When asked about care provided in the first 4 hours subsequent to the index case, 67% of respondents indicated that their ability to provide anesthesia was compromised to some degree, with 32% feeling compromised “a lot” during this period (Fig. 4). Fifty-one percent of respondents believed that their ability to provide care was compromised for the first 24 hours, 27% felt compromised for an entire week, and 16% felt compromised even longer. Only 7% of respondents were given time off after the event, a percentage that was similar among the subgroups of sex or trainee status. Of these, 95% found the time off helpful.
The most frequently engaged sources of postevent support were other anesthesia personnel (94%), members of the surgical team (73%), and spouse, family, or friends (72%). There seemed to be no differences in terms of training status (trainee versus licensed practitioner) or sex in the frequency of speaking with someone. Fifty-three percent of respondents attended some type of formal debriefing after the event, be it a departmental morbidity and mortality conference (M&M) (36%), confidential hospital quality-assurance meeting (25%), or other type of formal debriefing (9%). Debriefing seemed to occur as often for university hospital and nonacademic hospital respondents, but more frequently for attending anesthesiologists than for residents (56.6% vs 36.2%). Those who had formal debriefing were more likely to feel personally responsible (75% vs 67%), blamed (44% vs 31%), depressed (68% vs 57%), anxious (79.4% vs 66.1%), or to experience sleeplessness (57.3% vs 44%), fear of litigation (72% vs 53%), fear of judgment (54% vs 45), reliving of the event (78% vs 68%), and anger (54% vs 43%).
Future Management of Adverse Patient Outcomes
More than 75% of respondents believed that talking with other anesthesia personnel, debriefing with the entire operating room team involved, talking with patient's family, talking with respondent's spouse or family, attending a departmental M&M, attending interdepartmental M&M, and/or attending a confidential hospital quality-assurance meeting would be at least somewhat helpful after an adverse event (Table 3). More women than men believed that it would be helpful to debrief with the entire operating room team (96% vs 87%) and talk with a counselor (77% vs 60%). When asked if a mandatory debriefing session after an event was a good idea, 68% felt that it was, with women feeling stronger about this than men (78% vs 66%). As for time off, 75% of respondents felt that it should be offered, and 9% felt that it should be required. Of those who believed that time off should be offered or required, 35% felt that the remainder of the day would be an appropriate amount of time, 26% felt the remainder of the day plus the next day would be appropriate, and 33% felt it should be determined on a case-by-case basis.
We found that 62% of respondents had been involved in at least one perioperative catastrophe over the course of the past 10 years and 84% had been involved in at least one such event over the course of their entire career. In regards to one “memorable” event, we found a high degree of emotional impact with a majority of respondents experiencing guilt, depression, anxiety, sleeplessness, fear of litigation, fear of judgment by colleagues, anger, and reliving of the event. Five percent admitted to the use of drugs and alcohol as part of their coping mechanism. Eighty-eight percent of respondents indicated that they required some amount of time to recover emotionally from the event, 19% indicated that they never fully recovered from the experience, and 12% indicated that the event prompted them to consider a career change. In the period immediately subsequent to this index case, 67% believed that their ability to provide anesthesia was compromised to some degree, with 32% feeling compromised “a lot” during this period. Only 7%, however, were given time off.
Impact of Adverse Events on Physicians in Other Countries and Other Medical Specialties
A considerable body of literature addresses the impact of patient death on health care providers, particularly in other medical specialties.1 These studies reveal that 25% to 75% of physicians suffer a strong emotional response to the death or injury of a patient.2–7 Several studies have revealed that the death of a patient, often perceived as a personal failure, can be a “disturbing,” guilt-laden experience for medical students, interns, residents, and attending anesthesiologists.2–7 The need for better support for physicians in the aftermath of adverse events is a common suggestion in these studies.
One survey studied the impact of stillbirth and neonatal death on American obstetricians. Seventy-five percent of respondents reported that caring for a patient with a stillbirth “took a large toll on them emotionally.” In fact, almost 10% considered leaving obstetrical practice as a result of the emotional impact of such adverse outcomes. Informal conversation with colleagues (87%) or friends and family (56%) was the most frequently used coping strategy.9
The European experience also reflects the magnitude of the impact of adverse events on physicians.1 In 1998, a British surgeon, Professor Sir Alfred Cuschieri, described a death on the operating table as a “harrowing experience” and advised that surgeons not operate for the remainder of the day subsequent to an intraoperative death. He called for national guidelines to protect surgeons who had experienced an intraoperative death. In 2001, the Royal College of Surgeons of Edinburgh published guidelines that recommended that, subsequent to an intraoperative death, surgeons (and perhaps the entire operating room team) avoid further elective surgery that same day.13 Several survey studies of surgeons and anesthesiologists ensued.12,13,15,21,22 These surveys revealed that the majority of physicians had experienced the death or serious injury of a patient, often with a lasting and profound emotional toll. Although few respondents admitted to compromised functionality after these events, 25% to 71% believed that time off should be, at the very least, offered after the death or serious injury of a patient.
High Level of Emotional Impact
Whereas crisis avoidance and management have always been an integral component of anesthesia curricula, handling the aftermath of adverse events traditionally has not. In fact, the “focus of training in anesthesia is concerned with the avoidance of disasters, rather than the management of their aftermath.”23 The solitary nature of the practice of anesthesia, the rarity of these events, and evidence that anesthesiologists are unlikely to receive much in the way of professional support after a sentinel event, make them particularly prone to psychological distress should they experience the death or serious injury of a patient.13
We found that 84% of our survey respondents had experienced at least one perioperative catastrophe over the course of their career, with the majority of respondents indicating that at least one of these events had a profound emotional impact on them. Regardless of whether the patient was healthy, whether the catastrophe was anesthesia related or preventable, and regardless of sex or number of years in practice, respondents indicated a high level of emotional impact. More than 70% experienced guilt, anxiety, and reliving the event. Eighty-eight percent indicated that it took them some time to recover emotionally from the event, 12% considered a career change, and 19% of respondents reported never having fully recovered emotionally from the event. This is double the 7% to 10% of respondents who indicated longstanding emotional impact in European surveys.12,15 Although we did not ask respondents about potential causes for prolonged emotional impact, we can speculate that inadequate departmental or institutional support contributed. In fact, Wee12 found that the majority of British anesthesiologists who felt “deeply affected” by an adverse event blamed their departments for lack of support.
We were surprised to find that those who had formal debriefing were more likely to experience a number of undesirable emotions such as depression, anxiety, anger, fear of litigation, fear of judgment, and reliving of the event. Whether this association was attributable to the nature of the adverse events (formal debriefing held when the events were deemed preventable, clearly caused by error, or were associated with more serious adverse outcomes), attributable to a selection bias (the debriefing sessions were not randomized), or attributable to the sessions themselves remains unclear: we did not ask whether respondents found these sessions to be helpful. Furthermore, 68% of respondents believed that mandatory debriefing sessions would be a good idea. It should be noted that although debriefing has generally and anecdotally been viewed positively by its recipients, there is little empiric evidence to demonstrate that debriefing accelerates recovery subsequent to traumatic events.24–28
Potential Impact on Subsequent Patient Care
Almost all physicians, whether during medical training or practice, care for the dying patient. A substantial amount of emotional stress can result from a patient's death, even when the patient is relatively new to the physician.2 Physicians' emotions can reflect a need to rescue the patient, a sense of failure and powerlessness, a fear of becoming ill oneself, or a desire to separate from and avoid patients to escape these feelings.29,30 It has been suggested that both physician attitude and stress have a major role in influencing medical errors.31–37 Physicians tend to underestimate the deleterious effects of stressors, believing that their decision-making is as good in emergencies as in normal situations.31 Psychological research over the last century indicates an inverted U-shaped relationship between stress and performance: performance improves as stress increases up to an optimal level, after which performance declines with increasing stress.32 Additional studies have found that stress directly influences an individual's thought processes: as stress increases, an individual's thought processes and attention span narrow.33,34 And although performance may improve at moderate levels of stress, current psychology models suggest that situations requiring excess sustained mental energy eventually induce lax compensatory mechanisms that can hamper performance; this includes less use of working memory, increased mental effort, and risky decision-making in subsequent novel tasks.34 The deleterious effect on performance caused by high levels of stress has been studied and the results presented in the surgical literature.35,36 However, medical staff are more likely to deny the effects of stress and fatigue on their performance.37 As studies indicate that well-rehearsed actions are poorly performed under stressful conditions, high risk/stress industries such as aviation and the military have introduced crisis-management training models to prepare trainees to respond effectively and efficiently to stressors.38,39
We were surprised to find that more than two-thirds of study respondents believed that, in the aftermath of their “memorable event,” their ability to provide anesthesia was compromised to some degree, with 32% feeling compromised “a lot” during this period. Although 74% believed that time off should be offered in the aftermath of a perioperative catastrophe, only 7% were actually given any time off after their most memorable event. Whether this sense of being compromised was perceived or real is still unestablished.
We included residents in our sample population and received 99 resident responses, but we found few notable differences between trainees and licensed practitioners. We did find a trend for greater sense of personal responsibility and greater degree of impact among attending anesthesiologists. We also found that, relative to more junior residents, more senior trainees experienced greater blame, guilt, depression, anxiety, sleeplessness, reliving of the event, loss of reputation, anger and self-doubt, perceived a greater impact on their ability to provide care in the aftermath of an adverse event, required longer recovery time, and considered a career change with greater frequency. One might extrapolate that more senior residents felt a greater sense of personal responsibility and culpability than the more junior residents and that the attendings felt a greater sense of personal responsibility and liability relative to all trainees. We plan to further investigate these findings with a follow-up study focusing on impact of adverse events on anesthesiology residents.
This study has limitations inherent in survey studies such as random sampling error, selection bias, or the core feature that our data are “based on self reports of subjective perceptions and observations.”40
Although there is no standard for an acceptable survey response rate, a review of the published epidemiologic literature suggests a good response rate may range from 50% to >80%.41–43 Published surveys, however, have shown lower response rates for physicians compared with nonphysicians (54% vs 68%).41,44 In addition to the methods described above (see Fig. 1), we used a postal survey rather than an Internet survey, because previous survey studies of physicians indicate the former have a higher response rate among physicians.45–47 Our response rate was 56%, which is comparable to previously published postal survey studies of physicians.13,41,48 Indeed, our response rate is significantly higher than the response rate of 28.7% of the online survey conducted by the Association of Anaesthetists of Great Britain and Ireland.
Similar to all retrospective cross-sectional surveys, our study is subject to the limitations of recall bias. Recall bias, an error in recall of past exposures,49 can be affected by the time frame, degree of detail elicited, respondent demographics, exposure to social stigmata, and significance of the event.50 We attempted to limit recall bias by including an introductory cover letter (to stimulate respondent memory and give time to respond accurately) and providing respondents with a list of possible responses for certain questions.49,50 Because of these weaknesses inherent in the design of survey studies, we do not report statistical comparisons among the groups, which might be misleading because of response bias.
Lastly, because the terms “catastrophe” and “perioperative” are prone to subjective interpretation, we encompassed the variability of respondent responses in 2 of the questions that pertained to the definition of events that qualify as catastrophic. The term “perioperative catastrophe” has been used frequently in the literature1,12,16,18,51 to describe an adverse and sometimes lethal event associated with the surgical and anesthetic care of a patient. In all instances, “catastrophe” also implied a major degree of stress or turmoil experienced by the physician providing care during the event. Merriam-Webster dictionary defines catastrophe as “a momentous tragic event ranging from extreme misfortune to utter overthrow or ruin.”52 In the literature, the catastrophe is akin to the dénouement, the final action that unravels the plot, particularly in a tragedy.53
This national survey provides evidence that the perioperative death or serious injury of a patient has a profound and often lasting emotional impact on the anesthesiologist involved, including a perception by the anesthesiologist that it may affect quality of care in the immediate aftermath of these events. These emotional and potentially cognitive effects can have repercussions not only for the physician involved but also, conceivably, for patients subsequently cared for.
Whereas anesthesia curricula have long focused on crisis avoidance and management, handling the aftermath of perioperative catastrophes has not traditionally been a focus of attention or concern. Despite the move toward therapeutic and diagnostic algorithms and protocols within the American medical system, we have very little in place to allow for proper physician care in the aftermath of adverse events. Our data suggest that we must develop protocols and guidelines for support after perioperative catastrophes and other types of major adverse events, and incorporate skills for handling the aftermath of adverse events into our training programs. This will not only promote the wellness of anesthesiologists, but will also ensure that “no patient will be harmed.”
Marcel E. Durieux is Section Editor of Anesthetic Preclinical Pharmacology for the Journal. This manuscript was handled by Sorin J. Brull, Section Editor of Patient Safety, and Dr. Durieux was not involved in any way with the editorial process or decision.
We gratefully acknowledge the contributions of Dr. Robert K. Stoelting, MD, President of the Anesthesia Patient Safety Foundation, Dr. Carl Lynch, III, MD, PhD, Professor of Anesthesiology at the University of Virginia, Dr. Michael Wee, MD, Vice President of the Association of Anaesthetists of Great Britain and Ireland, and Thomas M. Guterbock, PhD, Robin A. Bebel, and Deborah L. Rexrode, MA, from the Center for Survey Research at the University of Virginia.
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