DESCRIPT BTK_November 2024 Episode

Hello, everybody, and welcome to the next episode of Behind the Knife. We got something different planned this time around, but first I want to welcome the rest of the group. The whole gang's here today. So we got Dr. Ashley Nadler from Toronto and Dr. Graham Sculler Gross coming to us from Buffalo now. Hi, everyone.

I'm excited about today's topic. As am I. Hi, everyone. And today we're also welcoming back Dr. Marika Savanyi, who has been off on maternity leave. Welcome back. Thanks, Jordan. I'm happy to be back and looking forward to an interesting discussion. So today we're going to be talking about a really important subject and something I'm sure we've all faced at some point in our training and careers, even early on.

What happens when things do not go well, despite our best efforts, the dreaded complications and how they impact us. Oh, I got a pit in my stomach just hearing the word complication. Yeah, it's often part of the job with acute care surgery, especially you can't plan what comes in, you can't select your patients and the conditions are

often suboptimal.

Yeah, and even when you think everything has gone right, you've got the right patient, you've done the right operation, right technique, sometimes there's just forces that seem to wreak havoc anyway. Yeah, it's something that we all face, but really have for many years, let's be realistic, not openly talked about.

Yeah, it's definitely changing, but it's still not easy. We've got a better culture around morbidity and mortality rounds at our center, which we've actually called QI rounds or quality improvement rounds for some time. When this is done right, it can enable great discussions and without placing blame, so that's good, but it's hard to deal with your own feelings around a bad outcome.

I completely agree, Ashley. I feel like as a resident, I never heard my staff talk openly about mistakes or cases that affected them, and it was really hard to navigate this when I started operating independently, especially when something didn't go right. As a trainee, sometimes you can kind of dismiss the bad thoughts because you're not the most responsible physician, but that sense of responsibility can

be crushing when you're out on your own.

It can feel really isolating, even when you know it's part of the practice. It's becoming less taboo for sure, and the literature is really beginning to reflect this. So, we've actually got two great papers today that discuss this issue and really use two different approaches. Okay, great. Let's get started.

The first article we're going to review is called Helping a Surgeon Recover, Peer to Peer Coaching After Bile Duct Injury. The lead author is one of our residents at the University Zhu. And the contributors include several of our excellent hepatobiliary colleagues at the University of Toronto, including the corresponding author, Dr.

Shiva Jayaraman. Yes, this is such a great article to review, and most importantly, such a great service that this group is providing to all of us who operate on gallbladders in the Greater Toronto Area. As acute care surgeons operating on gallbladders, can be really different than doing elective lap colies.

The anatomy can be really distorted, very

challenging to even get a hold of the gallbladder to hold it. And of course, we all fear the dreaded bile duct injury. Yeah, for sure, Marika. But I think one of the key messages of our podcast today is that these injuries do happen and they happen to the best of us.

Having a bile duct injury doesn't make someone a bad surgeon. And the real question is, how do we move forward from there to continue to provide great care for our patients? I think this article highlights a really nice program that this group has started related to this issue. Exactly, Jordan. So, this study involved six surgeons who had recently injured a bile duct while performing an emergency laparoscopic cholecystectomy.

Now, all of them were staff surgeons, and they were identified because they had actually referred this, their cases to the Suppatibility Center of Excellence for further management. So, interestingly, of the participants, five of six were fellowship trained, including three that had specialty training in minimally invasive surgery.

And their experience really ranged widely. One had only been in practice for two years, but another had been in practice for 24 years, which I think to your point,

Jordan, really does highlight that these injuries can and do happen to any surgeon. Yeah, definitely. So upon enrollment, the participants received videos of a step by step approach to doing a safe laparoscopic cholecystectomy.

Following this, they underwent a one hour, one on one video conference session with a surgical coach, who was an HPB trained senior surgeon. This video conference took place within one month of the event. During the coaching session, the two discussed the concept of a safe lap coli, including obtaining a critical view of safety and proper landmarking.

Next, and I think this is a really valuable aspect of the program, is they reviewed a video taken at the laparoscopic re exploration. Mm hmm. And this is a really nice feature. So this particular HPV group had developed a protocol approach to surgical re exploration for bile duct injury. The process begins with laparoscopy during which they would look for the injury, then perform a cholangiogram, if this was

feasible, and obtain optimal source control for the bile.

They then would determine the best strategy and timing for the next step and definitive surgical repair, or if endoscopic intervention would be preferable. And these laparoscopic cases were all recorded and then shown back to the initial surgeon to review the important anatomical landmarks and discuss how the injury likely occurred.

Yeah, I really liked that they had a standardized protocol for this. I think it's important for us to remember that, you know, of course, some of these injuries require surgical repair. Some of them may just need an ERCP and the associated intervention. Some of them are best managed in a delayed fashion.

And, You know, for the initial surgeon, I'm sure it's really hard to take yourself out of the driver's seat and they probably want it fixed immediately. Uh, but I think giving that decision making over to our colleagues and who are experts in this at HPB really helps and having an established protocol for that so they can establish the best timing to

benefit the patient most.

Uh, it's really, really important. Yeah, for sure, Jordan. So, six months after the coaching sessions, the participants then took part in a one on one semi structured interview. And they were asked a number of questions focusing on their general impressions of coaching and surgery, um, their perceptions of complication in surgery, um, sort of broadly, and then really focused on specific to bile duct injuries and laparoscopic cholecystectomy.

The participants were also asked to comment on their personal experience in the coaching program. There are some really important themes that emerged from these interviews. First, that surgeons are lifelong learners. We don't finish training knowing everything, but we continue to learn as attendings.

Second, the participants felt that individualized coaching for practicing surgeons is beneficial. Five of the six had positive feelings about being approached to partake in the coaching. And all of them found that it was a positive experience overall. In fact, all participants have maintained a relationship with a surgical

coach.

Those are all great things. It's important that the participants felt the sessions were successful because of the non judgmental and collegial relationship they had with the senior coach. And they liked the interactive format where they could see the video of that take back and be able to ask questions around what they were seeing.

They also appreciated doing the session so soon after the injury, so it was still fresh in their minds. So a lot of positives about the program itself, and that's great. But I think this study also captures a lot of aspects related to the effect this experience had on the surgeons themselves. So five out of six reported a decline in self confidence after a bile duct injury.

Four of them described the challenging emotional aspect of being involved in that injury. And I'm sure that each of these surgeons got out of bed that morning looking to provide great care for these patients. That's a massive change for them and a hit to them. So complications, I think this really highlights, are really hard on us.

Yeah, so, so well said. And, you know, I mean, throughout my training, it's been, you know,

always difficult when my patients weren't doing well. But now that I am a brand new attending, I find that I'm really feeling it on a whole different level. I'm so glad we're taking the chance to talk about this openly and what it's like when we have complications.

Definitely. So there were many strengths of this paper. First, I really appreciate the topic. We definitely don't talk about these issues enough. I also like the way the group developed a peer to peer support network. resources for providing safe laparoscopic cholecystectomies that can be used by all surgeons doing gallbladder surgery.

I commend the authors for providing this service to their colleagues and for being available at the time of injury and for ongoing training and support. Okay, but we do have to talk about some of the paper's weaknesses, and with that caveat, I do want to say we really like the paper and hope the authors will still take our referrals here in Toronto, especially if we have the unfortunate outcome of a bile duct injury down the line.

But the study did have a very small sample

size and didn't really have long term follow up on these surgeons. beyond the initial study. It would be really nice to know how the program affected the practice of the surgeons involved in a more long term fashion and what they now do differently. Are they perhaps safer now?

How did their approach change from this coaching? Although given that bile duct injuries are rare, this would be hard to capture or measure properly. Yeah, as always, there's some future opportunities here that the paper highlights, and I do think that assessing long term outcomes is definitely one of them.

I also wondered if this program could be a useful resource for any surgeon to send in a video of one of their cases to get some coaching, even if an injury doesn't necessarily occur, maybe with a particularly difficult case, so maybe this would offer an opportunity to prevent bile duct injuries before they actually happen.

And of course, that supposes that they have access to video recording in their cases, which can be a huge challenge. Oh yeah, that's a really good idea. I, I was also wondering about how they could expand on the

emotional needs that the surgeons expressed after they had the injury. You know, I think it sounds like they have a really robust program to address, address the technical issues, but, but some of the surgeons were actually hoping for something more really on that emotional level.

So I was wondering if maybe having a counselor or psychiatrist, really somebody. Kind of regularly helps people manage a stressful event, having that as part of the team. I wonder if that would be helpful. Yes, but still overall a great paper, great resource, and I really think the most important takeaway is that these injuries really can happen to any surgeon.

We've all had complications. It's terrible. In any way we can support one another is really important. All right, great discussion all and you know really good talk about these complications which leads nicely into our next paper. So we're going to be talking about the Surgeon as a Second Victim results of the Boston Interoperative Adverse Events Surgeon's Attitude Study which was published in 2017 in the Journal of the American College of Surgeons.

So I thought this was a really interesting study as far as providing a bit of a bird's eye

view so to speak covering several important parts of dealing with complications as a surgeon. That's great. I think we do need to get a better grasp on what the problem looks like before we can really make any solid progress to address it and we all know this is a very challenging problem to study.

So, so what exactly did they look at and how did they approach this problem? This group looked at both some quantitative and qualitative data for this paper, which is great and well justified for this type of problem that they were examining. The study was done as a cross sectional survey across three academic hospitals in Boston using a web based seminar.

Right, and essentially they wanted to use self reported, anonymized data to estimate what they called intraoperative adverse event incidents. Uh, as well as emotional response, available social support systems, and, uh, barriers to intraoperative adverse event reporting. They were pretty broad in their definition of what they labeled as IAEs,

the intraoperative adverse events, which basically they called any inadvertent injury during an operation.

Yeah, so as far as who they included, they selected only practicing surgeons across a variety of specialties, so this wouldn't include trainees such as residents, fellows, or anybody else in the healthcare team. They also excluded non practicing researchers and retired surgeons because they only wanted to look at those who were active clinically.

And they asked all these surgeons to report on various aspects of intraoperative adverse events as they had experienced them. So, you know, what did the, or so following that, what did the cohort end up looking like, and more importantly, what did they find out? Well, 126 of the surgeons filled out the survey for a response rate of around 45 percent.

The average age of the respondent was 49, and more than three quarters were male, so just, and just over half came from general surgery. Now, of course, we expect any estimates of incidents to be a real challenge in this arena when we're looking at self reported outcomes of something with a

definition that is tough to nail down.

With that in mind, over 90 percent of respondents said they'd experienced an intraoperative adverse event before, and most had experienced at least one in the last 12 months. So I think we can say with certainty that this is something that surgeons recognize in their practice and something that most of us are experiencing.

Mm hmm. They gathered some information on how this affected surgeons emotionally, which I think is pretty telling. Over 80 percent of these surgeons experience some combination of anxiety, guilt, and depression. Sadness, shame, embarrassment, and anger associated with these events. I think anyone who has dealt with an intraoperative adverse event, that being almost all surgeons by both this estimate, and what I would think is common sense, isn't surprised to see these particular emotions at play.

These are really tough events for most surgeons, and I think given how intricately tied this is to who we are as people, and how we see ourselves. On that note, it's pretty

interesting actually to look at some of the differences in feelings amongst groups. So they actually found that four fifths of the surgeons who didn't have negative feelings associated with these adverse events were more experienced with 10 plus years of experience.

So, uh, we can only speculate about the meaning behind this, but I think it brings up some interesting questions about the potentially protective effect of gained experience, maybe having had time to establish some support networks, et cetera. Yeah, I think one thing that really struck me from this paper was that these events seem like they're happening fairly regularly for one reason or another, but, you know, we don't really hear that much about them.

So, so why is that? And, you know, I think a big part of what's going on and what this group is trying to capture with the study, you know, most of the surgeons were fairly clear that the competitive and unforgiving nature of surgical culture made any discussions of complications, you know, a huge challenge.

Surgeons are worried about the effects that disclosing or talking about intraoperative adverse events will have on their employment and their reputation, and potentially even how they're compensated. So these are obviously huge

issues and a reflection of, of really hard to change aspects of how we look at these events within our culture.

Absolutely, and that plays right into the next aspect, which is looking at how intraoperative adverse events are or aren't reported or tracked. About half of surgeons reported no existing reporting system. Thank you. And where it did exist, it mostly took the form of morbidity and mortality rounds. The qualitative information really plays a key role here in reporting some of the limitations with these realms being described as hostile.

They make it pretty clear that many surgeons feel like the current venue in which they review intraoperative adverse events is inadequate and looks more at blame. Okay, so here I come again with the limitations to the study using a survey study for a difficult to quantify self reported outcome. I think it can be kind of obvious that there might be issues here, but I do feel it's useful enough to talk

about what we can glean from a study like this, even with the limitations and why it's so important.

I think overall we see that adverse events are common and aside from the obvious effect that they can have on our patients, they are also detrimental to the surgeon's well being and they aren't adequately quantified or evaluated in many settings, if not most settings. Yeah, those are some of the big takeaways for me too, and I think an important part of this as well is that any approach to dealing with adverse events should be done in a way where our focus is on improving outcomes for patients and providing surgeons with support and guidance rather than judgment.

This is of course easier said than done, but I think the use of anonymized data, having some sort of systematic reporting system in place and not tying these types of systems to monetary policies or putting physicians at legal risk, are key parts of what needs to be done and how it could be done right.

For sure. I mean, so much of this really comes down to culture. And I do think we have, you know, in many places, a lot of work to do to create

better culture for those around us. Because just like you said, I mean, it's really all about providing feedback and guidance without attacking each other. And people are only going to be willing to talk about these things and to get better for themselves and for their patients if they feel like it's safe to do that.

And, and I do think that often we're missing the mark there. Yeah, great point. I think it's also important to realize that this is a small picture of a very pervasive problem. Surgeons take a lot of ownership for their patients, which I think is a part of what makes our work so rewarding, but I'm sure these same things affect our colleagues in other specialties, anesthesia, ICU, nursing, and across the board.

We're likely missing a huge part of that understanding, and I think we need to consider everyone with a stake in patient outcomes to being at risk of a second vic being a second victim, so to speak. You know, I'm so glad we're taking the time to talk about this and and really the impact that the complications have on surgeons.

And these 2 papers are really great. And I think they highlighted

this so well. I think maybe we can take a little bit of time to discuss some real life strategies for dealing with complications and for improving the surrounding surgical culture as we've, as we've mentioned. Yeah, unfortunately, you know, to let everybody down a little bit, I didn't, we didn't think it was an appropriate topic to play a game about, so that'll be unfortunately missing from this particular episode out of a, as a sign of respect.

Uh, but to end on a positive note, we wanted to talk a little bit about what we can do to help ourselves and our colleagues to cope with these complications. I personally think a great start is for us to be open to sharing our experiences and voicing the challenges we all deal with when we're dealing with a patient's negative outcomes, as this is often done alone.

I check in with my team and residents when a patient has a complication or an operation didn't go as well as we would have liked to make it clear that it's okay to feel that way and okay to talk about. I think this opens the dialogue and ensures that everyone has a forum to openly discuss how they're coping.

I agree. These real time

conversations are very important, and it's definitely easier to bring these things up when you're the attending because you have less fear of consequences than a trainee might. It also allows for that just culture to be started from the top down. Yeah, and you know, it's so important to have a network of colleagues and mentors that you can trust.

I've been so lucky to to have that. And, you know, many of people in that network are on this podcast, but you know, I've just found it invaluable to run cases by mentors and get their insight for how they've dealt with similar situations or complications. And then how are they able to move forward to the next case without, you know, really being paralyzed by fear or anxiety about a similar outcome?

Yeah, for sure, Graham. I agree. Having that professional network is key, which is reflected in how surgeons dealt with complications in our second study. You'll also want to have a social or family network that can help you reset or put everything else in perspective. While your family and friends are not always the people to discuss specifics of case with, cases with, they can provide perspective to help

you so that the complication doesn't become all encompassing.

It can also be really helpful to seek out a professional coach, as mentioned in the first article, or peer to peer support programs. They can help you work through common issues and develop strategies, and it can also be helpful to see someone. Like a therapist or psychologist, as complications can have major effects on our self esteem, well being, and mental health.

I think that's great advice, Ashley. I'm just so glad that, you know, surgeons are being more open about this and how they deal with complications and that there are resources out there and what those are. As we mentioned in the second paper, M& M rounds are, you know, often such a source of stress for us and especially when we have complications being presented.

But it's also an opportunity to improve, you know, and improve our culture and, and improve the way we, we, uh, support and, you know, our own colleagues when they're going through something similar. Yeah, 100%. You know, these rounds can certainly be a source of pimping and a

culture that kind of focuses on blame.

And I think we've all seen that to some degree, but we're all trying to change this and this change does take time. There are a few ways we can make these rounds more supportive for the surgeon and still improve the patient care that we provide. The Ottawa M& M model provides a great example of how to improve the process and the outcomes of these rounds.

First of all, the focus can be shifted away from individual blame to focusing on preventable system issues that may have led to certain adverse outcomes or contributed to them. And this helps to take away from the blame being put on an individual surgeon. It really focuses on the context in which the, you know, the work was done.

And all of this together has a big role in patient care. We can also focus on other things like perception biases that may have been present. This acknowledges that it's not always a single individual who is prone to error, but that we all are. This creates a joint culture and understanding of where each surgeon

was coming from, rather than an assumption that they were incompetent or negligent or didn't care.

Yeah, I think these changes then set the tone for the rounds to allow us to ask how the surgeon felt or what they have reflected on since the complication occurred. I have no doubt that the surgeon involved has spent more time reflecting on the case than anyone else, but we'll only learn from them and their contemplation if we allow the forum to be open to this.

Since we have changed our rounds to reflect this style, I've been part of some very open, emotional, and moving discussions where I've learned a lot from junior and senior colleagues alike. Well, you know, obviously not all encompassing. These are some excellent suggestions to help promote support and well being around complications.

We all hope that today's discussion has been uplifting and sharing work to support surgeons following complications and hopeful as to the culture that we can continue to create together. Yeah, thanks everybody for joining us. Take care of yourselves and each other

and dominate the day.