The Case for Surgical Self-Compassion

by Dr. Michael Maddaus
Retired Thoracic Surgeon, Public Speaker, and MSC Teacher-in-Training

I walked into my first Surgical Complications Conference through a barely cracked-open door at the back of a room filled with surgeons, residents, and medical students. It was as if I had just walked into a police interrogation. A chief surgical resident was up on the “stage,” behind the podium, wiping his visibly sweating forehead with his hands, rocking side-to-side, stuttering and sputtering attempted answers to the machine gun fire of questions from an internationally famous surgeon parked in the front row. Leaning forward in his seat, the surgeon was thrusting his arm and his pointed finger in the air at him, yelling, “Look at him up there shuffling and sweating and making excuses!” and then demanding more answers about what happened. 

What happened is that the resident, apparently tentative and obfuscating, was being humiliated and shamed. The story created in my mind as a brand-new surgical intern was that telling the exact truth about what I did wrong was critical to my survival as a surgeon. What my story was really about was the need for belonging and a fear of shame. My newly erected fence was raw, in your face, truth-telling, no matter what. Someone else observing this scene may have ended up creating another story and a different fence; perhaps something like “All surgeons are mean-spirited, hyper-critical assholes,” which could really be about kindness and acceptance. It all depends on the psychological gear you are carrying when you show up to the event. 

When a patient gets hurt

From that moment on, I was determined to be ruthlessly honest with myself about any error I made. This is not easy considering the psychological pain associated with making a mistake that has led to a patient complication. The mind, having a mind of its own, automatically tries to lessen the pain of a mistake in one of two ways. The first way is rationalization. Here, the mind looks for “reasons” or excuses outside of the mistake itself such as, “Well, he had cancer and was going to die anyway,” or “The tissues were weak,” or “If so and so hadn’t done____ (fill in the blank), then this wouldn’t have happened.”

The trouble is, sometimes there are mitigating factors that do contribute to a complication. However, the danger of rationalizing is a failure to take full responsibility for both the exact error made and for the responsibility to improve and prevent it in the future. Complications conferences are, in general, very effective at weeding out rationalizations and excuses. Current complications conferences are now civil affairs that do serve the purpose of seeking the truth of what happened combined with learning from the mistake. Thus surgeons, overall, are not excuse-makers. 

The second response to the mistake is to be internally hypercritical and shaming since that is, after all, what is deserved and because it seems to be the necessary path to improvement and avoiding future errors. Whipping oneself with this mental cat-o’-nine-tails (a medieval whip with nine tails) generates a physiologic stress and threat response just as surely as if someone else were standing in front of you yelling the same criticisms or threats, with all of the negative consequences of a chronic stress response.

Chronic whippings with one’s personal cat-o’-nine-tails can, over time, lead to a very rational and perhaps subconscious survival strategy of avoidance of emotions by shrugging one’s shoulders and saying “whatever” to the error and moving on. The danger here is emotional disconnection with yourself and with your patients. Both lose.

Suffering in silence: the dread of isolation

These days, before the knife cuts the skin of any patient, there is a mandatory “time-out” where all involved check in with each other to ensure that everything is in order. There is no similar time-out in most physicians lives. 

After telling her grief-stricken husband, I tossed and turned all night, then got up the next morning for my day’s cases, and as I walked by the main desk of the operating room I felt like all eyes were on me – since the stories of big complications spread through the social field of the operating rooms like wildfire. But, as always, we all pretended it didn’t exist, I went on with my day and my cases, psychologically alone. I suffered from negative personal ruminations about the case for over a year before I could fully accept what had happened and move on.

I suspect that to the outside world I seemed just fine. I was showing up everyday, doing my cases, clinics, and academic work. I didn’t tell anyone how I sometimes found myself stopped in the middle of a dog walk at night, standing still, so deeply locked up in the rumination that I failed to recognize I had stopped moving or that my dog was standing there, looking up at me, waiting to see what the next move was. 

Rethinking “failure:” the role of compassionate community

I meet with a group of surgeons every two weeks outside of home and work where we can share our personal and professional struggles in strict confidence. They are exceptionally hard on themselves, and they each have their own personal set of cat-o’-nine-tails used not only for surgical complications but also for a range of so called personal “failures,” “mistakes,” and “shortcomings.” When I started the group it became clear that most were deeply steeped in the internal habitual hypercritical response to perceived failures or mistakes and they believed (the fence), to their core, that it was an essential part of improving. Being in a group has given them a much needed place to breathe emotionally and a place to start to break down their fences, allowing them to learn new skills such as self-compassion and acceptance. It is as if they are finally taking the time to stop outside their mental house, pause, take a look around, and intentionally start to redesign it. It is the critical time-out that they so desperately needed. 

Because young physicians show up at the start of medical school or residency with their own psychological gear, it is vital that we help them construct the right fences early in their training. By intentionally teaching young physicians that kickstarting the engine of self-compassion as soon as possible after an error or complication will 1) provide them with more positive internal resources that will allow more rapid acceptance and ownership of the error, and 2) a greater capacity and willingness to improve in the future, we can participate in the preservation of their wellbeing over time as the realities of medicine assault them. It is constriction or expansion. It is more limited performance or higher performance. It is a choice, but only if they are aware.