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surgery counterparts, hypothesizing that general surgeons may be less accustomed
to life-threatening complications or a complication in a low-risk patient takes a
higher toll than if the patient were high risk [ 28 ]. According to survey results from
Shanafelt et al., surgeons may be more sensitive to burnout than their nonsurgeon
colleagues as they were less likely to report that they would become a surgeon again
and less likely to recommend their children pursue a career in surgery [ 29 ].
Physician burnout and medical errors appear to be intimately associated, although
direct causation is more difficult to establish [ 30 , 31 ]. Both patients and physicians
attribute stress, fatigue, and exhaustion leading to medical errors [ 32 , 33 ]. Fahrenkopf
et al. established a relationship between depression and medical errors in pediatric
residents when they determined that residents suffering from depression were six
times more likely than their nondepressed colleagues to make a medication error
[ 31 ]. The relationships between adverse events and surgeon wellness and expertise
are clear. Next, we will outline what might be going on in a surgeon’s head as they
navigate the experience of an adverse event.
Inside the Head of the Surgeon: The Psychology
of the Surgeon’s Reaction to Error
In this section we consider literature from the field of social psychology as a lens
through which we might think about surgeons’ reaction to error in a new way. Here
we will introduce theories of cognitive dissonance, self, and counterfactual thinking.
First proposed by Festinger, the theory of cognitive dissonance refers to the
notion that if a person holds two psychologically (not necessarily logically) discrep-
ant thoughts, psychological discomfort will occur [ 34 ]. Psychologically, individuals
are motivated to reduce dissonance, either by changing one or both of the thoughts
or by introducing a new thought. For example, a reputable surgeon who takes pride
in her operative skills will develop cognitive dissonance if a technical error is made
(“I am a very good surgeon” and “I made a mistake”). In order to resolve the dis-
comfort, she can introduce a new thought—maybe that the patient’s case was con-
founding—and thus the error had nothing to do with her technical skill or judgment.
A colorectal surgeon who injures the left ureter in a difficult sigmoid resection, for
example, may “know” that the ureter was in its normal position in the retroperito-
neum but may “think” (by introduction of a new thought) that an unusual variant,
such as peritoneal adhesions, “caused” the error, as she deals with her uncomfort-
able cognitive dissonance.
The theory of self utilizes self-affirmation to explain the approaches that individu-
als take when dealing with cognitive dissonance, understanding that the goal of an
individual’s self is to protect their self-integrity. When the image of self-integrity is
threatened, the individual will take steps to restore self-worth [ 35 ]. There are a vari-
ety of ways to maintain self-integrity but, when possible, individuals will choose to
respond to threats using indirect psychological adaptations in which they can adapt
affirmations unrelated to the immediate situation. These unrelated affirmations allow
the individual to realize that their self-integrity and self-worth are independent of the
M.H. Mobilio and C.-a. Moulton