TABLE 4.

Source of Feelings (External Pressures)

Medicolegal	“I think that in general, the other big thing, the other elephant in the room that we haven’t talked about is the medicolegal consequences of complications. I mean, that’s kind of bigger than just surgeons, but particularly in Medicaid and uninsured patient populations, rates of litigation are high. And so admitting that you have had a complication is sometimes a delicate process where you want to acknowledge the complication but not emphasize how it was your fault, or you want to, you’re just basically walking on eggshells when you’re talking to a patient or the family of a patient who has had a complication. You don’t want it to end up in a lawsuit, and so probably conversations aren’t quite as open as they could be if that weren’t at the back of your mind as their provider.” (ID 1)
	“I think also if indeed you’re concerned, you know, besides the emotional part of everything and the physical part to the patient, I guess if you ever are concerned about any litiginous effect from it, you can also contact risk management as well.” (ID 22)
	“The people that you have to worry about is not the patient or yourself that you did the wrong thing, but some daughter, some son, who lives far away, who hasn’t been involved, doesn’t understand the discussion of the circumstances going forward, and when a complication occurs, all of a sudden, they’re the ones that talk with a lawyer and… a lawsuit against you.” (ID 31)
Reputation	“That’s kind of one of the things with American medicine in general is everyone is trying to demonstrate why they are vital to their hospital or their care is appropriate, why they have good outcomes because if they get poor patient satisfaction scores, that affects their pay from their hospital. If they get any complications, it might affect their credentialing. And so everyone is kind of in this defensive mode trying to show that they’re adequate and why other people are at least as bad as they are. So, there’s got to be a culture shift in that regard.” (ID 1)
	“I want the best for my patient. I think in my institution, there’s a ton of support for using best practices, trying to create the best situation, great supportive care for patients in the hospital, rescue strategies, rapid response teams, counseling support for patients and their families, so I tend not to worry about the professional implications under my position at the institution or in outcomes. Mostly the impact on that patient’s life, that’s where I feel the most is.” (ID 9)
	“Well, because you’re judged. You know, referring people don’t want to send cases to somebody that they think is going to screw them up. And yet, everybody’s got, everybody. If you think you don’t have complications…” (ID 19)
	“Trying to, kind of beating yourself up kind of a thing, but also anxiety about how is this going to affect my reputation? How is this going to affect my job? How is this going to affect my relationship with administration or whatever? I mean, it’s hard not to have those feelings. And there’s always anxiety when someone doesn’t have the outcome you want. If someone doesn’t have a perfect outcome, there’s always some degree of anxiety for yourself. And, I mean, that’s just the truth.” (ID 20)