311help toward a greater understanding of the surgeon in the midst of an adverse event
are suggested. While psychological theories help explain the inner workings of our
brain and subsequent emotional reactions as human beings to these events, we are
also embedded in a very powerful culture that influences our interpretation and
experience of events. Therefore, we will also interrogate the surgical culture and
accuse it somewhat of being at the epicenter of these reactions. Recognizing that it
is impossible to “do no harm” over the course of a surgical career, we will provide
a language to conceptualize, understand, and teach the experience of adverse events
in surgery in a new way. We argue that, by reducing the stigma around admitting
error and instead framing the unavoidable experience of adverse events as an oppor-
tunity for growth and reflection, surgeons and learners may open new avenues in
which to harness surgical expertise.
To set the stage for what is to follow, it is necessary to first discuss the different
terms used when talking about surgical mishaps. When a patient suffers an adverse
event following surgery, it is not always possible to link the event with surgeon error.
More often than not, the degree to which the surgeon is responsible for that particular
event is difficult to ascertain. Surgical procedures will necessarily result in complica-
tions in a percentage of patients, even if the surgery was done “perfectly.” Other
times surgeon error is recognized as the cause of the mishap. In the latter situation, it
is clear there is a direct causal link between surgeon error and adverse patient out-
comes. It is worth noting that this clear link is not the norm. To further complicate the
relationship between surgeon error and adverse outcomes, a surgical error does not
always lead to a bad outcome for the patient. Surgical errors can be safely corrected
during or after a procedure without necessarily causing harm to a patient. Therefore,
it is necessary to state at the outset that a surgeon’s reaction to an adverse event might
be the same whether or not an error was recognized and/or acknowledged. Granted,
the reaction might be more severe if there is a clear link between the error and event,
but the nature of the reaction appears to be similar regardless. For this reason, in the
section that follows, we will focus on the phases of the reaction generally and not get
hung up on the impossible task of quantifying the specific cause of individual events
as they relate to surgeon reaction to error.
Phases of Reactions to Adverse Events
What is the nature of the reaction a surgeon experiences after a patient’s adverse
event?
In a recent qualitative study, as part of a larger research program on surgeon
cognition and culture, we interviewed 20 surgeons about their reactions to adverse
events. Our aim in this study was to develop a conceptual framework [ 13 ] for under-
standing these reactions for the purposes of providing a tool for self-reflection, dis-
cussion, teaching, and further error-reduction strategies.
Luu et al. identified four phases of progression after an adverse event: the kick,
the fall, the recovery, and the long-term impact [ 13 ]. The initial stage, the kick, was
18 Surgeons’ Reactions to Error