A considerable body of literature addresses the impact of patient death on health care providers.1 Research, across specialty lines and national borders, has shown that dealing with the death or injury of patients is a major source of stress for physicians, with many studies indicating a high degree of often longstanding, emotional impact.2–9 Studies have shown that a negative outcome (regardless of “fault”) may cause an involved physician to feel impaired during the remainder of his/her workday8 or impair a physician's decision-making schema.10 Adverse events may also initiate depression and drug and alcohol abuse.11 Some physicians have reported that adverse events have prompted them to consider a career change.9,12
Surveys conducted outside the United States have revealed that the majority (up to 92%) of practicing anesthesiologists will experience at least one perioperative death or serious injury of a patient over the course of their career, with a majority of survey respondents indicating that they were emotionally affected but received very little institutional support in the aftermath of these events.1,12–19 Although most survey respondents denied that their ability to provide anesthesia care in the aftermath of a perioperative catastrophe was compromised, many would have liked time off in the immediate aftermath of the event. These surveys, several of which have been published in handbooks and newsletters rather than peer-reviewed journals, have been limited by small sample size and poor response rates.
Given that no survey has been conducted in the United States where training programs, practice patterns, attitudes, expectations, and support systems are likely to be quite different than in other countries, we know little about the impact of perioperative catastrophes on American anesthesiologists and very little about the effect catastrophes may have on subsequent patient care. We therefore conducted a national survey of 1200 anesthesiologists to examine the emotional impact of perioperative catastrophes and to elucidate the postevent support desired. We also sought to determine whether respondents believed their ability to provide anesthesia care was compromised in the immediate aftermath of a perioperative catastrophe, and whether or not they believed time off from work would be desirable and/or beneficial to themselves and/or to subsequent patients.
We hypothesized that (1) the majority of respondents would have experienced at least one perioperative catastrophe, (2) the majority of respondents would report a high level of emotional impact after the death or serious injury of a patient, (3) the majority would believe that their ability to administer anesthesia was not compromised in the immediate aftermath of the event, but (4) in the future, most would like time off to reflect on and recover from such incidents.
Instrument and Key Measures
The instrument was designed to assess the impact of perioperative catastrophes on anesthesiologists. To develop the questionnaire, we worked closely with staff at the Center for Survey Research (CSR) at the University of Virginia and consulted with a psychologist with training in posttraumatic stress disorder. To refine the survey, a pretest of the survey instrument was conducted in 2008. We conducted the survey and conducted a semistructured telephone interview with 12 volunteers from across the United States who had responded to a poster that was placed on an announcement board at the American Society of Anesthesiologists' (ASA) annual meeting in 2008.
The survey consisted of several types of questions, including 1-answer responses, multiple responses, 3-point scales, and open-ended responses. The sections included in the questionnaire were: (1) Demographics, (2) Experiences, (3) A Memorable Event, and (4) Your Opinions. The full survey is shown in Appendix A (see Supplemental Digital Content 1, https://links.lww.com/AA/A293).
Data Collection and Sample
The survey was administered by the CSR at the University of Virginia. The mail-out protocol for the self-administered paper survey was guided by Dillman's Tailored Design Method.20 This included an advance letter notifying participants of the purpose and merit of the survey, a letter of support from Robert K. Stoelting, MD, President of the Anesthesia Patient Safety Foundation, a $2.00 cash incentive in the first packet, a second packet mailed to nonrespondents, and a final follow-up postcard to encourage participation (Fig. 1).
The questionnaire was designed so that all responses would be completely anonymous. Instructions included in the questionnaire asked respondents to complete the questionnaire and return it to CSR in an enclosed business-reply mail envelope. To ensure that the respondent's answers remained anonymous, the respondent was asked to return separately a confirmation postcard so that CSR could stop sending further reminder notices. Respondents could indicate on the confirmation postcard their desire not to participate in the study.
Power analysis indicated that we should attempt to secure between 650 and 700 completions. This decreased the “margin of error” of the survey to less than ±4 percentage points and yielded a critical value of ±5 percentage points in comparisons of these survey results with results from any future survey of like size on this same population. Based on an expected response rate of 55%, we targeted a population of 1200. A total of 1200 physician and resident members were selected randomly from the ASA mailing list to participate in the study: 960 (80%) were selected randomly from the list of active members; 240 (20%) were selected randomly from the list of resident members. Survey packets were mailed to the sample of 1200 physicians and residents on March 19, 2009. Six hundred fifty-nine completed questionnaires were received.
The response rate was calculated by dividing the number of completed questionnaires (659) by the number of potential valid respondents in the sample (1185); 15 packets were returned because of change of address. The response rate for this survey was 56%. The “margin of error” for the survey is ±4% (Table 1).
We received 659 responses (56% response rate) of which 15% were from residents. Seventy-seven percent of respondents were male, which very closely matches the 78% male make-up of the ASA. Forty-six percent of responses came from physicians practicing in community hospitals, 28% came from university or affiliated hospitals, 21% were from ambulatory surgical centers, and the remainder came from other clinical or research settings (some physicians indicated working in several settings). The number of years in practice ranged from <5 to >25, with the highest number of responses from anesthesiologists in practice for >25 years (19%) and the lowest number of responses from anesthesiologists in practice for 5 to 10 years (14%).
Sixty-two percent of respondents had been involved in at least one unanticipated death or serious injury within the last 10 years and 84% had been involved in at least one unanticipated death or serious injury within his/her entire career. The mean number of perioperative events experienced in the last 10 years was 2.8, and over an entire career that number was 4.4 events.
When asked what specific events respondents would include in the category of “perioperative catastrophic event,” the majority included death, cardiac arrest, myocardial infarction, stroke or other brain injury, perioperative visual loss, and wrong site or wrong patient procedure (Table 2). When asked when respondents believed the perioperative period ended, the majority indicated 24 hours postsurgery.
A “Memorable Event”
Five hundred seventy respondents participated in the “memorable event” portion of the questionnaire. Of these, 67% of cases involved patient death and 46% occurred during surgery. Only 54% involved the respondent as primary anesthesia provider. Fifty percent of index cases were elective procedures, 23% were urgent, and 28% were emergent. Eleven percent of patients were ASA physical status I, 23% were status II, 28% status III, 29% status IV, and 8.0% status V. Sixty-one percent of the events were believed to be definitely or probably not anesthesia-related events, whereas 40% were believed to be definitely or probably anesthesia-related events. Fifty-two percent believed the catastrophe was definitely or probably preventable. Among those who believed the catastrophe was preventable, 76% felt personally responsible. Of respondents who believed the event was not preventable, 64% felt personally responsible. Thus, the majority of respondents were more likely to report feeling personally responsible in the face of an outcome that was considered unpreventable.
Regarding the index case, a majority of respondents indicated that they experienced guilt, depression, anxiety, sleeplessness, fear of litigation, fear of judgment by colleagues, anger, and reliving of the event (Fig. 2). Five percent experienced use of drugs or alcohol and 12% considered a career change after the event. Eighty-eight percent of respondents indicated that they required some amount of time to recover emotionally from the event (Fig. 3). When asked how long it took them to recover emotionally from the index case, the most frequently selected time frame was 1 week (21%). “Emotional recovery” was not specifically defined, but was left open to respondents' interpretation. Nineteen percent of subjects indicated that they never fully recovered from the experience. There were no statistically significant differences in recovery time by physician sex or number of years in practice, by ASA physical status of the patient, by whether the catastrophe was believed to be preventable, or by whether the case was elective, urgent, or emergent.
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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