trainees feel reluctant to question authority. Hierarchy is very strict here, and speaking up is not something I’ve seen commonly done. I think that’s dangerous and I think when you see something heading towards an adverse event, no matter who the staff or fellow is at the table, it doesn’t make a difference. You have to speak up and that as a culture has to be learned because the person who’s leading the operation might not be 100% perfect. Other examples of system deficiencies included: (i) time limitations in an environment where trainees often feel overworked, especially in the early years of training; (ii) communication gaps created by large care teams; and (iii) existing pressures to discharge patients instead of admitting to hospital for further management. The concept of error as a summation of multiple events is illustrated in the following quote: I think that nothing happens because of one mistake. It’s always a complete chain of things going on. If you can interrupt at one point, you might still have an adverse outcome, and you might still have a problem, but you won’t have the disaster. Things can go wrong but you’ve got to recognize when things are going the wrong way and try to interrupt that chain. Although Trainees Felt a Broad Array of Emotions When Catastrophic Errors Occurred, These Mistakes Served As Important Lessons for Future Practice Participants felt many different emotions because of exposure to catastrophic errors, including anger, frustration, guilt, self-doubt, sadness, and shock. However, when asked how the experience of catastrophic error would affect their future career decisions and practice, most trainees found that exposure to error forced them to become more thorough and proactive physicians. Moreover, the experience of catastrophic error, though oftentimes profoundly negative, did not have any effect on future career decisions.
experiences. Although mortality and morbidity meetings can serve as avenues to learn from others’ experiences, there was unanimous agreement that mortality and morbidity meeting rounds do not address the emotional needs of trainees. The following quote describes the sequence of emotions that a neurosurgery resident felt after experiencing a catastrophic event: The first thing is probably a bit of shock, and horror. That’s quickly replaced by some sort of sadness and depression to some extent … this patient trusted me and my team to do something and we betrayed that trust. So I think for me that’s the path of emotions that I follow: initial shock and horror followed by a sadness and depression followed by a component of guilt and then self-doubt. Although Trainees Highly Valued Mentoring Relationships With Senior Staff, Many Trainees did not Feel Comfortable Approaching Their Supervisors When Catastrophic Events Occurred Most participants felt that support following a catastrophic error is best received from someone in the same surgical discipline who can better understand the context of such errors. However, it was also important to trainees that the individual be neither judgmental nor paternalistic. Although many trainees consulted family and friends to help overcome the emotional sequelae of catastrophic outcomes, some trainees also discussed the event with a staff member or senior mentor who was not directly involved in the case. Unlike more senior residents and fellows, junior residents often had not developed close relationships with senior staff and therefore did not consult them as often for advice. Moreover, trainees were often concerned that staff would view these errors as a negative reflection of the trainee’s competence. Debriefing discussions generally focused on the academic and educational, rather than the emotional aspects of the event.
Every time a complication develops it just makes you think more and plan more for next time. It just means more reflection. So whenever I face a complication or unexpected outcome, I try to reflect more on the cases to see what I could have done differently.
Anyone who ever experiences severe adverse outcome needs to have someone to be able to talk to who’s not going to judge their professional integrity and who’s not going to point at them and say it’s your fault the patient has died. Sure the patient is dead or doing poorly and it’s partly your fault, but that’s because it’s your job and your duty to do something. You can’t be blamed for things and if you don’t have anyone to talk to in a blame free environment then it can get very distressing.
Participants coped with the negative emotions resulting from the experience of catastrophic errors in many ways, including discussions with friends, family, and senior mentors. Some participants gravitated toward artistic endeavors or physical activity for emotional relief. Most of the participants also channeled their emotional energy into helping others; however, junior residents cope with their own negative
Counseling Services Should be Offered to Help a Subset of Trainees Who Might Benefit From These Services Overall, experiences of catastrophic outcome elicited a plentitude of emotional responses, which were highly varied and individual. Moreover, coping mechanisms of trainees dealing with the emotional repercussions of catastrophic
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outcomes ranged from repression, rationalization, selfeffacing humor, and stoicism to “just moving on”. There were no common themes identified among participants based on self-identified sex, religion, or race. A number of the trainees spoke to their fellow trainees about the cases in order to compare their own experiences to the experiences of others at a similar level of training. Other trainees felt an obligation to speak directly with the patients’ family members following a catastrophic event, which sometimes brought emotional relief. Although some trainees therefore found effective ways of coping, others felt like they lacked the proper support to deal with their emotions. Interestingly, many participants admitted that they were unaware of existing resources at the University and within the Department of Surgery, suggesting that existing resources should be advertised more widely. Junior trainees may be especially vulnerable as they likely have not developed mechanisms for coping with catastrophic errors owing to their relative inexperience. Nonetheless, junior trainees also felt less responsible when catastrophic events occurred owing to their less senior position in the medical hierarchy: Now that I’m going to be a senior, if things go badly I’m going to feel a lot more personally culpable than I did as a junior resident. The following quote describes the experience of a junior trainee in neurosurgery: For sure one thing I feel when really terrible things happen and you’re in the hospital and you’re totally by yourself and you feel very alone, very isolated. And there were a bunch of times I felt like I’m too young for this, like life has not prepared me, like this is the job of grown adults to be experiencing these terrible things. This is a lot to be shouldering with very little life experience to back you up. So I think you age very very quickly in this specialty. Overall, most participants indicated that counseling resources, though not used by all trainees, would be beneficial to some to help cope with catastrophic events. A formal debriefing process may also be helpful, as indicated in the following quote: I compare it to my knowledge of other industries. When you have critical incidents in the aviation industry or in the police force they actually have trained psychologists that help debrief … you have a formal debrief and figure out what went wrong, what was random … I think in medicine the tragedies are no more or less horrible than what these other professions encounter but we don’t have formalized processes in terms of the debriefing. 4
The Culture of Surgery, Which Often Equates Emotional Vulnerability With Personal Weakness, is a Significant Barrier to Trainees Seeking Help Almost all surgical trainees thought that the act of seeking help for emotional reasons is often perceived as a sign of personal weakness, an attitude that reflects the general culture of surgery. It was also noted that there is often little benefit to admitting to error as this is often viewed as a flaw in one’s character or ability. I think the staff who is the team leader needs to create an environment where mistakes are not viewed as problems with someone’s character. Mistakes happen because you’re a doctor in training and everyone has made a mistake at some point.
DISCUSSION This study set out to investigate the response of surgical trainees to catastrophic errors and to evaluate the need for a support system to help trainees cope when catastrophic events occur. A number of findings emerged from the study. First, catastrophic errors were rarely caused by individual error. Second, catastrophic events provided important lessons for future practice. Third, many trainees did not feel comfortable seeking support from staff owing to the perception of error as a reflection of personal weakness or clinical incompetence. Fourth, coping mechanisms among trainees were varied, and many trainees expressed interest in expanding services to include counseling and formal debriefing sessions. Fifth, the perception of emotional vulnerability as weakness is fairly common in surgery and can be a significant barrier to trainees seeking help. The hierarchical nature of medicine and especially surgery was cited as a major barrier to trainees’ expression of potentially critical or contradictory opinions. If an error was observed in the operating room, trainees often felt restrained from drawing attention to the error as junior members of the team. Although it may be beneficial to create an environment that is more conducive to the expression of divergent opinions, trainees should also be reminded that they have the right and duty to speak up if they believe that an action may compromise patient care. The hierarchical nature of surgery also means that staff surgeons, who are generally at the top of the hierarchy, should initiate discussions when catastrophic events occur. Moreover, staff surgeons should be more open to discussing their own errors so that trainees feel less isolated and can appreciate that being fallible is not unique to him or her.4,6,20 Many participants felt that the introduction of medical errors as a topic of discussion into the residency training curriculum guided by staff surgeons would be very helpful to prepare trainees to deal with future catastrophic events. A similar proposal in an earlier study concluded that faculty within teaching institutions should be instrumental Journal of Surgical Education Volume ]/Number ] ] 2015
in the process of shifting the culture from one of blame to one of continuous improvement.21 The emotional response of trainees to catastrophic error was highly individualized as people generally respond to emotional distress in different ways.3,12,17,22,23 In general, in addition to the severity of the catastrophic event, catastrophic outcomes were more poignant to the individual if (1) the patient was admitted for an elective procedure; (2) the patient was without deficits upon admission to hospital; and (3) the physician had developed some sort of personal relationship with the patient or the patient’s family. Most participants dealt with catastrophic error by discussing their feelings with family members or significant others. However, most participants also wanted support from their direct supervisors. Unconditional support for fellow physicians is essential, particularly for trainees.7,20,24 Despite the fact that most trainees thought that it would be best to speak with a staff member who could identify with their experience, most of the participants were reluctant to consult a staff surgeon for advice. Importantly, trainees wanted to discuss the event with someone who would be nonjudgmental, and not interpret the error as a deficiency in the trainee. It is important therefore for staff surgeons to engage trainees in an objective and impartial manner when catastrophic events occur, and engage trainees in the first place. Moreover, to encourage these interactions, there should be increased mentoring opportunities with staff surgeons so that trainees feel more comfortable approaching staff for advice when the need arises. Although none of the trainees reported that the emotional consequences of experiencing catastrophic events were debilitating, there were instances of intense distress more common among junior trainees. Furthermore, psychological distress has been shown to influence future work performance and may contribute to further medical error.25 Consequently, it is pertinent to address ways of supporting the emotional needs of trainees to avoid the development of dysfunctional coping mechanisms26 and to prevent burnout, depression, and the loss of empathy, which may result from repeated exposure to medical errors.7 Although there was some skepticism about trainees’ predisposition to the use of professional counseling or psychological support services due to a fear of stigmatization, there was a general consensus that these services should be provided and advertised to trainees. A similar approach involving psychiatrists has been suggested by others.23
addressed in surgical training curriculums. First, communication between senior surgeons and surgical trainees is critical and has implications for patient safety.27 Senior surgeons should remain cognizant of the possible psychological effects of trainee’s exposure to catastrophic error, and discussions surrounding the sources of error and strategies for preventing similar mistakes should be initiated by senior surgeons outside morbidity and mortality rounds. Second, counseling services may be beneficial to a subset of surgical trainees, and should be accessible to individuals needing additional support. Finally, programs should try to foster an atmosphere devoid of fear and intimidation in which the admission of error is not regarded as a character flaw and emotions are not regarded as personal weaknesses but rather a natural human response to an unexpected and sometimes tragic situation. Above all, the importance of trustworthy mentoring relationships between staff surgeons and trainees should not be underestimated. Study Limitations We interviewed a small number of trainees (23) from a large academic Department of Surgery in a country with a predominantly socialized health care system. The results of this work may therefore not be generalized to surgical trainees in other universities and other countries. It is also of note that 8 of the 9 clinical fellows finished postgraduate training outside Canada and therefore may have different experiences of catastrophic outcomes. However, the interviewees included clinical fellows who completed postgraduate surgical training outside Canada. The study also included a large number of neurosurgical trainees, although there were also representatives from many other surgical disciplines, including ENT and vascular surgery.
ACKNOWLEDGMENTS The authors would like to thank the Greg Wilkins-Barrick Chair in International Surgery for the outstanding and ongoing support. We would also like to thank all the trainees who participated in the research study for their time and contributions.
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SUPPLEMENTARY DATA Supplementary data associated with this article can be found in the online version at doi:10.1016/j.jsurg.2015.05.003.
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