Bouncing Back: Symposium Offers Strategies for Surgeons after Adverse Events

Every person who practices medicine will have a patient experience complications, explained Colonel Mary Carnduff, MD, MBA, CPE, FAAOS, during Monday’s Symposium E, “Bouncing Back from Complications.” It is important that physicians have an environment where they feel safe and comfortable speaking about the impact of adverse events.

General orthopaedic complication rates are usually quoted to be around 2 to 4 percent for most surgeons, but a wider range has been reported in the literature, according to Dr. Carnduff, who is the Medical Treatment Facility Director/Commander 412th Medical Group at the Edwards Air Force Base in California. “Regardless of how you define them, [complications] are part of any orthopaedic practice,” Dr. Carnduff said.

During the symposium, which was moderated by Dr. Carnduff, members of the AAOS Committee on Healthcare Safety explored some of the personal, professional, and medicolegal aspects of coping with complications.

Emotional impact
Hilton P. Gottschalk, MD, FAAOS, FAOA, assistant professor of surgery and perioperative care at Dell Medical School at the University of Texas at Austin, discussed what has been coined the “second victim” phenomenon—the emotional and psychological toll of adverse events on healthcare professionals.

Surgeons may be ill-prepared to handle the personal impacts of an adverse event. One study examining the effects of surgical complications on trainees found that 80 percent were emotionally affected by a complication event, experiencing responses such as anxiety, sleep issues, or anger.

“I trained at a few places and I don’t think we sat down and discussed how to deal with it … [or] how to bounce back,” Dr. Gottschalk said. “We talk about them at [morbidity and mortality conferences] but don’t do a good job supporting colleagues or supporting ourselves.”

Data from the United Kingdom showed that almost half (42.5 percent) of surgeons whose patients experienced an adverse event did not talk to anyone about it, and fewer than 3 percent accessed a support service. After an adverse event, trauma recovery for healthcare professionals can include intrusive thinking, questioning one’s personal integrity, attempting to endure, and ultimately, depending on the trajectory, thriving, surviving, or dropping out.

“We are not robots. We are people,” Dr. Gottschalk said. “We have spouses, kids, partners, and what is going on in our external life affects what happens in our work life.”

During an audience participation segment, Dr. Gottschalk and audience members discussed ways they have managed these situations. Strategies included talking openly and honestly with the patient, discussing these cases with colleagues, and asking for a second scrub during difficult times. Dr. Gottschalk encouraged attendees to access available resources, including the AAOS webinar “Behind the Mask: The Second Victim Phenomenon,” which examines emotional challenges related to clinical adverse events and strategies for creating a supportive environment.

Lawsuits
In addition to the emotional toll on patients and clinicians, complications can sometimes result in lawsuits, explained Ajay K. Srivastava, MD, FAAOS, who is a clinical associate professor at both Michigan State University and Central Michigan University, as well as the program director for the McLaren Flint Orthopaedic Surgery Residency program. One study estimated that 99 percent of orthopaedic surgeons will have a suit filed against them by the age of 65.

Dr. Srivastava shared his experience being sued a few years ago, a lawsuit he eventually won and learned from. Malpractice suits are generally grouped into three areas: procedural error, such as improper surgery or other complications; diagnostic error; or patient dissatisfaction.

However, he noted that most medical lawsuits will not go to trial, and of those that do, most verdicts are in favor of surgeons. However, even if a surgeon successfully navigates a lawsuit, it can have huge personal, professional, or financial effects. “In your personal and professional life, it can lead to anxiety and stress; it can be emotionally draining,” Dr. Srivastava acknowledged. “It affects your personal relationships, with reports of lawsuits leading to divorce. All those things can pile up and lead to burnout.” Burnout, in turn, can lead to medical errors. All of these factors taken together can lead to what is called “Medical Malpractice Stress Syndrome.”

“The worst thing is that it changes your outlook on patients,” Dr. Srivastava said. “Now I am looking at every patient as a potential litigant. I don’t trust them as much.”

Dr. Srivastava pointed to a study of a peer support program where physicians and nonphysicians affected by medical litigation were brought together to discuss what they were going through. “All of them thought it was a great experience and recommended that it should be done more often,” said Dr. Srivastava, who shared that he also turned to a colleague for support during the course of his lawsuit.

“Dealing with it is difficult by yourself,” Dr. Srivastava said. “That is why meetings like this [AAOS Annual Meeting], where we can talk about our issues, are very helpful.”

Peer-review fears
Jonathan R. Dubin, MD, FAAOS, UMKC Franklin Dickson Associate Professor of Orthopedics at the University of Missouri at Kansas City, closed the symposium with a discussion of complications as they relate to peer-review actions. “I sit on a credentialing committee and have learned a lot about how complaints and the peer-review process can impact physicians,” Dr. Dubin said.

Peer review, he said, was designed to give an objective evaluation of a colleague’s practice; it should be fair and honest, providing “due process.” However, in some situations, the peer-review process can be misused, Dr. Dubin shared. Peer review can also result in reports to the National Practitioner Data Bank; although it is not open to the public, it can be searched by hospitals.

“If in the peer-review process they withdraw your privileges, for example, you have to report that,” Dr. Dubin said. “That can hurt your chances of getting a job, and that is certainly a fear.”

Fears related to peer review, complaints to state medical boards, or of patient litigation are all valid. Dr. Dubin also discussed how physicians being a “second victim” or a “collateral victim” can lead to a cycle of stress, defensive practice, and more.

“Doctors are people. People are human. Humans err. They feel and they live,” Dr. Dubin said. “These are things we have to acknowledge. Acknowledging it is a big step, but it’s also useful to have resources.” He pointed attendees to physicianlitigationstress.org, a website of medical malpractice support resources.

Leah Lawrence is a freelance writer for AAOS Now.

References

1. Galloway LAS, Luckenbaugh AN. Preparing Trainees to Rebound from Surgical Complications. Curr Urol Rep. 2024 Aug;25(8):169-172.
2. Turner K, Bolderston H, Thomas K, Greville-Harris M, Withers C, McDougall S. Impact of adverse events on surgeons. Br J Surg. 2022 Mar 15;109(4):308-310.
3. Cichos KH, Ewing MA, Sheppard ED, et al. Trends and Risk Factors in Orthopedic Lawsuits: Analysis of a National Legal Database. Orthopedics. 2019;42(2):e260-e267.
4. Doehring MC, Strachan CC, Haut L, et al. Establishing a Novel Group-based Litigation Peer Support Program to Promote Wellness for Physicians Involved in Medical Malpractice Lawsuits. Clin Pract Cases Emerg Med. 2023;7(4):205-209.