SGO Wellness: Surgical Complications: We’re in This Together | Jason A. Lachance, MD, MSc
Jason A. Lachance, MD, MSc
One evening this Spring, I got a text from a former resident: “I just cut a hole in my patient’s bladder 😭.” I know firsthand that this graduate is a good surgeon and that they have been surgically independent for several years. We have exchanged texts infrequently, usually focused on leisure or news from the department. So, I was surprised to hear from them on a Friday night, yet flattered by their confidence in me and impressed by the maturity and vulnerability necessary to reach out.
After we exchanged some words about the “hows” and “whys” and “what happened,” I shifted my attention: “are you OK?” This released a string of texts of concerns about the case. The beauty of a text exchange is the opportunity it offered me for a thoughtful reflective reply, tempering my urge towards boilerplate feedback. Eventually, my friend was able to share what concerned them the most:
“this has never happened to me before,” and, “I couldn’t fix it myself.”
There is growing literature on the second victim and how our hospitals can create a just culture to support physicians through surgical complications (1, 2). This work is long overdue, meaningful, and valuable. With time and effort, I remain hopeful we can change the narrative that complications reflect surgical ineptitude or negligence. However, the growing focus on quality outcomes hasn’t always landed where we hoped, sometimes creating the impression that the goal is zero, when that is realistically unachievable. Complications will happen, surgeons are human, and humans are fallible.
The path to surgical independence and aptitude can be a unique experience and surgical complications present the loneliness of circumstances. When a complication occurs, you may feel doubts about your career path, you may feel insulated from the responsibility – “I’m not the attending,” and you may feel shame discussing it with your colleagues and peers. It can be even more difficult to openly discuss it when faculty make disdainful remarks towards others’ surgical complications, such as, “did you hear so and so ‘bagged’ a ureter?” or dismissive remarks, such as, “ah that happens to everyone, shake it off.” As a junior faculty, these become magnified without your resident/fellow cohort to commiserate.
In academics we are pretty good at breaking down the case over morbidity and mortality (M&M) and reviewing the literature, discussing preventive techniques, risk factors, and so forth. However, when my resident reached out the other day, none of that mattered. This won’t set off any quality alarms at their hospital. They weren’t looking for me to send along a PDF of an article or a video of repair techniques. However, they will still worry: “Will the patient get a fistula?” “Will she sue me?” “What do my partners think?” “Am I bad surgeon?” Of course, the answers to those deeply personal questions weren’t available in that moment, but the important thing is that we discussed them anyway.
It takes a fair degree of audacity for us to cut people open. Years of studying, training, and practice give us the necessary fearlessness. And yet, with a complication, that may come undone, and our image and identity can feel threatened. Humility in modeling how to manage the anxiety and insecurity of our own failings will allow others to come forward. When a peer shares their vulnerability, it is often instinctive to slip into surgeon mentality, yet it may be more valuable to draw on our unique experience as gynecologic oncologists. We pride ourselves on being more than surgeons. We are also oncologists who deal with the uncertainty and vulnerability of cancer and survival on a daily basis. When a cancer patient confides in us that they are scared about the end of their life, we don’t tell them to “buck up” or say, “it happens to everyone!” We have the skill, compassion, and experience to allow that patient to be scared and comfort them even if we don’t have the answers. Why don’t we use those same skills on one another in our most vulnerable moments? Our best solution to complications is not new equipment, computer software or registry reporting – it’s one another, creating a safe space to confide in, so that when the inevitable complications occur, we don’t feel alone.
- Wu, AW. Medical error: the second victim. BMJ 2000;320:726-7.
- Edwards, MT. An assessment of the impact of just culture on quality and safety in US hospitals. Am J Med Qual 2018;33(5):502-508.
Jason A. Lachance, MD, MSc, is a gynecologic oncologist at Maine Medical Partners in Scarborough, ME.