Saturday, March 26, 2016

Surgical Trainee Response Patterns to Catastrophic Events, are we failing as parental models?

      In his book, Forgive and Remember: Managing Medical Failure, Bosk describes the contradictory life a surgeon faces. We live in a world where patients, families and referring physicians always have the expectation of a quick success but our craft carries the risk of failure. The obvious question to ask after any failure is “what did you do wrong?” or “what did I do wrong”? Unfortunately, most of us harbor maladaptive behavior in times of failure or significant change. 
       Bernstein et al understood that “surgical trainees are often subject to the negative consequences of medical error…” Their group conducted resident interviews “to determine how trainees cope with error and to find ways of supporting trainees when catastrophic events occur.   Their work conveyed five themes: 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.  It was clear to me that in this assessment on the mental response residents have after a catastrophic event, we have not improved upon training surgeons to handle this stress in a more productive manner. 
          I previously conversed with Carol-Anne Moulton about their paper on boundaries and risk taking and we touched upon the topic of what molds us into the amount of risk taking one takes during the various phases of their surgical career. Certainly, our response (or our peer’s response) shapes our desire to take on risk as we get older. Clearly when there is a negative impact on our psyche, we shy away from or stress over cases that in the past we would not have given a second thought. During our crisis management leadership course, we teach residents the four most dangerous periods during a crisis. The one that is often overlooked is the recovery phase- that period in the first 24-48 hours after a catastrophe. 
         I spoke with Patrick Sweeney and Michael Mathews about this topic they describe so well in their book. After a particularly threatening, highly emotional event, it appears that the prefrontal cortex is suppressed by activation of the amygdala and subsequently the hippocampus. The effect is that memory is enhanced making this event and cues immediately preceding the event, the sole focus of attention (aka weapons focus). Recovery is suppressed for several minutes and new memory formation is suppressed during this refractory period. Full recovery can take hours or days. A 2012 American Society of Anesthesia Survey revealed that 84% of anesthesiologists were impacted by an unanticipated death or serious injury of a perioperative patient over their career. The majority felt guilt, anxiety AND noted a compromised ability to provide patient care for the next four hours. In spite of this, only 7% were provided time off. A similar study by the American College of Surgeons revealed a tight relationship between causing a patient error and stress, fatigue, burnout, alcoholism, and suicidal ideation. Further assessment of the responders noted that a prior medical error was independently predictive of high alcohol use and suicide ideations. 
         So the University of Toronto study begs the question of why do we recreate the mistakes of our fathers in teaching our children? A Virginia State trooper told me of a night he responded to a scene where three college coeds were divided by their seatbelts after a drunk driver ripped through their car on a freezing January evening. He remembers the details vividly (the steam arising from the bodies at 2am). He said as soon as they processed the scene, an on scene assessor pulled him aside to discuss the effects of the incident and his need to retire for the evening and seek counseling before beginning work in the next 48 hours. Physicians seek a colleague who has absolutely no training whatsoever to counsel them after a disaster. Bernstein’s group teaches us a valuable lesson that perhaps we can mold our children’s response to trauma differently than our parental surgeon figures taught us.
 Kenneth A. Lipshy, MD, FACS
  •                 Balogun JA, Bramall AN, Bernstein M. How Surgical Trainees Handle Catastrophic Errors: A Qualitative Study. JSE 2015.72(6):1179-1184.
  •  Bosk CL. Forgive and Remember: Managing Medical Failure. 2nd ed. Chicago, IL: University of Chicago Press; 2003.
  •   Zilbert NR, Murnaghan L, Gallinger S, Regehr G, Moulton C. Taking a chance or playing it safe: reframing risk assessment within the surgeon’s comfort zone. Ann Surg. 2015; 262(2):253-259.
  •    Sweeney PJ, Matthews MD, Lester PB. Leadership in Dangerous Situations. Annapolis, MD: Naval Institute Press; 2011.
  •   Gazoni FM, Amato PE, Malik ZM, Durieu ME. The impact of perioperative catastrophes on anesthesiologists: results of a national survey. Anesth Analg. 2012;114(3):596–603.
  • Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995-1000. 

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