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Surgeons spend many years training and countless hours practicing to master their craft and deliver the best care to patients. Training and even early years in practice are a continuous cycle of reflection on performance and refinement of techniques. Not surprisingly, a surgeon's response to making a technical error or experiencing complications can be devastating. One surgeon admitted to nearly crashing into four parked cars when leaving the hospital parking garage after making an error.1 For many surgeons, one's career becomes a large part of one's identity. Because of this, technical errors often feel like not only professional failures but personal failures. One surgeon described feeling personally devalued after an error and not entitled to wear a white coat or scrubs.1 Many describe these events as causing not only acute effects but also long-term misery, with some even recounting that there is not a single day a past surgical error does not affect them.2 Despite the advances in modern medicine, the best quality control systems to prevent errors, and the brightest doctors and most talented surgeons providing care, there will always be fallibility in medicine.3 Reflecting on this imperfect system, surgeon and author Atul Gawande states, "No matter what measures are taken, doctors will sometimes falter, and it isn't reasonable to ask that we achieve perfection. What is reasonable is to ask that we never cease to aim for it."3 Studies have shown that surgeons experience even greater hardship after errors caused by a technical mistake.4 Although we know this fallibility exists, it is a concept starkly juxtaposed against a relentless pursuit of perfecting technical skills throughout surgical training and carries throughout the surgeon's professional career. This creates a perfect storm for emotional turmoil following errors and complications. A surgeon's ability to cope with errors, complications, and stress is essential, as the future of surgery depends on the health and well-being of those who perform it.5 "Coping" is defined as a dynamic process in which a person utilizes constantly changing cognitive and behavioral efforts to manage internal and external demands that are appraised as stressful or exceeding the resources of the person.6 It is a conscious, voluntary act and does not include unconscious or involuntary responses. When a person perceives a situation to be threatening or stressful, a flurry of negative emotion, including fear, shame, anxiety, or sadness, often follows. This is accompanied by one of three coping responses: emotion-focused coping, problem-focused coping, or avoidance coping (Fig. 1).6 Often, there will be a secondary appraisal of the threat or stressor after the initial response, and a secondary coping strategy may also be used.Fig. 1.: Model of stressor appraisal and coping strategies. Using the model described by Lazarus and Folkman (Lazarus RS, Folkman S. Stress, Appraisal, and Coping. New York: Springer; 1984), one appraises a situation to be threatening or stressful. This is often followed by an emotional response and evokes one of three coping responses: emotion-focused coping, problem-focused coping, or avoidance coping. Often, there will be a secondary appraisal of the threat or stressor after the initial response, and a secondary coping strategy may be used.Emotion-focused coping relies on emotional regulation and other mindfulness techniques to calm stress responses. This technique uses cognitive or behavioral actions to deal with the emotions arising from a situation. Examples include seeking social support; using mental imagery for reinterpretation or mental rehearsal, self-talk, and practice of self-forgiveness; deep breathing; and progressive muscle relaxation. Problem-focused coping refers to actively troubleshooting and problem-solving to counteract stressful stimuli in a specific context. This approach applies cognitive or behavioral demands to deal with the situation, rather than an emotional response to the situation. Examples include deconstructing the event, debriefing after an error, and implementing adaptive changes. Finally, avoidance coping physically or psychologically blocks out the source of stress. Examples include sleep, distraction, and alcohol or substance use. While avoidance coping techniques may help reduce distressing emotions in the short term, they have been found to be ineffective in the long term. Studies on surgeons have demonstrated the use of problem-focused coping techniques in dealing with errors and complications. Examples include deconstructing the incident; discussing with colleagues, both informally and through forums such as morbidity and mortality conferences; and implementing changes to practice patterns.4 These studies show that discussions with colleagues are typically more focused on technical aspects of the error and further management, but do not address the emotional impact of the error or complication.7 Surgeons report feeling ashamed of the emotional impact errors have on them, and also report a lack of effective means for emotional coping, given the limitations of what they can disclose to their family, unwillingness to discuss their emotions with colleagues, and inadequate institutional support.4,8 While there are select studies on surgeons' coping responses to errors, complications, and stress, coping has been well studied in elite-level athletes. Many professional and Olympic athletes have worked with sports psychologists to optimize their performance in high-pressure settings. Although athletics and surgery have many undeniable fundamental differences and stakes, parallels can be drawn between the extreme pressures of high-level performance and the ubiquitous expectation for excellence. The importance of emotion-focused coping has recently been in the spotlight after several world-class athletes forfeited competitions because of overwhelming mental health struggles and surmounting pressure. Olympic gymnast Simone Biles withdrew from several events in the 2020 Summer Olympics in Tokyo after extreme anxiety caused her to lose her sense of spatial recognition in air, a phenomenon known as the "twisties."9 Alpine skier Mikaela Shiffrin stumbled through the slaloms in the 2022 Winter Olympics in Beijing and skied off course, never to finish in any of her three of her events owing to crippling performance anxiety.10 With increasing focus on how even the most talented athletes can succumb to such pressures, tactics for emotional regulation to optimize performance hold increasing importance. Mental skills training is a well-studied area of performance psychology that is used by elite athletes and sports psychologists. Emotion-focused coping strategies that include various mindfulness techniques have been utilized to optimize performance under circumstances of extreme pressure. In the 2008 Summer Olympics in Beijing, swimmer Michael Phelps's goggles filled with water with 175 meters remaining in the 200-meter butterfly. He swam the race blind, yet his performance was flawless. He not only finished the race, but won the gold medal and set a new world record. Phelps credits his ability to remain calm to his training in imagery. Before every race, Phelps utilized imagery to visualize, feel, and experience the race in three ways: how it could go, how he wanted it to go, and how he did not want it to go. He explains that in preparing in this way he can be ready for whatever happens, as he has already rehearsed how many strokes it would take to get from wall to wall, when he would take breaths, and when he needed to reach for the wall.11 Imagery is a form of cognitive restructuring that helps one to reinterpret previous negative experiences and to mentally rehearse different steps of a technique or performance. Similar techniques utilizing imagery and mental rehearsal have been employed in military and law enforcement in preparation for high-stakes special operations. Self-talk, another form of emotion-focused coping, is dialogue with oneself that is either internal or spoken aloud, and can be either negative or positive. Basketball star Michael Jordan was an early adopter of mental skills training. Under the tutelage of mindfulness expert George Mumford, Jordan adopted the practice of positive self-talk to enhance his athletic performance under stress. The practice of self-forgiveness is another form of self-talk that can be applied as a means of emotion-focused coping after failure, which has also been well studied in sports psychology.12–14 Self-forgiveness following failure is defined as an adaptive form of coping in which an individual acknowledges appropriate responsibility for the outcome (lack of concentration, rushing through steps, and so on), affirms the self, and reconciles negative emotional experiences associated with the outcome (eg, guilt, shame, and anxiety).13 This has been shown to be an effective way to overcome the cycle of rumination and self-condemnation, and may be applicable for surgeons coping with errors and complications. Deep breathing and progressive muscle relaxation are other emotion-focused coping techniques aimed at slowing the sympathetic nervous system response. "Tactical breathing" is a deep-breathing technique employed by Navy SEALs to promote a calm and focused mind while under stress.15 This technique involves a 4-second inhale and 6-second exhale, focusing on breathing in and out of the abdomen instead of the chest. The science behind this technique is to trigger the parasympathetic nervous system, slow the heart rate, and dampen the sympathetic nervous system response. Progressive muscle relaxation is another tool that can be used to reduce the physical manifestations of stress and anxiety, including muscle tension and body aches. This is done by systematically tensing and releasing targeted muscle groups by contracting the muscles tightly while inhaling and, after 5 seconds, relaxing the muscles while exhaling. This should be done three times total for each muscle group and can be used for targeted muscle groups or from head to toe.16 Problem-focused coping, on the other hand, emphasizes techniques that directly address the demand, not just the emotional response it evokes. Deconstructing an event is one commonly used problem-focused coping strategy that utilizes a systematic review of the event. This can include formal methods, such as root-cause analysis models, or less formal methods, such as discussing details of the event with trusted confidants, advisors, or colleagues. These methods can help identify how an event occurred and what could have been done differently. Elite athletes apply similar concepts in watching game film. In The Mamba Mentality: How I Play, basketball star Kobe Bryant says that he would not only watch film of his opponents to learn how they play and how to beat them, but he would also watch himself to identify his weaknesses and develop strategies to improve.17 Debriefing after an error is another commonly used problem-focused coping strategy. Debriefing should happen immediately after the event to evaluate what happened and what could be improved, and to set goals for better future performance. In the military, there are several different types of debriefing, including operational debriefing and critical incident stress debriefing. In these types, emphasis is placed on promoting the well-being of the individuals involved and, based on the debriefing, staging other interventions to prevent adverse effects to personnel as needed. Ultimately, debriefing and deconstructing events can often help implement adaptive changes at an individual or organizational level. Numerous studies have shown that physicians do not feel adequately supported after errors or complications.1,4,8 Although every surgeon will experience errors and complications, they are discussed infrequently, which amplifies feelings of isolation and lack of support. Therefore, for surgeons dealing with emotional turmoil after a surgical error, this culture inaccurately fosters a sense that the feelings a surgeon is experiencing are unique. Normalizing the emotional response after errors and complications is the first step in the healing process. In recent years, increasing numbers of athletes have disclosed their mental struggles related to both their sport and personal life. Among these are some of the most decorated athletes in the world, including Phelps, Biles, and tennis champion Naomi Osaka. By virtue of these athletes sharing their struggles publicly, others experiencing similar challenges are able to understand that they are not alone and that there is support. Similar concepts can be applied to the field of surgery, to normalize the emotional impact that a highly demanding surgical career can have on individuals and create a feeling of community, support, and understanding that such feelings are not unique. Coping is not a technique reserved for the weak, the sensitive, or what some refer to as the "new culture" of surgery. It is a critical skill that surgeons must develop to persevere and sustain their demanding pursuits.5 Surgeons report that programs that offer formal mental skills training would be beneficial to improving their practice.18 Providing access to optional mental skills training through confidential telehealth services can help increase the support available to surgeons. In addition, implementing employee assistance programs to support surgeons after adverse events increases the perceived sense of institutional support. The United States has optimized so many aspects of medicine, yet the health care system is seemingly behind in providing necessary resources and support for medical personnel when they may need it most. These programs include support for debriefing after the event; guidance on how to disclose and discuss errors and complications with patients and their families; and resources for dealing with the emotional impact of an adverse event, including access to confidential counseling services. Increasing support and resources for physicians is critical to the health and well-being of surgeons and, therefore, the future of surgery. DISCLOSURE Dr. Chung receives funding from the National Institutes of Health, book royalties from Wolters Kluwer and Elsevier, and a research grant from Sonex to study carpal tunnel outcomes. Dr. Luby has no financial interests to report. No funding was received for this work. ACKNOWLEDGMENTS The authors would like to thank Meghan Cichocki, for her contributions to the development of this writing; and Mike Stokes, staff vice-president of communications at the American Society of Plastic Surgeons, for peer review and manuscript editing.
Luby et al. (Mon,) studied this question.