Abstract
Background:
This study was designed to investigate incidences of surgeons’ mental distress following severe complications after radical gastrectomy.
Methods:
A cross-sectional survey was conducted between 1 June 2021 and 30 September 2021 among Chinese general and/or gastrointestinal surgeons who experienced severe complications after radical gastrectomy. The clinical features collected in the questionnaire included: (i) feeling burnout, anxiety, or depression; (ii) avoiding radical gastrectomy or feeling stress, slowing down the process during radical gastrectomy operations; (iii) having physical reactions, including heart pounding, trouble breathing, or sweating while recalling; (iv) having urges to quit being a surgeon; (v) taking psychiatric medications; and (vi) seeking psychological counselling. Analyses were performed to identify risk factors of severe mental distress, which was defined as meeting three or more of the above-mentioned clinical features.
Results:
A total of 1062 valid questionnaires were received. The survey showed that most of the participating surgeons (69.02%) had at least one clinical feature of mental distress following severe complications after radical gastrectomy, and more than 25% of the surgeons suffered from severe mental distress. Surgeons from non-university affiliated hospitals, the junior surgeons, and existing violent doctor–patient conflicts were recognized as independent risk factors for surgeons’ severe mental distress related to the severe complications after radical gastrectomy.
Conclusions:
About 70% of surgeons had mental health problems following severe complications after radical gastrectomy, and more than 25% of the surgeons suffered from severe mental distress. More strategies and policies are needed to improve the mental well-being of these surgeons after such incidences.
Keywords: Mental distress, mental well-being, radical gastrectomy, severe complications, surgeon
Introduction
Highlights
Most surgeons had mental health problems after severe complications of gastrectomy.
More than 25% of the surgeons suffered from severe mental distress.
Strategies and policies are needed to improve the mental well-being of surgeons.
Surgeons experience higher levels of work stress, even under normal circumstances1. Many can suffer from substantial levels of mental health issues, especially when faced with severe complications1. However, due to a variety of reasons, many surgeons are reluctant to disclose mental health issues or seek psychological help2.
Gastric cancer is the fifth most common malignancy globally and accounts for the fourth leading cause of death from cancer3,4. In China specifically, gastric cancer is a major public health issue, with some 400 000 new cases diagnosed every year5,6. Of those cases, more than 80% patients are at advanced stages when diagnosed6. At present, radical gastrectomy is considered the standard approach for patients with resectable advanced gastric cancer[7]. Severe complications following radical gastrectomy ranged from 2.7 to 9.4% worldwide8–11. In addition to delaying patients’ recovery courses, severe complications also place enormous pressure on chief surgeons who performed the operations12. Such pressures may bring great risks of psychological distress13.
Surgeons are also the victims when they encounter severe complications following radical gastrectomy. Their mental distress should not be minimized. Until now, little has been known about the effects of surgical complications on surgeons. In the current study, based on a large-scale questionnaire survey in China, we aimed to investigate incidences of surgeons’ mental distress following severe complications after radical gastrectomy. We also aimed to identify independent risk factors which could help develop strategies to improve the mental well-being of these surgeons after such incidences.
Methods
Questionnaire
This questionnaire was generated by two senior surgeons (L.Z. and F.L.) and one psychologist (X.H.) who referred to a previous nationwide survey on the impacts of iatrogenic biliary injuries during laparoscopic cholecystectomy on surgeons’ mental distress14. The questionnaire was piloted in a small group of senior and junior professional level surgeons who experienced severe complications following radical gastrectomy, and then modified according to the feedback twice before distribution. The Clavien–Dindo classification system was used to stratify for surgical complications (severe complications: grade III, IV, and V)15. The final questionnaire consisted of 32 questions (3 essay, 28 single-choice, 1 multiple-choice) is shown in Supplement File 1 (the English edition). This survey was conducted in the form of an online questionnaire (Questionnaire Star): https://www.wjx.cn/wjx/design/previewmobile.aspx?activity=119152698&s=1. Now, this survey has been closed. Under the support of the China Gastrointestinal Cancer Surgery Union and Chinese Journal of Practical Surgery, this electronic questionnaire was sent to general surgeons and/or gastrointestinal surgeons from 31 provinces and regions throughout China mainland between 1 June 2021 and 30 September 2021. The cities and hospitals where the participants located were not limited. Participation was voluntary and anonymous. The participants were limited to surgeons who had previously experienced severe complications following radical gastrectomy as chief surgeons. And the participants should choose the most impressive severe complication which left the deepest impression. The study was reported in line with the STROCSS criteria16. The study was approved by Institutional Review Boards at the Zhongshan Hospital of Fudan University, China (B2023-089).
The clinical features collected in the questionnaire relating to the surgeons’ mental distress included: (i) feeling burnout, anxiety, or depression; (ii) avoiding radical gastrectomy or feeling stress, slowing down the process during radical gastrectomy operations; (iii) having physical reactions, including heart pounding, trouble breathing, or sweating while recalling; (iv) having urges to quit being a surgeon; (v) taking psychiatric medications; and (vi) seeking psychological counselling. The definition and classification of mental distress was proposed by the professional psychologist (X.H.). Meeting any one of the above six clinical features was regarded as having mental distress; Meeting one or two was defined as mild mental distress, and meeting three or more was defined as severe mental distress.
Three distinct aspects relating to the severe complications following radical gastrectomy under investigation in this questionnaire survey included: (i) surgeon-related variables, including age, sex, hospital type (university affiliated hospital vs. non-university affiliated hospital), professional level (senior: more than 10 years working experience vs. junior: less than 10 years working experience), number of previous cases of performing radical gastrectomy, previous history of severe complications following radical gastrectomy, and the district (large cities vs. small/mid-sized cities) which are defined according to The new standard of city-size classification in China (2014); (ii) patient-related variables, including age, sex, occurrence time of the severe complications, presence or absence of assistance from experienced surgeons, presence or absence of second operation, unavoidable even with reasonable care, length of postoperative hospital stays, and patient’s in-hospital death; (iii) subsequent processing-related variables, including presence or absence of medical dispute, malpractice liability, lawsuit litigation, violent doctor–patient conflicts, economic compensation, surgeon’s personal compensation, and punishment by hospitals. In addition, surgeons’ recommendations to alleviate mental stress during the incidents were also collected in this questionnaire survey.
Statistical analysis
Questionnaires that properly completed all the questions were included in the final analysis. Statistical analysis was performed with SPSS Software (version 25.0; SPSS Inc.). The statistical significance of categorical data was evaluated using χ2 or Fisher’s exact test. The Cox proportional hazards regression model was used to perform univariate and multivariate analyses. All P values were two sided, and differences were considered significant at values of P less than 0.05.
Results
Clinical features of mental distress among surgeons after severe complications following radical gastrectomy
Between 1 June 2021 and 30 September 2021, 1062 valid questionnaires were received. The survey covered 30 sample provinces and regions throughout China mainland. Participating surgeons were predominantly male (1038/1062, 97.74%). 66.85% (710/1062) of participating surgeons were from university affiliated hospitals, and 33.15% (352/1062) of them were from non-university affiliated hospitals. The survey showed that most of the participating surgeons (69.02%, 733/1062) had at least one clinical feature of mental distress after severe complications following radical gastrectomy. The most common clinical features of the surgeons’ mental distress were burnout, anxiety, or depression (603/1062, 56.78%), followed by avoiding radical gastrectomy or stress during radical gastrectomy (322/1062, 30.32%), having physical reactions when recalling the incidence (e.g. faster heartbeats, higher blood pressure) (344/1062, 32.39%), and having urges to quit being a surgeon (255/1062, 32.3%). Only a few surgeons took psychiatric medications (e.g. fluoxetine, diazepam) (22/1062, 2.07%) or sought professional psychological counselling (90/1062, 8.47%). There were 460 (43.31%) and 273 (25.71%) participating surgeons who had mild mental distress and severe mental distress, respectively, using the predefined definition on the degree of mental distress (Table 1).
Table 1.
Clinical features of mental distress among surgeons after severe complications following radical gastrectomy.
| Factor | N (%) |
|---|---|
| All surgeons | 1062 (100) |
| Clinical features of mental distress | |
| Feeling burnout, anxiety, or depression | 603 (56.78) |
| Avoiding radical gastrectomy or feeling stress, slowing down the process during radical gastrectomy | 322 (30.32) |
| Having physical reactionsa | 344 (32.39) |
| Having urges to quit being a surgeon | 255 (24.01) |
| Taking psychiatric medications | 22 (2.07) |
| Seeking psychological counselling | 90 (8.47) |
| Numbers of the above-mentioned clinical features | |
| 0 | 329 (30.98) |
| 1 | 251 (23.63) |
| 2 | 209 (19.68) |
| 3 | 151 (14.22) |
| 4 | 98 (9.23) |
| 5 | 22 (2.07) |
| 6 | 2 (0.19) |
| Severity of mental distress | |
| No mental distress | 329 (30.98) |
| Mild mental distress (1–2 clinical features) | 460 (43.31) |
| Severe mental distress (≥3 clinical features) | 273 (25.71) |
Including heart pounding, trouble breathing, or sweating.
Surgeon and patient-related variables related to severe complications following radical gastrectomy
As shown in Table 2, surgeons in the non-university affiliated hospitals and in small/mid-sized cities were more prone to the development of severe mental distress following severe complications after radical gastrectomy compared with university affiliated hospitals and large cities (P=0.002 and P=0.010). In addition, junior surgeons and surgeons who performed fewer than 100 radical gastrostomies were also more likely to develop severe mental distress (P=0.008 and P=0.038). While, the patient-related variables did not affect the surgeons’ mental health (Table 3).
Table 2.
Comparisons of surgeon-related variables related to severe complications following radical gastrectomy.
| Factor | Severe mental distress | No/mild mental distress | P | ||
|---|---|---|---|---|---|
| All surgeons, N % | 273 | 100 | 789 | 100 | |
| Age (years)a, N % | 0.481 | ||||
| ≤37 | 152 | 55.68 | 418 | 52.98 | |
| >37 | 121 | 44.32 | 371 | 47.02 | |
| Sex, N % | 1.000 | ||||
| Female | 6 | 2.20 | 18 | 2.28 | |
| Male | 267 | 97.80 | 771 | 97.72 | |
| Hospital type, N % | 0.002 | ||||
| University affiliated hospital | 161 | 58.97 | 549 | 69.58 | |
| Non-university affiliated hospital | 112 | 41.03 | 240 | 30.42 | |
| Professional level, N % | 0.008 | ||||
| Senior | 121 | 44.32 | 425 | 53.87 | |
| Junior | 152 | 55.68 | 364 | 46.13 | |
| Previous cases of RG, N % | 0.038 | ||||
| ≤ 100 | 228 | 83.52 | 612 | 77.57 | |
| >100 | 45 | 16.48 | 177 | 22.43 | |
| Previous history of RG-SC, N % | 0.538 | ||||
| Yes | 85 | 31.14 | 229 | 29.02 | |
| No | 188 | 68.86 | 560 | 70.98 | |
| District, N % | 0.010 | ||||
| Large cities | 93 | 34.07 | 340 | 43.09 | |
| Small and mid-sized cities | 180 | 65.93 | 449 | 56.91 | |
Split at median.
RG, radical gastrectomy; SC, severe complications.
Table 3.
Comparisons of patient-related variables related to severe complications following radical gastrectomy.
| Factor | Severe mental distress | No/mild mental distress | P | ||
|---|---|---|---|---|---|
| Age (years), N % | 0.319 | ||||
| ≤40 | 28 | 10.26 | 60 | 7.60 | |
| 40–60 | 94 | 34.43 | 263 | 33.33 | |
| ≥60 | 151 | 55.31 | 466 | 59.06 | |
| Sex, N % | 0.142 | ||||
| Female | 76 | 27.84 | 184 | 23.32 | |
| Male | 197 | 72.16 | 605 | 76.68 | |
| Time of RG-SC happen, N % | 0.791 | ||||
| Postoperative 1–3 days | 82 | 30.04 | 225 | 28.52 | |
| Postoperative 4–7 days | 114 | 41.76 | 348 | 44.11 | |
| Postoperative>7 days | 77 | 28.21 | 216 | 27.38 | |
| Assistance from experienced surgeon, N % | 0.930 | ||||
| Yes | 220 | 80.59 | 632 | 80.10 | |
| No | 53 | 19.41 | 157 | 19.90 | |
| Second operation for RG-SC, N % | 0.069 | ||||
| Yes | 184 | 67.40 | 482 | 61.09 | |
| No | 89 | 32.60 | 307 | 38.91 | |
| Unavoidable even with reasonable care, N % | 0.881 | ||||
| Yes | 88 | 32.23 | 259 | 32.83 | |
| No | 185 | 67.77 | 530 | 61.17 | |
| Hospital stays, N % | 0.669 | ||||
| ≤4 weeks | 164 | 60.07 | 461 | 58.43 | |
| >4 weeks | 109 | 39.93 | 328 | 41.57 | |
| Patients’ in-hospital death, N % | 0.215 | ||||
| Yes | 166 | 60.81 | 513 | 65.02 | |
| No | 107 | 39.19 | 276 | 34.98 | |
RG, radical gastrectomy; SC, severe complications.
Subsequent processing-related variables related to severe complications following radical gastrectomy
Medical disputes were more common in surgeons with severe mental distress than those who had no/mild mental distress (37.00% vs. 26.74%, P=0.002), and primary/major responsibilities were the main cause of the severe mental distress. In addition, compared with surgeons who had no/mild mental distress, those who had severe mental distress reported a greater frequency of lawsuit litigation (13.19% vs. 6.08%, P<0.001), violent doctor–patient conflicts (11.36% vs. 3.68%, P<0.001), economic compensation (44.69% vs. 30.93%, P<0.001), needing surgeon’s personal compensation (26.80% vs. 7.94%, P=0.008), as well as receiving additional administrative punishment by hospitals (15.38% vs. 7.60%, P<0.001) (Table 4).
Table 4.
Comparisons of subsequent processing-related variables related to severe complications following radical gastrectomy.
| Factor | Severe mental distress | No/mild mental distress | P | ||
|---|---|---|---|---|---|
| Medical dispute, N % | 0.0 | ||||
| Yes | 101 | 37.00 | 211 | 26.74 | |
| No | 172 | 63.00 | 578 | 73.26 | |
| Malpractice liability, N % | 0.007 | ||||
| Primary/major responsibility | 193 | 70.70 | 485 | 61.47 | |
| Secondary/minor responsibility | 80 | 29.30 | 304 | 38.53 | |
| Lawsuit litigation, N % | <0.001 | ||||
| Yes | 36 | 13.19 | 48 | 6.08 | |
| No | 237 | 86.81 | 741 | 93.92 | |
| Violent doctor–patient conflict , N % | <0.001 | ||||
| Yes | 31 | 11.36 | 29 | 3.68 | |
| No | 242 | 88.64 | 760 | 96.32 | |
| Economic compensation, N % | <0.001 | ||||
| Yes | 122 | 44.69 | 244 | 30.93 | |
| No | 151 | 55.31 | 545 | 69.07 | |
| Surgeon’s personal compensation, N % | 0.008 | ||||
| Yes | 26 | 26.80 | 39 | 7.94 | |
| No | 247 | 10.31 | 750 | 9.52 | |
| Punishment by hospitals, N % | <0.001 | ||||
| Yes | 42 | 15.38 | 60 | 7.60 | |
| No | 231 | 84.62 | 729 | 92.40 | |
Multivariable Cox regression analyses for surgeons’ severe mental distress
In order to estimate the clinical significance of surgeon and subsequent processing-related variables associated with surgeons’ severe mental distress, multivariable Cox regression analyses were performed with the same clinicopathological parameters that showing significance (P<0.05) in univariate analyses to control for confounders. As shown in Figure 1, among the surgeon-related variables, the hospital type (non-university affiliated hospitals vs. university affiliated hospitals, odds ratio (OR): 1.52; 95% CI: 1.14–2.03, P=0.005) and the professional level (junior vs. senior, OR: 1.39; 95% CI: 1.05–1.85, P=0.022) were both independent factors of surgeons’ severe mental distress. In addition, among the subsequent processing-related variables, existing violent doctor–patient conflicts (OR: 2.60, 95% CI: 1.46–4.62, P=0.001) was an independent risk factor of surgeons’ severe mental distress. Taken together, our findings indicate that the surgeons from non-university affiliated hospitals, junior surgeons, and existing violent doctor–patient conflicts were recognized as independent risk factors of surgeons’ severe mental distress following severe complications after radical gastrectomy.
Figure 1.
Surgeons from non-university affiliated hospitals, junior surgeons, and existing violent doctor–patient conflicts were recognized as independent risk factors of surgeons’ severe mental distress related to the severe complications after radical gastrectomy. RG: radical gastrectomy.
Respondent’s recommendation to alleviate surgeons’ severe mental distress
At the end of the questionnaire, there were some multiple-choice questions on how to alleviate surgeons’ severe mental distress by the hospitals administrations and governments. As shown in Table 5, the most recommended approach was that hospitals should become the principal part in medical dispute or lawsuit litigation instead of surgeons (890/1062, 83.80%), followed by guaranteeing every surgeon have medical liability insurance (876/1062, 82.49%), offering more care than administrative punishment (864/1062, 81.36%), protecting doctors in violent doctor–patient conflicts (883/1062, 80.32%), and correctly guiding public opinion and public media (840/1062, 79.10%). In addition, more than three quarters of surgeons thought that hospitals should offer paid leave and psychological treatment for the surgeons who experience severe mental distress (814/1062, 76.65%).
Table 5.
Recommendation to alleviate surgeons’ mental stress during the incident.
| Government and hospital should protect doctors in violent doctor–patient conflicts | 80.32% |
| Government should guide public opinion and public media correctly | 79.10% |
| Government and hospital should guarantee every surgeon have medical liability insurance | 82.49% |
| Hospital should become the principal part in medical dispute or lawsuit litigation instead of surgeons | 83.80% |
| Hospital should offer paid leave vacation and seek psychological treatment for the surgeon when they have severe mental distress | 76.65% |
| Hospital should offer more care to surgeons than administrative punishment | 81.36% |
Discussion
Gastric cancer is still a universal health problem and accounts for the fourth leading cause of cancer-related mortality globally3,4. Gastrectomy with D2 lymphadenectomy is the standard approach for resectable advanced gastric cancer7. The postoperative morbidity and mortality rates following radical gastrectomy was about 20%, and the severe complications (grade III or greater) according to the Clavien–Dindo classification system were less than 10%8–11,15. Most mild complications are relatively easy to manage and do little harm to patients. While, severe postoperative complications can be devastating and result in serious consequences, even perioperative death. Except economic and emotional impacts on patients, the experience of severe complications treatments and mental suffering to the surgeons also leave lasting memories.
To investigate the mental health of surgeons following severe complications after radical gastrectomy, we launched an investigation for surgeons with such experience in China. This study demonstrated that severe complications following radical gastrectomy caused varying degrees of mental distress to surgeons. About 70% of surgeons had at least one clinical feature of mental distress related to severe complications following radical gastrectomy, and more than a quarter of participating surgeons had severe mental distress. While, less than 10% of surgeons took psychiatric medications or sought professional psychological counselling.
Surgeons’ mental distress following severe complications after radical gastrectomy might be caused by subjective and objective factors17. Subjective factors, including personality and the ability of stress resistance, were difficult to investigate and not included in this survey. The present survey only investigated possible objective factors causing surgeon’s mental distress after radical gastrectomy, which come from the characteristics from the surgeons themselves, as well as adverse events and subsequent processing. The results of this survey showed that surgeons in non-university affiliated hospitals and small/mid-sized cities are more prone to develop severe mental distress following the severe complications after radical gastrectomy compared with the surgeons from university affiliated hospitals and large cities. This may be due to higher levels of surgical experience and expertise in university affiliated hospitals and large cities, in addition to more authoritative specialists for managing serious complications. In China, university affiliated hospitals in large cities are usually better overall hospitals. Because of this, patients and their families more easily accept surgical complications18. This often alleviate the psychological pressure of the chief surgeons who experience adverse events19. In this questionnaire, the junior surgeons were defined as the ones less than 10 years working experience. The junior surgeons are usually attending doctors or deputy chief physicians who can perform radical gastrectomy on their own in many regions in China. While, due to the relatively low professional level and the less experience in dealing with severe complications, junior surgeons are more easily affected by medical disputes. In this survey, our findings also showed that there were no relationships between patient-related variables and the surgeons’ mental health. This might be different from other studies. Patient in-hospital death, the most serious postoperative complication, was not a risk factor of surgeons’ severe mental distress in our study. This may be due to that the percentage of death cases was small in clinical work, therefore it is reasonable that after adjustments for other variables, this small-instance variable did not reveal any significance in analysis.
As a surgeon, perioperative complications are often unavoidable. Except for the surgeon/patient-related variables, subsequent processing measures after severe postoperative complications, such as medical dispute, malpractice liability, lawsuit litigation, violent doctor–patient conflicts, economic compensation, surgeon’s personal compensation, and punishment by hospitals, could greatly influence the mental health of the chief surgeons who performed the operation18,20–22. Among these variables, we identified that the surgeons from non-university affiliated hospitals, junior surgeons, and existing violent doctor–patient conflicts were independent risk factors of surgeon’s severe mental distress related to the severe complications after radical gastrectomy. Such pressure could bring a great risk of psychological distress for them. To some extent, doctors belong to a vulnerable group, and more attention needs to be paid to the mental health23. The surgeons must be brave to face such issues and escalate them when overwhelmed.
There are several limitations of this study. First, this survey research may have recall biases. In order to reduce the recall bias, we asked the participants to choose the one which left the deepest impression. The most impressive one might remain fresh in the surgeon’s memory even after a long time. We hope that such a measure can reduce the recall bias as much as possible. Second, this study only considered the mental health of chief surgeons. While, in the clinical work, complications could also bring a risk of mental distress to surgical assistants. The assistants’ mental health should also be considered. Third, subjective factors that might influence the mental health of the surgeons were not included. To a certain extent, subjective factors may be as or more important than objective factors. Fourth, this questionnaire was generated by two senior surgeons and one psychologist, and the participating psychologist deemed the definition of severe mental distress reasonable and feasible. This might not be the best method, especially when the cutoff was between mild and severe mental distress in order to analyze the risk factors. However, there is currently no formal definition of severe mental distress, and it would be challenging to revise the definition. To make the research more reasonable and feasible, we will try to redesign the criteria of classification in future research.
In summary, our results demonstrate that about 70% of surgeons have mental health problems after severe complications following radical gastrectomy, and more than a quarter of the instances were considered severe. More strategies and policies are needed to improve the mental well-being of surgeons after such complications.
Ethical approval
The study was approved by Institutional Review Boards at the Zhongshan Hospital of Fudan University, China (B2023-089).
Source of funding
This work was sponsored by National Natural Science Fund of China (82172803) and Natural Science Foundation of Shanghai (23ZR1409900).
Author contribution
H.H.: methodology, software, formal analysis, writing—original draft preparation. C.L.: formal analysis, writing—original draft preparation. R.L.: formal analysis, writing—review and editing. L.Z.: data curation, supervision. X.H.: conceptualization, supervision. F.L.: conceptualization, supervision, writing—review and editing.
Conflicts of interest disclosure
None declared.
Research registration unique identifying number (UIN)
Name of the registry: Surgeons’ Mental Distress and Risks After Severe Complications Following Radical Gastrectomy.
Unique Identifying number or registration ID: ClinicalTrials.gov Identifier: NCT05782205.
Hyperlink to your specific registration (must be publicly accessible and will be checked): https://www.clinicaltrials.gov/ct2/results?recrs=&cond=&term=NCT05782205&cntry=&state=&city=&dist=
Guarantor
Fenglin Liu.
Data statement
All data generated and used in this study are available.
Provenance and peer review
Not commissioned, externally peer-reviewed.
Acknowledgements
The authors thank the help from Elite Group of Chinese Digestive Surgery Gastrointestinal Branch.
Footnotes
H.H. and C.L. contributed equally to this work.
Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.
Published online 9 May 2023
Contributor Information
Hongyong He, Email: he.hongyong@zs-hospital.sh.cn.
Chao Lin, Email: lin.chao@zs-hospital.sh.cn.
Ruochen Li, Email: li.ruochen@zs-hospital.sh.cn.
Lu Zang, Email: zanglu@yeah.net.
Xiao Huang, Email: huang.xiao@zs-hospital.sh.cn.
Fenglin Liu, Email: liu.fenglin@zs-hospital.sh.cn.
References
- 1.Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg 2010;251:995–1000. [DOI] [PubMed] [Google Scholar]
- 2.Ruitenburg MM, Frings-Dresen MH, Sluiter JK. The prevalence of common mental disorders among hospital physicians and their association with self-reported work ability: a cross-sectional study. BMC Health Serv Res 2012;12:292–298. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Sung H, Ferlay J, Siegel RL, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin 2021;71:209–249. [DOI] [PubMed] [Google Scholar]
- 4.Siegel RL, Miller KD, Fuchs HE, et al. Cancer Statistics, 2021. CA Cancer J Clin 2021;71:7–33. [DOI] [PubMed] [Google Scholar]
- 5.Xia C, Dong X, Li H, et al. Cancer statistics in China and United States, 2022: profiles, trends, and determinants. Chin Med J (Engl) 2022;135:584–590. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Chen W, Zheng R, Baade PD, et al. Cancer statistics in China, 2015. CA Cancer J Clin 2016;66:115–132. [DOI] [PubMed] [Google Scholar]
- 7.Joshi SS, Badgwell BD. Current treatment and recent progress in gastric cancer. CA Cancer J Clin 2021;71:264–279. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Liu F, Huang C, Xu Z, et al. Morbidity and mortality of laparoscopic vs open total gastrectomy for clinical stage I gastric cancer: the CLASS02 multicenter randomized clinical trial. JAMA Oncol 2020;6:1590–1597. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Yu J, Huang C, Sun Y, et al. Effect of laparoscopic vs open distal gastrectomy on 3-year disease-free survival in patients with locally advanced gastric cancer: the CLASS-01 randomized clinical trial. JAMA 2019;321:1983–1992. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Lee HJ, Hyung WJ, Yang HK, et al. Short-term outcomes of a multicenter randomized controlled trial comparing laparoscopic distal gastrectomy with D2 lymphadenectomy to open distal gastrectomy for locally advanced gastric cancer (KLASS-02-RCT). Ann Surg 2019;270:983–991. [DOI] [PubMed] [Google Scholar]
- 11.Kim HH, Han SU, Kim MC, et al. Effect of laparoscopic distal gastrectomy vs open distal gastrectomy on long-term survival among patients with stage I gastric cancer: the KLASS-01 randomized clinical trial. JAMA Oncol 2019;5:506–513. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Pinto A, Faiz O, Bicknell C, et al. Surgical complications and their implications for surgeons’ well-being. Br J Surg 2013;100:1748–1755. [DOI] [PubMed] [Google Scholar]
- 13.West CP, Huschka MM, Novotny PJ, et al. Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. JAMA 2006;296:1071–1078. [DOI] [PubMed] [Google Scholar]
- 14.Dai HS, Liang L, Zhang CC, et al. Impact of iatrogenic biliary injury during laparoscopic cholecystectomy on surgeon’s mental distress: a nationwide survey from China. HPB (Oxford) 2020;22:1722–1731. [DOI] [PubMed] [Google Scholar]
- 15.Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205–213. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Agha R, Abdall-Razak A, Crossley E, et al. for the STROCSS Group. The STROCSS 2019 Guideline: Strengthening the Reporting of Cohort Studies in Surgery. Int J Surg 2019;72:156–165. [DOI] [PubMed] [Google Scholar]
- 17.Yang Q, Tai-Seale M, Liu S, et al. Measuring public reaction to violence against doctors in China: interrupted time series analysis of media reports. J Med Internet Res 2021;23:e19651. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Amirthalingam K. Medical dispute resolution, patient safety and the doctor-patient relationship. Singapore Med J 2017;58:681–684. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Yang T, Zhang H, Shen F, et al. Appeal from Chinese doctors to end violence. Lancet 2013;382:1703–1704. [DOI] [PubMed] [Google Scholar]
- 20.Kumari A, Kaur T, Ranjan P, et al. Workplace violence against doctors: Characteristics, risk factors, and mitigation strategies. J Postgrad Med 2020;66:149–154. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Liu J, Gan Y, Jiang H, et al. Prevalence of workplace violence against healthcare workers: a systematic review and meta-analysis. Occup Environ Med 2019;76:927–937. [DOI] [PubMed] [Google Scholar]
- 22.Nakamura N, Yamashita Y. Malpractice lawsuits and change in work in Japanese surgeons. J Surg Res 2015;193:210–216. [DOI] [PubMed] [Google Scholar]
- 23.Berman L, Rialon KL, Mueller CM, et al. Supporting recovery after adverse events: An essential component of surgeon well-being. J Pediatr Surg 2021;56:833–838. [DOI] [PubMed] [Google Scholar]