How do surgeons deal with failure

Being a doctor: The doctor's fear

It is better not to confide in a doctor who never doubts his own abilities and is not afraid of failing in his job.

Fear is a basic emotion and is important for survival in the service of averting danger. Fear also has a regulative and protective function in an interpersonal context. To the extent that one takes responsibility for other people and cares for others, fears of mistakes or one's own failure are usually aroused. In the medical profession, one could speak of work-related fears, which medical art and modern technology can perhaps reduce, but which can never be completely calmed down. These fears are often suppressed, only rarely reflected on and even more rarely communicated openly with colleagues.

It is better not to confide in a doctor who never doubts his own abilities and who knows no fear of failing in his profession. The danger is too great that blind optimism and confidence will hide the possibility of failure of the medical treatment. The fact that treatment errors can occur or unexpected complications can arise should not only be taken into account when informing the patient for legal reasons, but also an important consideration in the context of a responsible risk-benefit assessment.

Fear as a constant companion

The doctor's job-related fear has nothing to do with neurotic or existential fears. It is also not a question of overvalue fears in the sense of phobic fears that would be inappropriate to the situation. From an organizational psychological point of view, one speaks of a "primary risk" associated with certain work processes. Every doctor is exposed to this risk and must learn to deal with it. The doctor's fear is an indicator of the extent to which the risks inherent in the profession are consciously perceived and how they are dealt with professionally. On closer inspection, the doctor's job-related fears are complex. It is not just about the fear of malpractice, but also the fear of personal failure that accompanies every medical activity from the start.

Constant challenge

As soon as a young assistant doctor has started his first job, well-known but untried achievements are expected. The informational talk about an operation already turns into a walk through unknown terrain, like the first independent visit, later smaller invasive measures, such as joint or CSF punctures. The required technical skills, including the decisions to be made independently, are becoming more and more difficult. New challenges have to be mastered; Despite inexperience, sometimes even ignorance, qualified treatment should be provided. The routine of frequently repeated performances is broken by ever new challenges. Will there ever be an equilibrium so that failure is no longer a threat? With some people this fear never gives way, neurotically it sticks to self-reproach that it is not enough.

Everyone is afraid of making mistakes, not just doctors. But the expectations of medical success are more extensive, because health must not be lost. The chief physician must not tolerate the inadmissible error, and the senior physician and the assistant doctor will also feel this. There seems to be a job-specific fear of failing as a doctor. Perhaps this particular fear also has something to do with the claim of medicine to achieve health, a high standard and sometimes a task that is bound to fail. Even a doctor makes mistakes. He can't be perfect. Admitting and recognizing this helps more than the vain struggle for flawlessness.

Fear of ethical offense - The medical world of work has changed. Economists not only have their say, successful business has become a priority. Economic resources were assumed a good 20 years ago; This was followed by a changed accounting system for hospitals, case numbers and case mix indices; Patients are operationalized, categorized, target agreements are concluded with service providers. The semantics alone are not medical. In this economic context, the doctor becomes a service provider and the patient becomes a customer. The role of doctor and patient is changing.

This economization of medical work harbors the risk of violating medical ethos. The possible guilt in every contact with patients in the outpatient clinic or on the ward is unbearable in the long run. Only being a service provider for the managing director and the hospital operator leads a long way away from the conviction that we are on the patient's side against the disease. The medical conscience comes in. The doctor is afraid of his conscience, the knowledge of the calling to turn to the patient. Cynicism can follow fear. But this fear also remains a driving force to defend oneself against the economic doctrine.

Fear of devaluation - If randomized studies show that some medical measures are no better than a sham measure, there is usually an outcry of indignation from the medical community. After all, what would a doctor be who acted through appearances? A placebo! Then all that studying, learning, and practicing would have been unnecessary, even nonsensical. All the drudgery for nothing. Sisyphus in a doctor's smock. The outcry of indignation is aimed at warding off the fear that the doctor will not be effective through knowledge and technical skill, but that the desire or the will to recover can play a decisive role. In order for the placebo effect to be effective, however, a medical catalyst is required.

Fear of illness and expectations of salvation - the patient's demand for help and healing must first be withstood by the doctor. The patient's fear of losing their functions, their performance and then their lives is not addressed, but only hinted at, more or less transformed, perhaps somatized, in expectations, in desires, in pressure in the doctor-patient relationship. Doctors can capitulate to this and turn away: “Find another doctor, I cannot help you.” By breaking off the relationship, you would have fled the fear of not being able to withstand the patient. You can also build up counter pressure to suppress the fear of failure through your own urgent action, would punish the patient's fear and demands in aggressive countertransference with excessive therapies. Only the experienced and trained doctor can look into the patient's fear and offer him support.

To perceive the patient means to perceive the patient's fear without being afraid of it. At least knowing this fear as a doctor. And not to admit counteraphobically that everything is under control and can be controlled.

The fear of illness also affects every doctor. Doctors are paradigmatically instructed in studies and further education in the requirement to do everything to prolong life and improve the quality of life, to do research. Knowing about one's own vulnerability and frailty can calm the therapeutic relationship between transference and countertransference.

Fear of their own powerlessness as a doctor - In the illness of his patients, the doctor not only encounters the fear of his own illness, but also the knowledge that although he encounters the patient in his illness, he can generally stay away from his illness. He has to carry ulcers, pus and odors, but he can close the door behind the patient and leave the patient alone. He will keep asking himself, “Why him, why not me.” There is a similar fear of guilt that survivors of a disaster feel, of the guilt of survival. The distance that the doctor can build, has to build in order to be able to go on living himself, will lead to the question of guilt.

It would be good if the doctor was aware of this constant fear between guilt and powerlessness. So that he doesn't just have to act in defense. Or get addicted. It is well known that doctors - also because of the simplified access - are particularly threatened by alcohol and drug addiction. But: “Feelings of guilt and shame also have a positive side. Although they have negative connotations for the person concerned, they are proof that the person has a high level of responsibility. ”* There is something purifying about them. And: between guilt and powerlessness, compassion provides the appropriate closeness in the relationship.

Prof. Dr. med. Marcus Schiltenwolf

Department of Orthopedics and Trauma Surgery

Heidelberg University Hospital,

[email protected]

Prof. Dr. med. Martin Sack

Clinic for Psychosomatic Medicine and Psychotherapy, Klinikum rechts der Isar, Technical University of Munich, [email protected]

* Rosentreter M: The personal handling of mistakes in the hospital - aspects of social perception and patient safety. In: Kurt W. Schmidt et al. (Ed.): On dealing with malpractice. Proceedings of the ELSA exam week 2012. Berlin: Lit-Verlag 2012: 113.