Introduction

Surgical training and practice consist of confronting, treating, and responding to surgical complications. The complications faced by surgeons may impact current and future attitudes and decision-making.¹ Physicians report decreased quality of life, increased symptoms of burnout, and higher rates of depression within 3 months of experiencing a complication. Active support and education around this topic should be emphasized to combat these inevitable issues better. However, less attention is given to preparing surgical residents to cope mentally and emotionally with such issues.²

This study aimed to assess urology residents’ responses to complications, how they deal with these complications, and future directions on how better to prepare residents for their future as an attending surgeon.

Methods

After Institutional Review Board approval was obtained, we performed a cross-sectional, survey-based study that was distributed to urology residents within the US. An electronic survey of 15 questions regarding surgical complications was distributed via email to program managers and program directors. Demographic information was obtained including year of postgraduate training, age, gender, and ethnic group. Respondents were compared by level of training, where postgraduate years (PGYs) 1 through 3 were considered “junior residents,” and residents and fellows beyond year 3 were considered “senior residents.”

Additional questions ascertained trainees’ experience with complications by number, response to the complication, and the availability of institutional support for coping with complications. Participants were asked about the psychological and emotional effects of stress and if sleep played a role in their response.

Results

A total of 107 residents completed the survey, of whom 41 were classified as junior residents (PGY 1-3) and 66 as senior residents (PGY 4-5). The average age was 30.9 years. There were 67 male and 40 female respondents. Most trainees were White (78%) or Asian (15%), while 1% were Black/African American and 6% were “other.”

Of the different coping mechanisms, “discussion of the case among peers” was the main coping mechanism reported by respondents (98.1%). Over one-quarter (26.4%) of trainees used alcohol to cope with their surgical complications.

Surgical complications affected trainees by causing performance anxiety (70%), loss of confidence (70.7%), and excessive thoughts regarding the complication (70%). Most residents expressed some emotional response to complications, including feelings of anxiety/fear (72%), sadness/grief/depression (68%), and feelings of being overwhelmed, helpless, or hopeless (51.5%). Nearly 60% of respondents lost at least some sleep over their complication with 15% losing sleep “always” or “most of the time” following a complication.

Subgroup analysis was performed to compare the responses of junior residents to senior residents. Of note, senior residents were more likely to cope by discussing complications with faculty (86% vs 73%, P = .048; Figure 1, A). Similarly, senior residents may be more likely to use alcohol to cope with a complication (18%) vs junior residents (10%; Figure 1, A).

In the other subgroup analysis, when comparing male and female residents, there was no significant difference in the number of complications experienced (P = .677) and no significant age difference (P = .847). Female residents were less likely to use alcohol (9%) compared to the male residents (19%) as a coping mechanism (Figure 1, B). No differences were identified in the emotional response to a complication (Figure 2). Female residents rated the support of their coresidents more highly compared to their male cohorts (P = .014; Table 1). Female residents are more likely to avoid a procedure in the future following a complication (56.8% vs 37.3%, P = .044). Female residents were more likely to lose sleep than male residents (P = .020; Table 2).

Table 1. Perceived Resident Support System Following a Complication Based on Gender Identification of the Resident

Table 2. Resident Responses to Complications Based on Gender Identification of the Resident

Discussion

Urology residents reported that discussion among peers (98.1%) and discussion with attending faculty (83.0%) were the primary coping mechanisms when experiencing complications. More maladaptive mechanisms, including substance use, such as alcohol, are also commonly reported in the literature and in this study.³ Le et al reported a recent 10% increase in alcohol and substance use with surgeons involved in complications.⁴ In our study, over one-quarter (26.4%) of participants reported using alcohol to cope with complications. As we move forward with studying topics on complication management, it is incumbent to provide residents with the awareness of healthy ways to cope with undesired outcomes.

In this study, surgical complications affected trainees by causing performance anxiety (70%), loss of confidence (70.7%), and excessive thoughts regarding the complication (70%). Most respondents expressed some negative responses, including feelings of anxiety/fear (72%), sadness/grief/depression (68%), and feelings of being overwhelmed, helpless, or hopeless (51.5%). Nearly 60% of respondents lost at least some sleep over their complication, with 15% losing sleep “always” or “most of the time” following a complication. Female residents were more likely to lose sleep than male residents (P = .020). It is important to continually discuss the impact that sleep deprivation has on patient outcomes.⁵ Female residents are more likely to avoid a procedure during residency following a complication (56.8% vs 37.3%, P = .044). Recognizing the emotional and intellectual responses that residents feel after dealing with a complication can aid in building support systems for residents.²

While this is the first survey to our knowledge reporting urology resident experiences with complications, it has limitations worth noting. Although we obtained over 100 responses, our response rate was low, limiting our ability to generalize our results. A survey-based approach to the study may introduce a recall bias for the responders. Despite the limitations, residents are clearly impacted by surgical complications; further research in how to minimize negative consequences while enabling residents to learn from complications is key.

Conclusion

Our study aimed to assess how urology residents responded to surgical complications through a 15-question survey. Complications led to performance anxiety, loss of confidence, and excessive thoughts of the complication. These are coupled with feelings of anxiety/fear, sadness/grief/depression, and hopelessness. Of particular concern, residents often suffer from a loss of sleep when dealing with complications, and those included in our study often turned to alcohol use as a coping mechanism. Female residents are more likely than male residents to avoid a future surgery associated with the complication experienced. As the medical field continues to evolve and become more complex, additional research into optimized resources for surgical residents affected by complications is warranted.

Funding/Support: None.

Conflict of Interest Disclosures: The Authors have no conflicts of interest to disclose.

Ethics Approval: This study was approved by Wayne State Institutional Review Board 21-05-3607.