The consequences of an adverse event that happens as part of a patient's care are varied and complex, and the effects are felt by everyone involved in many different ways and for a wide variety of reasons.
'Medicine can be a rewarding profession when things go according to plan and patients are happy,' says Dr Michael Devlin, the MDU's head of professional standards and liaison. 'However, surgeons are not immune from adverse events or their consequences. When things go wrong as a result of surgical treatment it can be devastating not only for the patient, but also for the doctor.
'Recognising the harmful effects that adverse events have on those in providing clinical care, the term 'second victim' has been used. This is a useful concept and helps us to understand why such events can be incredibly stressful to deal with, sometimes leading to prolonged stress and affecting an individual's health, ultimately impacting on professional and family life.
'Because of this, we welcome and support important research being carried out to better understand the effects on surgeons of medical errors and what strategies help them cope and develop professional resilience.'
Kevin Turner is a consultant urological surgeon who is spearheading research into the particular circumstances and effects of adverse incidents on surgeons, and leads the team behind Surgeon Wellbeing. Here he speaks to the MDU about his research and aims.
Can you explain the concept of 'second victims' as it relates to surgeons?
The term 'second victims' was coined by Albert Wu in 2000. Though some dislike the term, it's simple in concept: when things go wrong in surgery, surgeons suffer too. We all know that this is the case, and aspects of that suffering are fairly obvious - guilt, risk aversion, anxiety about consequences. There is surprisingly little research though that has explored in detail exactly how surgeons are affected, and much of the research that has been done has not been in a UK context.
Furthermore, surgeons who have experienced adverse events tell us that they felt unprepared for those events by their surgical training, and that those around them were ill equipped to deal with a colleague going through the experience of an adverse event. My research group is motivated by a desire to better help surgeons when adverse events happen.
Are surgeons particularly at risk (compared to other clinicians), and if so, why?
There are aspects of the impact of adverse events that will be common to all doctors. But there are some unique or dominant issues for surgeons. Surgical adverse events are linked (by surgeons, their patients, hospital staff, and the media) to individual decisions and actions/inactions by a named surgeon in a way that just doesn't occur so prevalently in other areas of medicine.
Anecdotally, surgeons are also less likely to engage with existing support services. So whilst we hope that our work will be of benefit to all doctors, surgeons are our focus.
You recently wrote that surgeons are generally quite resilient as a group. Do you think this is an innate trait, or something that can be trained?
We think it's probably a bit of both. Certain personality types are attracted to surgery, and being a surgeon probably draws those innate traits out and magnifies them. But all surgeons are different and will need different amounts of help in developing positive traits: resilience, decision making under pressure, tough mindedness are all examples.
It's accepted that technical and non-technical skills (eg, communication skills) can be taught. We think that resilience can be taught or at least enhanced too. But even if it can't, preparing surgeons for how they might feel when things go wrong, and giving them some tools to reduce the negative impact of those feelings, can only be a good thing.
We want to build up an accurate picture of how UK surgeons are affected when things go wrong, and then we want to recommend ways in which surgeons could be helped to prepare for and deal with adverse events.
You make a distinction between 'errors' and 'complications' when talking about surgery. What's the difference and why is it important?
At the extremes, the difference between errors and complications is easy. Failing to ensure adequate thrombo-embolism prophylaxis is an error; a DVT that occurs despite adequate prophylaxis is a complication.
The middle ground is a grey area! There is a recognised risk or leakage of bowel anastomosis, but there are technical errors that can make this more likely. So when it occurs, is it an error, or a complication? Much of the literature to date has inadvertently (usually), or deliberately (sometimes) conflated the two terms in a way which is to the detriment of existing research in this area.
Probably the way in which a surgeon views an adverse event in terms of error vs. complication impacts on how much that event affects them. For our research we have used the following working definitions
- Complications: adverse events which are an acknowledged risk of surgical care or procedures
- Errors: commissions or omissions with the potential for negative consequences independent of whether there were actually any negative outcomes.
What do you hope your research will achieve?
Firstly we want to build up an accurate picture of how UK surgeons are affected when things go wrong, and then we want to recommend ways in which surgeons could be helped to prepare for and deal with adverse events. In doing so, we'd like to work alongside the Royal Colleges, the BMA, defence organisations, and anyone else who has an interest in the wellbeing of surgeons.
We'd like to see a culture change, where the inevitability of adverse events is a given, where accepting help in dealing with adverse events is the norm, and where the nature of that help is built on solid empirical research evidence of its efficacy.
The aim of this research is to provide evidence-based leverage for change to provide better support for surgeons but we need surgeons to provide our evidence!
How can readers contribute to your research?
We really want surgeons, of all grades and of all specialties, to complete our survey. The survey (and other information about our research) can be accessed via our website - surgeonwellbeing.co.uk.
We know that surgeons are asked to complete lots of surveys, but we've been thrilled by the encouragement we've had from surgeons about the importance of this work. We need surgeons to respond, and to encourage colleagues in their hospital to respond too.
What will come after this initial survey stage?
The second phase of our research is all about developing strategies to help surgeons. We fear that there is a lack of rigorous evidence to show what might work, and surgeons are unlikely to engage with interventions that don't help them.
Interventions in the work place can be tested, but we think we will be amongst the first to do this in the surgical profession. We are planning a controlled study looking at a training intervention at surgical trainee level.
Beyond taking the time to complete our survey, we would be delighted to hear directly from MDU members who are interested in our work and who might be interested in our research as things progress.
If you've been affected by the issues discussed in this article, you can speak to the MDU's expert medico-legal team for guidance, advice and support. Contact us here.
Mr Kevin Turner
MA DM FRCS (Urol)
Mr Kevin Turner has been a consultant urological surgeon in Bournemouth for 10 years. He trained in Cambridge, Oxford, Edinburgh and Melbourne. As a trainee he was awarded the European Association of Urology Thesis Award and was elected to the office of Hunterian Professor of the Royal College of Surgeons of England. He is a co-editor of the Oxford Handbook of Urological Surgery and is an examiner for the FRCS Urology examination. His principal clinical interests are in urological cancer and robotic surgery. His research is focused on the impact that errors and complications have on surgeons.
See more by Mr Kevin Turner