When Bad Things
Happen to Good
to Adverse Events
Shelly Luu, BSca,b, Shuk On Annie Leung, BASca,b,
Carol-anne Moulton, MBBS, MEd, PhD, FRACSa,c,*
Tom Sinclair is an active 56-year-old professor of engineering recently diagnosed
with colorectal cancer. Eager to find the best surgeon around, Tom asked advice
from a friend, a nurse on your surgical ward, who recommended he see you. He
came to your office with his wife of 30 years and was relieved that you recommen-
ded surgery the week after. He said he would delay a preorganized family holiday
he was taking with his wife and 3 children to get this surgery behind him. As he left
the office, you thought how difficult this diagnosis must be for him briefly imag-
ining how you might feel if you received the same news. You are not that different
inage after all,and the thought ofdying atsuch a young age was a littletoo difficult
to imagine. It was a fairly straightforward operation with no signs that the cancer
had spread elsewhere. The tumor was a little lower in the rectum than you ex-
pected, but you decided that a covering stoma was not necessary, so you per-
formed the anastomosis and closed. Tom’s wife and 3 teenaged children were
waiting in the operating room as you walked in to tell them the good news.
This work was supported by the Ministry of Research and Innovation Early Researcher Award
and the Royal College of Physicians and Surgeons of Canada Medical Education Research
aThe Wilson Centre for Research in Medical Education, University Health Network and
University of Toronto, 200 Elizabeth Street, 1ES-565, Toronto, Ontario M5G 2C4, Canada
bFaculty of Medicine, University of Toronto, 1 King’s College Circle, Room 2109, Toronto,
Ontario M5S 1A8, Canada
cDepartment of Surgery, University of Toronto, 100 College Street, Room 311, Toronto,
Ontario M5G 1L5, Canada
* Corresponding author. The Wilson Centre for Research in Medical Education, University
Health Network and University of Toronto, 200 Elizabeth Street, 1ES-565, Toronto, Ontario
M5G 2C4, Canada.
E-mail address: email@example.com
? Adverse events ? Judgment ? Psychological reactions
Surg Clin N Am 92 (2012) 153–161
0039-6109/12/$ – see front matter ? 2012 Published by Elsevier Inc.
“Thank-you doctor. You are our lifesaver,” his daughter said. You saw him every
day, and each time he and his family were very grateful to you, singing your
praises. You were a little embarrassed but accepted this acknowledgment as
a great perk of your job. On the sixth postoperative day, you were called by the
resident who had been on the night before to let you know that he thought Mr Sin-
clair—“your colon” from last week—was leaking. Tom had deteriorated overnight
with sudden onset of abdominal pain and fevers, and his blood pressure dropped.
He had a low-grade fever the day before, but you thought it was from a little
redness at the wound site. You had removed a few staples and thought he should
be fine. “How do you know he has leaked?” you asked somewhat agitatedly. A
computed tomographic scan was just performed, which showed large amounts
of free air and fluid throughout Tom’s abdomen and particularly in his pelvis.
You hang up the phone.
Adverse events are unfortunately a part of every surgical practice. As surgeons who
are intimately linked to these events, they affect each one of us, although the exact
nature and impact of these events have not been well articulated or understood.
Studies that haveattempted to characterize the surgical personality from apsycholog-
ical perspective have found that surgeons form the most distinct and consistent group
among physicians.1As a group, surgeons are trained for rapid and confident decision
making with little room for error2and reside in a culture where disclosure of error and
explicit discussion of their own personal causes for error are not always facilitated.3
Surgical residents experience internal conflict as they are taught about the uncertainty
of medicine in parallel with the unacceptability of error4and, as opposed to other
professions, counseling or debriefing at the individual level after medical errors is
not routine.3Moreover, surgeons are often reluctant to disclose errors to patients
and colleagues for fear of malpractice litigation,5shame, or self-disappointment.6
In-depth interviews conducted with general internists have found that error, whether
perceived or real, reduced physicians’ self-confidence and induced fear of stigmatiza-
tion and feelings of guilt.7The competitiveness of medical practice, belief in physician
control, and the basic principle of “first, do no harm” were noted to explain physicians’
responses to medical errors.3
During a recent qualitative study as part of a larger program of research exploring
surgical judgment, surgeons described considerable physiologic and psychological
reactions when things went wrong.8Surgeons would say, “I remember all my deaths,”
or “We all have our own graveyard,” with details of these events seemingly burned in
their memory.9This seemed to be in contradiction to a previous discussion in the
literature that suggested surgeons experience fewer symptoms of distress than inter-
nists10and surgeons are more willing to risk failure.11Given how relatively little is
known about surgeons’ reactions to such events, we embarked on another qualitative
study to explore this phenomenon in surgical practice. Terminology in this area is
confusing in the current literature, with some terms (eg, error or mistake) having
negative connotations associated with fault or, worse, negligence and others (eg,
complication or adverse event) implying acts of God.12,13It is often difficult to elicit
the exact cause of an adverse event and therefore difficult to ever fully appreciate
one’s exact role in the event. Was this an error or an act of God, a complication
that would have happened no matter what in the best of hands because of this inva-
sive intervention? This difficulty sets up a period of rumination of ‘was it my fault,’
which is described later.
In this article, we present a framework to understand surgeons’ reactions to adverse
events, which were derived from a more recent study (details and methodology have
been presented elsewhere)9as well as a review of both the relevant psychology and
Luu et al
social psychology literatures that helped guide us in our understanding of these reac-
tions. We situate this framework within the broader picture of mindful practice to gain
an appreciation of how the psychological and social dimensions of the surgeon can
affect judgment and cognition.
FRAMEWORK FOR UNDERSTANDING INDIVIDUAL SURGEONS’ REACTION TO
Surgeons who participated in the study were reported to believe that their own reac-
tions to adverse events were unique and relieved to hear that colleagues experienced
similar reactions. Interesting differences were described when men attributed their
reactions to being outliers (eg, when compared with their colleagues), whereas women
attributed their reactions to being women (eg, more emotional, less ego). The investi-
gators suggested thatparticipants were aware that external appearances during these
reactions may not be congruous with what was being experienced on the inside.
Surgeon’s culture promotes strength and certainty, and demonstrations of
vulnerability or self-doubt are discouraged. When participants interviewed surgeons
who had been described by their peers as cold or seemingly unaffected by these reac-
tions, they found these individuals suffered similar reactions to adverse events. Given
the consistency of these reactions, the investigators were able to define 4 phases that
occurred among surgeons: kick, fall, recovery, and long-term impact.9
4 PHASES OF REACTION TO ADVERSE EVENTS
The first phase that was described in this study was the kick; when surgeons first
heard news of the event, they experienced a physiologic stress or anxiety reaction.
There were physical manifestations of this phase, such as tachycardia, sweatiness,
and agitation, which was reported to last up to several hours. The investigators also
described significant feelings of failure that seemed complicated by not only sadness
for the patient but also sadness for how it made them feel personally.9Surgeons
described feeling like they were no longer worthy of being a surgeon, likening it to
getting a “D” on a test rather than the expected and usual “A.”9Several factors
were identified that influenced the severity of the reaction: the age of the patient,
the nature of the case (emergent vs elective), the relationship they had developed
with family and friends, and the severity of the complication.9The dissonance
surgeons felt between striving to be the ideal perfect surgeon and the current adverse
event led to exaggerated emotions and self-blame.9
spiral of emotions as they tried incessantly to find out details of the case in the hope
that they would be somewhat exonerated in the complication. In this phase, surgeons
questioned almost every aspect of the case to answer the question, “Was it my
fault?”9Long periods of rumination to uncover the details of the case were described.9
Although blame was not a big part of this phase, participants recognized the tendency
to blame in an attempt to feel better about the situation.
Although surgeons put forth an ardent effort to find out whether they were respon-
sible for the adverse event, it was often difficult to exactly discern the cause of the
adverse event, let alone determine the role they played. Surgeons were more
distressed if they felt they had contributed in some way to the adverse event. The
Reactions to Adverse Events
uncertainty resulted in extended periods of information searching and an inability to
focus on other tasks.9
The beginning of the recovery phase was marked by a return of feeling normal and
undistracted by the thoughts of failure associated with the first 2 phases. Surgeons
described being able to continue with their daily work with ruminating thoughts of
the event finally controlled. In brief interviews with surgeons after events, the investi-
gators noted that surgeons were calmer and more reflective during the recovery
phase. One surgeon was said to describe this as “the pall has lifted.” Surgeons real-
ized the need to recover and move on from the event.9
Surgeons had different coping strategies to deal with the adverse events in their
recovery phase, including discussion with colleagues and family. It seemed that
surgeons felt better able to cope with the event once they satisfied themselves that
they learned something from the event that will prevent future occurrences. One
surgeon described changing the standard of practice after every adverse event,
whereas another noted that teaching residents about the adverse event was a way
The Long-Term Impact
Even though surgeons experienced adverse events similarly in the short-term period,
there seemed to be differences in the cumulative effect of these reactions over time.
Several surgeons suggested the long-term impact was a negative one, recognizing
that these reactions were not getting any better or easier to handle with time. Several
suggested that these reactions were actually getting worse and became the primary
factor for considering early retirement or changing their scope of practice.9These
surgeons felt that the negative effect of these reactions over many years of their
practice was cumulative, perhaps understandably when it is not uncommon to hear
surgeons say, “I remember all my deaths by name.” An understanding of the severity
of these reactions in the acute phase coupled with an understanding of the surgical
culture sheds light on this statement.
IMPLICATIONS: PLACING THE FRAMEWORK INTO CONTEXT
The framework for understanding surgeons’ reaction to error illustrates the consis-
tency with which surgeons experience adverse events. Translating this knowledge
to promote patient safety in surgery requires an examination of the external or social
environment that surgeons operate in as well as the internal landscape and cognitive
processes inside the surgeon’s head.
The surgical culture stresses certitude, decisiveness, and confidence.14In the acute
phase after an adverse event has occurred, surgeons described the need to manifest
these qualities of strength despite experiencing powerful negative emotions—to put
on abrave face. Thus there is atension between needing to appear strong and actually
being strong after a complication.
The sociology literature describes social identity as an aspect of an individual’s self-
concept that is derived from the individual’s membership in a group15; a surgeon’s
professional identity, therefore, is derived from belonging to the larger social group
formed by health care practitioners.16When there is incongruence between personal
and professional identity, for example, feeling vulnerable and imperfect after a surgical
expectations around behaviors, attitudes, and belief systems is well documented in
Luu et al
health care trainees entering training programs as well as individuals who are not part
ronments).17–19In the following sections, guided by various literatures, we examine the
framework for surgeons’ reaction to error in the context of the surgical culture and its
various implications as we strive for safer surgery.
Operating After a Complication
“I honestly think I almost crashed into four parked cars before I got out of the parking
garage that day. I was so distraught.” (I-002).9
The first 2 stages, the kick and the fall, were described as incapacitating for many
surgeons because they found it difficult to concentrate on other activities during this
period.9Looking at the cognitive psychology literature on human attention, it suggests
thatalimited cognitive capacity exists for payingattention.20–22Humans havealimited
space of attentional resources, and, once that threshold is reached, the mind tends to
take mental shortcuts and oversimplify at the cost of accuracy. As nicely captured in
the aforementioned quotation, the ability to think straight after the recognition of
a significant adverse event might be compromised. Although “crashing into four
parked cars”9in this state is an extreme example, it exposes the potential for how
these reactions might interfere with subsequent judgment and decision making,
particularly in the operative setting. In any intraoperative moment, there are numerous
external and internal stimuli that are in essence competing for the surgeon’s attention
(see the article by Carol-anne Moulton and colleagues elsewhere in this issue). The
ability to think clearly and gather and process information at the moment of crisis
can be jeopardized by consuming thoughts and emotions associated with ruminating
on a previous complication.
Learning from Adverse Events: Reactions as a Source of Feedback
Learning from surgical errors and complications occur at both macrolevels and
microlevels. At the macrolevel, systems-based initiatives such as surgical checklists
are a result of recognized patterns of errors.23,24At the microlevel, individual surgeons
also learn to refine their procedural techniques and decision making from their errors.
Furthermore, it has been suggested that emotion-laden reactions to errors that are
subjective, variable, and surgeon dependent are also an important source for
Surgeons vividly described emotions, and their physiologic manifestations, during
the kick phase. These strong emotions are actually a powerful form of feedback for
learning in addition to other formal system-implemented sources of feedback. It has
been hypothesized that intuition comes from emotions and sensory input that are
packaged with experiences and form part of our memory; when the memory is
retrieved, the emotions and sensory experiences are automatically retrieved, often
influencing behavior and decision making.26,27Neurocognitive research has shown
that subcortical areas, especially those involved in emotion and reactions to threat,
process information beneath conscious awareness, and the input from these areas
directly shapes reasoning.28Therefore, the strong emotions evoked by a complication
become imprinted in the memory of the surgeon, having the potential to influence
decision making insubsequent cases in which this memory is retrieved unconsciously.
Counterfactual thinking is another psychological concept relevant to learning from
adverse events. It describes the process of asking oneself questions such as what
if or if only, comparing actual outcomes with imagined alternatives.29Surgeons
commonly engage in counterfactual thinking in response to a complication, particu-
larly in the information-gathering or the fall phase. Counterfactual thinking can be
Reactions to Adverse Events
either upward (better than reality) or downward (worse than reality) and also outward
focused (outside of my control) or self-focused (within my control).29In the context
of how surgeons interpret adverse events, counterfactuals that are both downward
(it could have been worse) and outward focused (it is out of my control) are effective
coping mechanisms but may lead to minimization of the event and blame (eg, other
colleagues, systems factors).29On the other hand, self-focused upward comparisons
are more likely to result in performance-promoting learning (eg, if I had checked the
blood work again before operating, this adverse event may have been avoided).30
Surgeons might use counterfactual thinking in their reflections on adverse events.
The pancreatic surgeon who resects a tumor resulting in positive oncological margins
may use the upward counterfactual, “It doesn’t matter; a positive margin doesn’t
always result in rapid local recurrence and death.” Alternatively, the surgeon may
use the following downward counterfactual after the same error: “It could be worse;
the patient may have died from a leaking pancreatic anastomosis.” Counterfactual
thinking and emotions associated with the event both serve as feedback for critical
reflection on personal performance.31It has been suggested that for feedback to be
effective, it should be specific, directed, and task oriented rather than self-oriented.31
However, the paradox is that surgeons’ sense of self or personal identity is inextricably
linked to their professional identity and performance as a surgeon.32Poor outcome
after surgery, particularly if attributable to surgeon error, can provide negative feed-
back on surgeon performance in self-assessment. This feedback, which is both
inconsistent with and lower than self-perceptions, can elicit negative emotions in
the surgeon. There are many psychological and neurocognitive mechanisms in place
to counteract negative feedback that surgeons receive.33Becoming aware of these
mechanisms might improve the potential for learning through critical self-reflection
around the event.
Why Error Disclosure is Difficult
An American professor of law, Carol Liebman, asked if it was possible to train physi-
cians to communicate better with their patients, with an end goal of improving and
facilitating error disclosure.34After 2 years of research, the investigator concluded,
“We’re putting good people in positions where no one can succeed. Communicating
with patients in these situations is just too difficult.” She further explained, “It’s just too
hard for physicians who are facing emotional turmoil themselves” and that “physicians
operate in a system in which the culture does not give them much space to process
The social pressures associated with the culture of decisiveness and certainty in
surgery contributes directly to the difficulties in disclosure. Physicians are often reluc-
tant to disclose errors to patients and superiors because of fear of malpractice litiga-
tion,5shame and sense of inadequacy, and also high expectations of themselves.36
The official institutional forum for the discussion of adverse events, Morbidity and
Mortality Conferences, has been evaluated with ambivalence by residents who are
detracted by the threat of remediation and fear of getting “toasted” by colleagues.37
In addition to the social pressures, results from our study also provide insight into
why error disclosure is so difficult from the perspective of negative emotions.9It has
been found that disclosing self-focused counterfactuals can imply (incorrectly) to
others that the surgeon was negligent or culpable in the adverse event. Therefore, it
is less likely that individuals performing under organizational accountability pressures
(such as surgeons under pressure of Morbidity and Mortality Rounds) would use such
counterfactuals immediately after an adverse event,30especially when they are imme-
diately distressed. This is unfortunate because self-focused upward counterfactuals
Luu et al
are the type of counterfactuals that are conducive to learning. Immediate reactions
may be the reason why physicians do not learn as much from Morbidity and Mortality
Rounds as hoped.38,39
FUTURE DIRECTIONS AND SUMMARY
The 4 phases of surgeons’ reaction to error characterizes the surgeon as the second
victim and might be a causative factor in the rising levels of surgeon depression and
burnout.11The reaction can be profound and is consistent across surgeons of different
genders, experience levels, and specialties.9Little research has been done in the way
of evaluating support measures for physicians undergoing distress from adverse
events.40It has been suggested that by modifying the medical curriculum, increasing
mentoring, and ultimately changing the culture in which adverse events are under-
stood, it may be possible to lessen the emotional distress that physicians will
encounter in the future.11By increasing the surgical community’s awareness and
understanding of the pervasiveness and severity of surgeons’ reactions to error, the
culture can be made more accommodating and discussions with colleagues can be
facilitated. Furthermore, special attention needs to be paid to surgical residents and
fellows to prepare them for their future roles as attending surgeons because the
new roles with greater responsibility for patients can result in greater distress in the
event of error.39
One way surgeons may better understand and process their own reaction and its
potential impact on subsequent judgment is to develop the habits of what Epstein and
others41have described as mindful practice, the definition of which is the “conscious
and intentional attentiveness to the present situation.” Applying the 4 habits of the
mind, attentive observation, critical curiosity, beginner’s mind, and presence, when
surgeons are experiencing these reactions allows surgeons to become more aware of
emotions evoked by a complication become imprinted in the memory of the surgeon,
having the potential to influence decision making in subsequent cases as this memory
is retrieved, sometimes subconsciously. It has been shown in a study with primary care
physicians that mindful practice can be taught,44offering benefits of not only reflective
abilities at the moment but also personal well-being.45
The framework presented in this article can serve as a platform for healthier and
more productive discussions about adverse events and errors. It has been suggested,
“the language people use both makes possible and constrains the thoughts they can
have. More than just a vehicle for ideas, language shapes ideas—and the practices
that follow from them.”46,47With the language provided by this framework, it might
be possible to better prepare and train the future generation of surgeons for what to
expect when adverse events occur. It is quite possible that once surgeons learn
they are not alone in these reactions and have a language to discuss them and a back-
ground to understand them, the negative impact of these reactions might be
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Reactions to Adverse Events