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use of counterfactual thoughts changes. In the stages of surgeons’ reactions to error
described above, we see surgeons moving through different phases, each of which
hold may be related to a different cognitive process. It is possible that counterfactual
thinking may be most relevant during the long-term impact phase [ 13 ].
Organizational theorists have been increasingly interested in counterfactual
thinking because of its implications for learning. It has been found that individuals
are more likely to draw performance-promoting lessons from ambiguous outcomes,
such as in surgical error, after they have responded with a self-focused upward
counterfactual comparison [ 46 ]. In addition, individuals performing under organi-
zational accountability (accountability to superiors) will be less likely to draw
performance- promoting lessons. This is because the use of self-focused upward
counterfactuals can imply negligence or culpability [ 47 ], a key concern for surgeons
who must consider both professional and legal implications when admitting error.
The additional threat from the organization evokes a reaction called “defensive bol-
stering,” an information processing strategy that leads to a tendency to avoid com-
plex or self-critical thoughts [ 48 ]. Defensive bolstering has been shown in physicians
performing under organizational pressure [ 49 ].
In conclusion, psychological theories support the notion that surgeons experi-
ence surgical complications as a personal affront that must be accommodated into
their professional sense of self. Thus, complications function as immediate perfor-
mance feedback that is “self-oriented,” emotionally driven, and based on a strong
link between “self” and “performance.”
Beyond the Individual: The Impact of Surgical Culture
on Surgeons’ Reactions to Error
Beyond their “personality” and cognitive processes, surgeons—as people—are
imbedded within a powerful surgical culture. Two key features of surgical culture
are of particular concern as we consider them in relation to surgeons’ reactions to
error: surgeons’ strive for perfection and concerns around reputation.
As a group, surgeons are trained for rapid and confident decision-making with
little room for error [ 50 ] and reside in a culture where they are forced to artificially
contain emotions for fear that they would otherwise be unable to practice. Surgical
residents often experience internal conflict as they are taught about the uncertainty
of medicine in parallel with the unacceptability of error [ 46 ]. Furthermore, unlike
many other professions, counseling or “debriefing” on the individual level after
medical errors is not routine [ 46 ]. Following the occurrence of an error, surgeons are
often reluctant to disclose the error to patients and colleagues for fear of malpractice
litigation [ 51 ], shame, or self-disappointment [ 46 ]. Similar findings occur in studies
in other areas of medicine, for example, in-depth interviews with general internists
found that error, whether perceived or real, result in diminished self-confidence,
fear of stigmatization, and feelings of guilt [ 21 ].
Social identity theories outline how individuals adopt shared attitudes and iden-
tify with social groups [ 52 ]. Current surgical culture holds, among other things,
“boldness of action” and “a take-charge machismo” in the operating theater as an
M.H. Mobilio and C.-a. Moulton