315situation [ 36 ]. In the previous example, the surgeon determined that her technical
skill and self-esteem were independent of error, thus allowing her to self-affirm.
When given the choice, individuals will tend to self-affirm in a domain that is unre-
lated to the perceived threat [ 37 ]. An affirmation that is related to the domain—such
as admitting the error was in fact a technical one—would increase cognitive disso-
nance [ 38 ]. Self-affirmation is not the only method of dealing with dissonance.
Direct psychological adaptations to the threat are also probable, such as denial or
avoidance [ 39 ], both of which can occur in a surgeon’s response to error.
Cognitive theorists describe counterfactual thinking as something that occurs
when an individual creates a thought around an outcome that did not happen. Using
statements that begin with “if only...” or “what if...” they either use an upward
counterfactual thought (better than reality) or a downward counterfactual thought
(worse than reality). Kahneman and Miller describe the “simulation heuristic,” in
which individuals travel forward or backward in subjective time in order to examine
how things might have turned out differently [ 40 ]. Kahneman and Tversky empha-
size that the way individuals make sense of events or outcomes they experience is
largely determined by their formation of counterfactual thoughts [ 41 ].
Surgeons might use counterfactual thinking in their reflections on error. The
hepatobiliary surgeon who resects a colorectal liver metastasis for cure resulting in
a positive oncologic margin may employ the upward counterfactual: ‘He is probably
cured anyway with good chemotherapy, it is good I didn't take too much liver.”
Alternatively, the surgeon may utilize the following downward counterfactual after
the same error: “What if the patient’s cancer recurs? I will feel really bad.”
Markman and McMullen made an addition to the hypothesis, called the “Reflection
and Evaluation Model” of counterfactual thinking [ 42 ]. In this model, they distin-
guished between two modes of thinking: evaluative and reflective. Unlike evaluative
thinking as Kahneman and Miller had originally described, when a standard—upward
or downward—is used as a reference point to evaluate reality, reflection is more expe-
riential. In this model, the individual will vividly simulate the information and imag-
ine themselves in it. As a result, less attention is paid to what actually happened [ 42 ].
In the above example, the surgeon using reflective thinking might say, “I likely got
enough for the chemotherapy to help with a cure.” However, the surgeon using evalu-
ative thinking might say “I got a positive margin, and failed to get a negative margin.”
A real-life example we can all likely relate to is the student who declares after receiv-
ing his test results, “I almost got an A” using reflective thinking as opposed to another
who says, “I got a B and I failed to get an A” using evaluative thinking. Choosing one
model of thinking over another will tend to favor either positive or negative emotions,
depending on both the situation and whether it was an upward or downward counter-
factual [ 43 ]. Some researchers have argued that upward counterfactuals are an auto-
matic default in response to negative affect (emotion), whereas downward
counterfactuals are an effort and controlled process to override the negative affect
[ 44 ]. However, there is no consensus, and it is often unpredictable what type of coun-
terfactual an individual will produce. In addition, extrapolating from Kübler-Ross’
work on the time-dependent seven stages of grief [ 45 ], we can expect that counterfac-
tual production may also be time dependent. As time passes and emotions change, the
18 Surgeons’ Reactions to Error