“You Remember Those Days”—A Qualitative Study of Resident Surgeon Responses to Complications and Deaths

Abstract

OBJECTIVE:

Postoperative complications and deaths are unavoidable aspects of a surgical career, but little is known about the impacts of these unwanted outcomes on resident surgeons. The goal of this study was to characterize the impact of complications and deaths on surgery residents in order to facilitate development of improved support systems.

DESIGN:

This qualitative study was designed to explore resident surgeons’ experiences with unwanted outcomes, including postoperative complications and death. Semi-structured interviews explored a range of topics related to personal experiences with unwanted outcomes. Analyses of interview transcripts were performed iteratively and informed by thematic analysis.

SETTING:

An anthropologist at the University of Michigan conducted interviews with general surgery residents from academic, community, and hybrid training programs across the country.

PARTICIPANTS:

Twenty-eight mid-level and senior residents (PGY3 and above) were recruited for participation from 14 different training programs across the United States.

RESULTS:

Resident surgeons described an initial period of emotional response, characterized by feelings of sadness, frustration, or grief. Simultaneously or soon afterward, interviewees described a period of intellectual response aimed at understanding how and why an outcome occurred, with the expressed goal of learning from it. Many residents described impacts to their personal lives. Several factors that influenced the duration and intensity of these responses were identified, including a sense of ownership, which was a powerful driver for improvement.

CONCLUSIONS:

This qualitative study provides a nuanced description of resident surgeons’ responses to unwanted outcomes. While emotional responses were characterized by strong feelings, such as sadness and grief, intellectual responses were focused on learning from the events. These data may help inform the development of structured support systems by residency programs.

STRUCTURED ABSTRACT:

Facing post-operative complications and deaths is an unavoidable aspect of surgical training, but the impacts on surgery residents has not been well characterized. Through semi-structured interviews with general surgery residents from programs across the United States, this qualitative study explored the ways that residents respond to unwanted outcomes. Residents described an initial period of emotional response, characterized by strong feelings, often of sadness or grief. There was a subsequent or concomitant period of intellectual response, in which residents examined how and why this outcome occurred, with the goal of learning from it. A feeling of ownership was strengthened by involvement in patient care and length of rotation. In light of this detailed description of resident experiences, residency programs can foster the development of improved support for trainees as they navigate these profoundly impactful events.

INTRODUCTION

Postoperative complications and deaths are unavoidable aspects of a surgical career. Their ubiquity and inevitability are best exemplified by the attention devoted to them in every surgery department’s Morbidity & Mortality Conference.^1-4 At teaching hospitals, resident surgeons are taught to openly discuss their complications in order to learn from them and decrease their incidence. However, the impact of unwanted outcomes on residents has not been well characterized, which may have important implications for overall well-being.

Resident physician well-being has been a growing focus of modern training programs alongside the Accreditation Council for Graduate Medical Education’s (ACGME) mandate that all residency programs address resident physician well-being directly and comprehensively.⁵ There is laudable effort to support residents’ emotional and psychological health, yet there has been very little scholarly work investigating the psychosocial effects of postoperative complications and deaths. The existing research primarily focuses on the impacts of medical errors,^6-15 which are distinctly different in character and much less common than unwanted outcomes among surgical patients. Further, prior work is not specific to resident surgeons⁷ and therefore inherently fails to address the uniquely intimate relationship that a surgeon has with a patient on whom they have operated.¹⁶

In this context, we sought to explore the impact of unwanted outcomes on resident surgeons. We designed a qualitative study of surgery residents across the United States and inquired about unwanted outcomes and their impacts. This report provides much-needed insight into how complications and death may lead to undesired and underappreciated consequences among surgical trainees, and is an important first step to develop improved support systems that are tailored to both the individual and institution.

METHODS

Study Design

This qualitative study was designed to explore resident surgeons’ experiences with unwanted outcomes, including postoperative complications and death. The findings in this report focus on the portion of the interview regarding responses to and impacts of the unwanted outcomes. To increase validity, we selected a research team representing diverse professional fields (anthropology, public health, and surgery).^17,18 We also conducted a form of member checking in which a group of resident surgeons reviewed the authors’ results and provided input related to the generalizability of the experiences discussed.^17,18 This study was deemed exempt from full review by the University of Michigan Institutional Review Board (HUM00157651).

Interview Participants

Convenience and snowball sampling were used to recruit 28 participants by email from 14 surgical residency programs across the United States (Fig. 1). These programs were selected by the senior author, based on personal relationships with surgeons at these sites. Participants were mid-level or senior residents, defined as having completed more than two years of clinical training, and were included in this analysis given their increased experience directly managing and operating on patients. Participants were diverse with respect to age, gender identity, and practice setting (Table 1). Participants received a $50 gift card in exchange for their participation.

FIGURE 1.

Geographic distribution of participating training programs.

TABLE 1.

Participant Demographics

	n	%
Gender
Male	15	54%
Female	13	46%
Self-Identified Race and Ethnicity
White / Non-Latinx	22	79%
Asian	5	18%
Indo-Caribbean	1	4%
Age
30-34	23	82%
35-39	4	14%
40-44	1	4%
Training Setting
Academic	16	57%
Community	8	29%
Hybrid	4	14%
ICU Practice Model
Closed	16	57%
Open	2	7%
Closed and Open Units	7	11%
Mixed Model	3	25%
Training Time Spent in ICU (months)
3 months or fewer	7	25%
4-6 months	13	46%
Greater than 6 months	8	29%
Frequency of Operative Responsibilities (days/week)
3 or fewer days	3	11%
4 days	9	32%
5 days	7	25%
6 or more days	5	18%
Varies across Rotation	4	14%

Interview Procedures

Individual interviews were conducted either in person or over the phone between December 2019 and April 2020 by an anthropologist (CAV) with extensive experience in qualitative interviewing. All participants provided verbal consent. An interview topic guide was developed by three members of the research team (MCB, CAV, and PAS) and explored experiences involving an unwanted outcome, including but not limited to post-operative complication and death as well as emotional responses and coping strategies following these events (Appendix 1).

Interviews lasted 30 to 60 minutes and were digitally recorded, deidentified, and subsequently transcribed to facilitate analysis. Observations about each interview (i.e., field notes) were documented. Interviews continued until data saturation was reached, which was determined when new themes emerged infrequently and the code definitions remained stable.¹⁷ Transcripts were not returned to participants for review.

Analysis

Analyses of transcripts were performed iteratively and informed by thematic analysis.¹⁹ Two members of the research team (MCB and CAV) independently read the first half of transcripts to identify an initial set of codes. The team (MCB, CAV, and PAS) then met to discuss codes and define a codebook, organized into overarching domains. This report focuses on themes within the domain, “Responses to Complications.” Two members of the research team (MCB and CAV) independently coded all transcripts using MAXQDA (version 18.2.3, VERBI Software, Berlin, Germany), to assist with organization and management of the data. Regular meetings were held to discuss discrepancies. The codebook was modified or expanded as needed during these consensus meetings.

RESULTS

Following an unwanted outcome, such as a postoperative complication or death, residents described emotional responses, characterized by strong feelings, and intellectual responses, which helped them learn from the event. Many residents experienced personal consequences, as their responses to unwanted outcomes affected their lives outside of the hospital. Residents identified multiple factors influencing responses, which affected the duration and intensity of these effects. Themes and illustrative quotes are displayed in Tables 2 through 5. Figure 2 offers a visual aid of our proposed conceptual framework.

TABLE 2.

Emotional Responses

"Fortunately, nothing was wrong, but I had a tremendous amount of guilt. I remember leaving the hospital that day in tears." (ID33)

"So it was really difficult because I felt a sense of guilt or inadequacy that I hadn't properly conveyed the urgency of the matter to the patient and the family … I felt very guilty that I hadn't done a good enough job of kind of relaying the urgency of the situation." (ID24)

"And then there’s this like stage where like you feel just terrible, and you feel like culpable, and there’s this tremendous guilt that comes with it and like maybe a little bit of depression that comes with it." (ID16)

"I felt regret, I think, mostly and just wishing I could have another chance to do it again so I could do things differently … Felt a lot of remorse." (ID10)

"I feel like there’s like stages of grief for complications." (ID16)

"But then I don't think anyone can have a death without feeling a little bit of loss, maybe not as much, I think, as losing a family member, but there is still some loss of you know the person, you see them more than probably anyone else that sees them over the weeks leading up to it, so those kinds of things, I think." (ID31)

"And then postoperatively, I, when the patient expired, I felt overwhelmingly sad. I mean, I cried with the family. I cried at home. I was, definitely had a sense of grief." (ID24)

"So as far as the immediate grief, you know, maybe a few days, you know, up to a week or so, but I don't think you ever truly forget it … I think there's a piece, you know, there's a bit of it that always f-, sticks with you and that you don't, you don't forget about." (ID9)

"Whenever I have complications, I take a step away, I try my best to make sure I mourn the situation, because I’m a human, and I want to make sure that the person that ought to be mourned is appropriately mourned.” (ID8)

"But, yeah, I usually just kind of brood about it for a while." (ID4)

"You feel really bad, and I still think about it sometimes. Yeah, you know, not every day, and it’s not like I’m haunted by this, but do I certainly feel terrible about that? Yeah, I really do." (ID1)

"It really feels like every day you come see them, you’ve failed them in some way, because their loved one is still in the ICU, still in the hospital, doing worse. That’s very challenging to deal with every day." (ID2)

"Yeah, I worry. I worry a lot. … But overall, emotionally, I think, I mean, it does weigh heavily on you." (ID28)

FIGURE 2.

Conceptual model of findings: following unwanted patient outcomes, surgical trainees experience emotional and intellectual responses, which are influenced by external and personal factors.

Emotional Responses

Following unwanted outcomes, residents described a range of emotional responses such as sadness, stress, frustration, self-doubt, mourning, regret, fear, and powerlessness (Table 2). One resident summarized her response to a patient’s death and indicated that she felt “major sadness, major anxiety” (ID4).

When describing these emotional responses, participants often reflected on their desire to improve the patient’s condition and the tension that existed when they were unable to achieve this. As one resident explained, “I think it’s sad, but I think overwhelmingly… I guess it makes you feel powerless” (ID2). Others described their sadness as an expression of empathy for the patient. Residents acknowledged the impact of the experience from the perspective of the patient and family. As one resident stated, “How did I feel about it? I mean, I felt bad for the patient” (ID30).

Intellectual Responses

Residents described an intellectual response, during which they analyzed how and why the event occurred. For some residents, the intellectual response occurred in parallel with the emotional response, but others described sequential responses, “after that like stage of just kind of feeling bad and like feeling like really culpable, you usually pick yourself up, and you go talk to somebody who like knows more than you do” (ID16).

What Went Wrong

Intellectual responses were characterized by focused reflection aimed at identifying factors that contributed to the unwanted outcome, often with the expressed goal of learning from the experience. This process rarely centered on blame or accusations of wrongdoing; rather, interviewees consistently described an analytic process of trying to determine what went wrong in order to avoid similar outcomes in the future. Some residents explained that they considered things that were initially missed because of a knowledge gap:

“The first thing is always, what could you have done differently and were there any risk factors or signs that you missed? … And then if there is something that you think you could’ve done differently, you kind of look into that, read into it more and think if that’s, what you should do for next time” (ID18).

Clinical Decision Making

Other residents focused on the process of clinical decision making, reviewing the reasons behind each step of care. In this way, they hypothetically reenacted how different outcomes may have resulted from different decisions, with a specific focus on evidence that may have led to a different decision initially. Some interviewees discussed care decisions as the result of a clinical team or shared between the resident and attending surgeon, rather than one individual.

Commitment to Improvement

The intellectual response was characterized by a clear commitment to improvement that required residents to identify areas that would help them to avoid similar outcomes in the future. Occasionally, residents were unable to identify anything they could have done differently, and this was described as “the frustrating part” (ID28), accompanied by a sense of dissatisfaction.

Some residents described an obligation to learn from an unwanted outcome as a moral imperative in order to improve care for future patients. “If you don’t learn from that,” one resident said, “you’re not only failing the patient you’re taking care of now, but all the ones that come after that” (ID16).

Personal Consequences of Unwanted Outcomes

Many residents discussed personal consequences that impacted their lives outside the hospital as they grappled with unwanted outcomes. Residents commonly described themselves as less communicative or more withdrawn, which had negative impacts on their loved ones. One resident described the way that her grief detracted from her ability to fulfill her family roles, “You certainly can’t be as good of a mom or spouse when you’re sad” (ID24).

Other residents, however, believed they effectively compartmentalized their responses in a way that does not impact their personal lives, as one stated, “I tend to try to keep a pretty good work life and personal life separation now. I try not to let the work come home with me as much” (ID22).

A few residents first described no impact to their personal lives, then proceeded to describe a concrete negative effect on their home life, then reiterated that there was no impact on their personal life. For example, “Not that I’ve noticed. I mean, I think I definitely come home, you know, sad and will be upset, and, you know, may cry openly or something, but so far, I haven’t seen a direct effect like with family life or anything” (ID9).

Factors Influencing Responses

Residents discussed a number of factors that influenced their emotional and intellectual responses. These included both internal and external factors that impacted the experience of unwanted outcomes.

Ownership

Residents frequently discussed a feeling of ownership over patient care and the development of an unwanted outcome. The strength of the feeling of ownership was often directly related to the perceived amount of involvement in the patient’s care, with a particular focus on the act of operating on a patient. As such, the ability to feel ownership increased over the course of residency, as residents assumed a more active role in both operating and clinical management.

There was a complex and inconsistent relationship between ownership and self-blame. Some residents expressed a strong feeling of ownership and investment in patient outcomes that was devoid of guilt or self-doubt while others connected their feeling of ownership to a feeling of self-blame, as if the unwanted outcome was their fault.

When residents expressed a feeling of responsibility, they often connected it to a strong commitment to learn from the event in order to avoid similar outcomes in the future. As one resident explained, “that sense of personal responsibility leads to a lot of self-reflection in that thinking back through the actual case, try and figure out how you could do things better and different in the future” (ID7).

Rotation structure impacted the feeling of ownership through effects on continuity of care. Resident surgeons who switched hospitals frequently and had shorter rotations on each service expressed a diminished sense of ownership. One resident explained that it felt “easier to remove yourself” from a patient’s outcome, “because you’ll operate on someone, and then you’ll switch hospitals the next week” (ID21). In contrast, longer rotations (e.g., two consecutive months) cultivated a deeper feeling of investment because the resident saw the patient through their postoperative course, often including readmissions for complications. As one resident summarized, “You get the bigger picture, and also you feel it more personally, because you’re trying to move their care forwards” (ID2).

Contextual Factors

There was wide variety in the patient vignettes that residents described when asked about their experiences with unwanted outcomes. While some residents described patients who had suffered trauma, including a large burn and lightning strike, many residents described complications that followed elective operations. Few residents described palliative operations that aimed to improve quality of life in terminally ill patients but instead hastened its end. Some residents described patients on whom they did not operate, but the outcome left a lasting impression. One such case involved a consult patient who deteriorated and passed away after the resident “signed off” during an initial period of improvement (ID16).

Residents described strong responses to both expected and unexpected outcomes. Furthermore, the sense of surprise and the sense of inevitability were both identified as factors affecting the strength of responses. While one resident cited the unanticipated nature of the event as a contributing factor to her emotional response, stating, “It was very difficult, very emotional… because it was such an unexpected outcome” (ID9), another resident explained that the expected nature of a complication does not dampen the emotional effect, “It was a known complication with the procedure and, but that doesn’t make you feel kind of any better in the moment” (ID26).

Personal Factors

For some residents, personal connections to patients and families resulted in emotional responses that were longer in duration and stronger in intensity. For example, one resident explained that her personal relationship with a patient’s family led to a prolonged period of intense grief, “I had gotten to know his family somewhat as well, and so his death was exceptionally sad, and I definitely grieved for him and his family for probably a, you know, at least a couple of weeks” (ID24).

For many residents, the length of time they cared for a patient impacted the intensity and duration of their responses to unwanted outcomes; many residents described a strong sense of grief in those cases. Others described a sense of emotional investment resulting from extensive involvement in the index operation, including decision to operate, often leading to stronger, longer responses.

External Factors

External factors were also found to impact the duration and intensity of responses. These factors included the need to operate with the attending surgeon associated with the unwanted outcome, the frequency with which the resident was required to see the patient with the unwanted outcome, or the requirement to perform the same type of operation that had just led to an unwanted outcome.

One resident described the act of rounding on a patient as a recurrent reminder that prolonged his emotional and intellectual responses, “it can be a little difficult to keep it out of your mind, because every morning and every evening when you see them, you’re reminded of it, day in and day out” (ID2). Once he stopped seeing the patient, he went on to explain, his strong emotional response ended.

Notably, resident participants did not cite inter-professional communication, systems-based challenges, or associated health policy as factors that influenced their responses to unwanted outcomes.

DISCUSSION

Postoperative complications and deaths profoundly impact resident surgeons. This report offers a detailed description of resident responses following these unwanted outcomes. Residents described emotional responses, characterized by strong feelings, as well as intellectual responses, characterized by a detailed review to understand how and why an event occurred. Underlying both types of response was a strong sense of ownership, which served as an important, and perhaps central, stimulus for improvement. Here we provide a deeper and more nuanced understanding of the surgical resident experience. These data present unique and important opportunities to guide resident surgeons through these events in such a way that promotes emotional well-being in addition to expanding surgical knowledge.

Currently, there is no proven gold standard treatment to decrease resident surgeon stress ²⁰or burnout, ^21,22 and the surgical care we provide can result in emotional stress that lasts for weeks or months following the index event,^23,24 leading some surgeons to become “second victims”,^14,25 suffering from a personal psychological wound. The period following complications and deaths has previously been characterized as one of enhanced vulnerability,⁸ and there is some evidence that coping skills may become harder to develop as surgeons progress through their careers.²⁶ The detailed accounts of resident surgeons provided here should serve as an important call to action for training programs to foster meaningful support for their residents following these impactful events.

During the period of emotional response, residents may benefit from structured peer support or frequent check-ins from their mentors. This may also be an important time to provide time and space for residents to engage coping skills of their choosing, which is often made difficult by long work hours. It is equally important that training programs offer support during the phase of intellectual response; this may be an opportunity to provide protected time for residents to review clinical details of the case one-on-one with a more experienced surgeon, who can aid in the identification of “what went wrong,” and guide residents through the steps that they currently navigate alone. While ownership was an important mediator of resident response to unwanted outcomes, we uncovered important nuance—for some residents, the feeling of ownership was inextricably tied to guilt and self-blame. The reasons for this are likely related to individual factors and remain unclear, but it is possible that with closely guided coaching from mentors during the period of intellectual response, these residents may be able to reframe their narrative toward ownership devoid of self-blame.

Finally, our data suggest that longer rotations lead to an increased sense of ownership, which in turn drives self-examination and self-improvement. In an effort to cultivate reflective and self-driven surgeons, programs may consider adopting two-month rotations for senior residents, as the increased exposure to continuity of care seems to bring invaluable learning opportunities.

This study differs from prior work examining the effects of error. More than forty years ago, Forgive and Remember provided an ethnographic description of surgical training through the eyes of sociologist Charles Bosk.²⁷ This seminal work became well known for its schema of error, certain types of which were posited to reflect deep character flaws and a personal failing to execute one’s duties as a surgeon. More recent qualitative work exploring how practicing surgeons respond to errors proposed a distinct phase in which surgeons review the steps of the patient’s care in order to find a reason that the error was not their fault.^11,12 Our work suggests instead that at least some resident surgeons review the steps of care not to indemnify themselves or to absolve themselves of blame, but rather to identify areas from which they can learn. This important difference in focus (culpability versus learning opportunity) between practicing surgeons in previous studies and resident surgeons in the current study may reflect an evolving culture of surgery.

We acknowledge several limitations to this study that may limit generalizability. We employed convenience sampling as opposed to purposeful sampling because our study population (general surgery residents) are not readily available or accessible, and we did not wish to place undue burden on participants. Convenience sampling provides a wide range of experiences, with opportunity in future studies to address specific populations. Our study population lacks racial and ethnic diversity; although our study sample mirrors current surgical trainees across the U.S., with the exception that white non-Hispanic individuals are slightly over-represented and Hispanic residents are under-represented,²⁸ we recognize that further work is needed to characterize these experiences among underrepresented minority residents specifically. In addition, we intentionally selected more senior level residents given their greater experience and opportunities for reflection. However, the impact of adverse outcomes on junior level residents may warrant additional study. Despite these limitations, here we provide the first nuanced investigation of the impact of unwanted outcomes among resident surgeons, which has important implications for resident well-being as well as personal and professional development.

CONCLUSIONS

This exploratory qualitative study demonstrated the impact of unwanted outcomes on resident surgeons, who experience emotional and intellectual responses in order to process their feelings and learn from these events. Residency programs should embrace these formative moments in a surgeon’s development and offer structured support initiatives in order to cultivate a thriving training environment. (Table 3, 4, 5)

TABLE 3.

Intellectual Responses

What Went Wrong	"I think, yeah, I don't think anything like that can happen without going through and rethinking about it … going back to the beginning, the indication for what we were doing, what the patient wanted, what the patient understood, making sure that we had all those questions answered with the patient as well as the risks and benefits. And then also when we offered the surgery … the option, so I think personally more so meaning just making sure that I rethink all the steps." (ID31) "Me personally, I always like to have a breakdown with the attending either soon after or within a day or two and be like, hey, what did I do? How could I improve from A, B, or C? Is, was this an issue that I did, or was this going to happen kind of regardless of what we did?" (ID22) "But definitely, I reflected on, I kind of break it down into, you know, was there anything preoperatively that we maybe could've done differently? Was there anything intraoperatively we could've done? Was there anything postoperatively? Is there anything I personally would do differently or lessons that I would take away from it?" (ID6)
Decision Making	"Like I made the decision to sign off of her, and as a result, she got sick and now she passed away from this, and therefore, it was like my responsibility." (ID16) "So I think after the fact, you know, just sitting there analyzing, okay, we obviously had this event intraoperatively, and that affected us, and there was an error in judgment and a technical error. And then afterwards, you know, they were compounded." (ID35) "It definitely plays a role in future decision making, because you're always going to have that in the back of your head of, hey, the last time you did this or that one time you did this, this went wrong." (ID22)
Commitment to Improvement	"And they, yeah, I mean, you remember those days, and you learn from mistakes." (ID28) "I guess I think in general with any bad outcome or, you know, devastating results, I think, especially if it's a complication from a surgery that we're involved in or a treatment plan, I think I personally, to some degree take it personally or, you know, really reflect on my role in the situation and what I or the team could have done better." (ID35) "I think as soon as you identify a postoperative complication, or, you know, as soon as you kind of sort out a course of action for the patient, there's always like a period of self-examination." (ID6) "Sometimes like you can like go over it a million times in a million different ways and like you’re just feeling like you could have caught it like a day early or something. But like there’s nothing inherently, whether it was a technical or a judgment call that you did that would have changed anything. Sometimes those are the hardest ones to like, oh, there’s nothing I could have done." (ID16)

TABLE 4.

Personal Consequences of Unwanted Outcomes

"I feel like I do bring it at home. Again, not as talkative, or, yeah, not as like, yeah. I kind of go into a shell a little bit at home definitely." (ID12)

"And I think I definitely had to work on it over the last couple of years of like what's the best thing for me, whether it's, you know, coming home and ta-, just out loud saying I had a bad day or my patient isn't doing well to my family or my fiancé. And I think it's been difficult for, you know, him as well to kind of hear about this from me." (ID14)

"I think probably some, but, you know, that’s one of several things that make personal life and being a resident hard. … It’s a little hard to say kind of how specifically that specific thing affected it. I don’t know if it affected my personal life outside the hospital any more than any of the other myriad stressors that are present as a resident." (ID2)

"But I know like with, when I wasn't with her and kind of dealing with complications, like it's absolutely all that you think about." (ID4)

"I don’t think, not really. I think it’s been, I mean, complications happen not infrequently, and so I think sometimes you have to sort of learn some way to cope with while you’re at work… I don’t really know why or how, but I think I try and compartmentalize what’s going on at work and what’s going on at home in some way." (ID7)

"I don't think so. I tend to try to keep a pretty good work life and personal life separation now. I try not to let the work come home with me as much." (ID22)

"Nope, no. You know, I’m able to somewhat, I’m able to really well kind of separate what happens from work and home. …But you know, I haven’t had like problems with drinking, drugs, you know, etc., etc., as a result of these things." (ID1)

TABLE 5.

Factors Influencing Responses

Ownership	"I think in terms of progressing through residency now, I'm much more actively involved in our actual operations, so I'm even more invested in them, whereas an intern, it's like, oh, yeah, this patient had a bad outcome. I was in that surgery, but I didn't do anything. You know, I wasn't operating. I wasn't the one doing it. So it would still affect me, but there would maybe be less of a personal connection versus now where, you know, we're doing most of the operations that really, as I mentioned before, have that ownership of the patient. So I think it affects us more, or me more." (ID35) "Now that I am a third year and starting to do some of my own surgeries and have more ownership over the patients, I feel like I feel more responsible for the outcome that they have than I did when I was just present in the case but not really doing the surgery." (ID21) "I take more personal responsibility for them now. I think that when I was a lower-level resident, I just kind of thought, well, bad things can happen. It's not really my fault. And I was able to move on from the bad outcome much more easily. I find now that I'm much more directly involved in these patients' care, that I take more responsibility, and they're harder to cope with after they happen than they were earlier in my treating." (ID24) "You can blame yourself at first, because you're the on-, you're the one in there. You're the one taking responsibility for everything. And then you kind of look at other factors and be like, okay, maybe it was not all me, and it was a little bit of this or a little bit of that. But I think we as a profession tend to blame ourselves a lot more." (ID22) "I think that sense of personal responsibility leads to a lot of self-reflection in that thinking back through the actual case, try and figure out how you could do things better and different in the future." (ID7) "So I think there's some shared responsibility in what we do. And this is certainly a team sport, so every person on the team, it certainly makes a difference." (ID33)
Situational Factors	"I guess it depends on what happens or what the expected outcome was. If we're doing kind of extreme measures for a trauma where someone comes in and, I mean, their odds of survival is less, I would say that it takes me less time, more so because of the, again, the extremes. When there's a complication more for an elective case… I think any good surgeon would never ever forget that type of complication or issue a death, so personally I can say that any time we think about that, doing that study again on someone, it's, it always reiterates thinking about that case." (ID31) "The ones that bother me the most are the ones where the surgeon makes the wrong decision or the one where the surgeon misinterprets a situation, and it leads to the wrong decision, leads to a major change in patient outcomes… hopefully operate on them in the future to give them a quality of life that matched what they were prior to all the problems. And to witness that on a daily basis, try and take care of that patient who is disappointed in you, and try to manage that patient in a way that could get them better faster.” (ID8)
Personal Factors	"I think it's different depending on the case and how involved I am in it. I think in patients that I'm more involved with and have longer term relationships with that have, you know, more devastating outcomes, I think it lasts longer where you think about it and then later on something similar can, you can be reminded of that. I think, you know, when it's more minor things, you think about it, you talk with staff, you talk with your team, what could we have done better, and then sometimes you just move on, and you never think about it again." (ID35) "You know, first thing when I got back in, I opened up his chart to see how he was doing and saw the next day when I came back that he had been extubated. So I thought about it less and less, I guess, as the days kind of went on from that. But certainly for the first, you know, first day following the event, I was just kicking myself every, constantly almost." (ID10)
External Factors	"It's absolutely all that you think about. And the length of time that you think about it probably depends on how bad the complication was in addition to how often you see the person afterwards. If you then move on to a different service, it's probably a little bit quicker. If you're then visiting someone in ICU for the next two weeks … that probably makes it much more difficult to kind of let go of some of those negative thoughts that come." (ID4) "They lasted up until the patient stopped coming in. I didn’t have to see them as much because they decided to go on hospice and to be on after. I think not having to see them as frequently, that’s put some distance between it, and I haven’t really thought about it as much since that time." (ID2)

APPENDIX 1. INTERVIEW GUIDE

Thank you for agreeing to participate today. My name is ____, and I am from the University of Michigan. We are conducting research to better understand how postoperative complications impact surgeons. We feel that it is important to talk with you directly to hear about your decision-making, experiences, and concerns so that we may better understand ways in which surgeons are impacted by unwanted or unexpected outcomes following surgery.

I am most interested to hear about your personal experiences, opinions and views on the issues we discuss, so please do not feel shy. There are no right or wrong answers to these questions. There is a spectrum to how people feel, and it is normal to feel conflicted. Your views are extremely valuable to us and we are here to learn from you. Also, I want you to know that your participation is completely voluntary, so if you want to stop at any time or don’t feel comfortable, please let me know.

I would like to record this discussion so that the rest of the research team can hear your views directly and so that we don’t miss anything you say. Our discussion will remain completely confidential. Only the research team will listen to the recording and the information you give will only be used for this research project. Do you have any questions or concerns? Is it OK to record this discussion?

This interview will last for no more than 30 to 45 minutes. Again, these answers are confidential and your responses are only available to the research team. Do you have any questions before we start?

I would like to start with a few demographic questions:

• Age

• Gender

• Race

• Ethnicity

• How many years do you have left in your residency training?

• Can you describe your training program (i.e., community vs academic, open vs closed ICU)? How would you describe the culture of the environment?

• How much of your time is spent on emergency services like Trauma or Acute Care Surgery compared to elective services?

• How much time during training have you spent in the ICU?

• How often do you operate, in terms of cases per week, or days per week?

• If there is an emergency case, how often are you the resident expected to operate on the patient?

Primary Inquiry	Prompt
Tell me about why you decided to become a surgeon.
Tell me about your experience as being a resident.	In what ways, if any, has the experience changed you?
Walk me through a time you experienced a serious complication.	Describe your thought process. Describe how you felt. How long did those feelings last? Where there any impacts to your personal life?
In what ways, if any, have your reactions to complications changed over time?	Does you experience differ in how you respond versus other residents? Attendings?
In what ways, if any, do past experiences influence how you approach caring for patients who experience surgical complications or facing death?	Personal experiences or clinical experiences. Do your reactions affect your decision making?
What institutional resources are available to you after an unwanted/unexpected outcome after surgery? What about personal practices?	How soon did you return to work? Did you discuss your feelings with anyone? Do you feel you had the appropriate time/space to process? Role of D&C/M&M
Can you think of any resources that would be helpful in navigating these situations?
Tell me how COVID-19 has impacted you.	Role as a resident, concerns about family, financial impacts, emotional health, perceived value
Is there anything else you think we should know about how you or others navigate postoperative complications or death? What about how the medical community is responding to COVID-19?