Surgeons who were less likely to follow recommended guidelines for open disclosure of adverse events were more likely to be negatively affected by such events, according to a survey-based study published online July 20 in JAMA Surgery.
In addition, those who were less likely to discuss difficult issues, such as the preventability of an adverse event, or who had poor communication experiences were more negatively affected by disclosure than others.
Specifically, surgeons who reported very difficult experiences discussing an adverse event were four times more likely to report that the event had a negative effect on their lives (odds ratio [OR], 4.09; 95% confidence interval [CI], 1.72-9.72).
“Quality improvement efforts focused on recognizing the association between disclosure and surgeons’ well-being may help sustain open disclosure policies,” write A. Rani Elwy, PhD, a health psychologist at the Veterans Affairs Boston Healthcare System and the Boston University School of Public Health in Massachusetts, and colleagues.
Using a 21-item web-based questionnaire administered to 67 of 75 surgeons in 12 specialties at three Veterans Affairs medical centers between 2011 and 2013, Dr Elwy and associates quantitatively assessed surgeons’ reports of disclosing actual adverse events and their experiences with the disclosure process.
The surgeons were asked to identify and discuss a case that required an unplanned return to the operating room or intervention within 30 days of the initial surgery. The surgical specialties included cardiac, general, gynecologic, neurology, ophthalmologic, orthopedic, otolaryngologic, plastic, podiatric, thoracic, urologic, and vascular. Surveys were completed by 21 female and 41 male surgeons
Dr Elwy and colleagues assessed respondents’ self-reports across eight recommended aspects of open disclosure, but most surgeons reported addressing just five items in conversations with patients. These comprised explaining why the event happened (92% of respondents), expressing regret (87%), voicing concern for the patient’s welfare (95%), disclosing the event within 24 hours (97%), and discussing steps taken to treat subsequent problems (98%).
As to the more difficult aspects of these conversations, only 55% of respondents reported apologizing to patients or discussing whether an event was preventable, and just 32% addressed how to prevent recurrences.
The researchers found that negative experiences of adverse events were more likely to be reported by the 55% who said they were less likely to discuss prevention, those who stated the event was very or extremely serious (66%), or those who reported very or somewhat difficult experiences discussing the event (26%).
Surgeons with more negative attitudes about disclosure at baseline reported more anxiety about patient’s surgical outcomes or events after disclosure (OR, 1.54; 95% CI, 1.16 – 2.06).
According to the authors, participating surgeons had not been trained in disclosure and would, therefore, be unlikely to consistently address all eight recommended items in their disclosures.
“Even in this self-selected group of surgeons who came forward and, I would argue, are more comfortable in having difficult conversations with patients, there were still some negative attitudes toward disclosure, as well as anxiety after the disclosure and the event,” Dr Elwy commented to Medscape Medical News. “I can only imagine it’s much worse for other surgeons.”
Negative Effects on Surgeons Not Uncommon
National guidelines call for full disclosure of adverse events or unanticipated outcomes, and this divulgence has been shown to benefit patients and families. Physician transparency toward patients has improved, and open disclosure programs are being implemented nationally. However, without training in the specific communication skills needed for these difficult conversations, surgeons may experience negative effects when disclosing adverse events, Dr Elwy and associated state.
Thirty-six of 60 respondents said an adverse event had affected them “moderately, quite a bit, or extremely,” but most did not report significant effects in job satisfaction, confidence, professional reputation, or sleep. Seventeen of 62 respondents reported being anxious about future outcomes.
In terms of positive attitudes, surgeons had more positive attitudes toward disclosure in a high-harm scenario (a retained surgical sponge, for example), where disclosure is mandated, than in a low-harm scenario (eg, blood loss; P < .001). No differences emerged in negative attitudes for either scenario (P = .32).
The authors note that surgeons themselves may categorize adverse events as low- vs high-harm. “However, if disclosure is deemed necessary by a hospital’s patient safety or risk management team, surgeons with more negative attitudes toward disclosure would find this communication more difficult, and, as in our study, might report greater anxiety about future outcomes or events as a result of having had this unwelcome conversation with patients,” they write.
Anxiety about these communications can adversely affect physician well-being, and improvement is called for. “By emphasizing the potential for surgeons being negatively affected after adverse events and disclosures, and recognizing the association between attitudes, perceived seriousness of events, surgeons’ experiences with disclosures, and training on how to include specific elements of disclosure in these difficult conversations, future quality improvement efforts may be able to help sustain the implementation of open disclosure programs nationwide while also ensuring a healthy surgeon workforce,” the authors write.
Dr Elwy added: “Health systems are making more progress in training physicians to be better communicators with their patients, but this study shows that even in a group that feels more comfortable with disclosure, there’s so much more to be done.”
She is also concerned about the health of the physician workforce. “These kinds of issues can lead to burnout, lack of resilience, and worse,” she said. “I want surgeons and physicians in general to be provided with the skills for rapid deployment of open, honest, and transparent communication with patients. I don’t want it to be something they fear.”
National efforts are underway to support physicians in this area. “The Disclosure Training Program, recently disseminated across 26 VA medical centers, would be a next step for training surgeons on how to discuss challenging issues such as preventability of adverse events,” the authors write. “Creating a culture of professionalism that allows for self-care following disclosures may also increase surgeons’ well-being, as has been done in other large health care systems.”