PEARLS: A mnemonic to help handle adversity

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PEARLS John F Reidt velasquez
John F. Eidt (left) and Gabriela Velasquez (right)

There is accumulating evidence that adverse clinical outcomes have a negative impact on the clinician. As vascular surgeons, we are particularly vulnerable to feelings of guilt, shame and self-doubt when we are confronted by a complication related to our actions. It hurts when a patient suffers as a consequence of our care. How we respond to adverse outcomes is critical to our ability to deliver compassionate, effective surgical care.

And yet, most of us have not had any training or preparation for dealing with adversity in a positive and constructive way. We are all too familiar with the statistics of burnout, depression, substance abuse and suicide prevalent in our specialty. How can we as surgical specialists learn to care for ourselves and our colleagues in the face of the inevitable adverse outcomes that are unfortunately common in our specialty?

Over the last two years, we have asked a number of leaders in surgery for their advice in dealing with adversity. After reviewing their responses, we identified six common themes and developed the mnemonic PEARLS to help us remember them. P is for patient. Our highest priority must be to assure that the patient—if alive—continues to receive appropriate care.

The second priority is emotional support not only for the patient and family, but also the surgeon. Usually, this means being an active, sympathetic listener. You don’t need to—nor should you—try to provide answers or false reassurances. These are difficult situations that may lead to a variety of unpleasant consequences (lawsuits, disciplinary actions, etc.), and giving false hope is not really helpful, potentially hindering recovery.

The next priority is the apology/disclosure. It is usually appropriate to have a frank discussion with the patient and/or family about the facts of the case. It may be appropriate to include a colleague or hospital representative during these conversations. One surgery chairman said that he accompanies his faculty during these sometimes challenging conversations.

The following step is review. In some cases, it may be appropriate to provide a “competent critique” of the care rendered. We all have a desire to improve our surgical skills. Having an opportunity to review the facts of a case and consider strategies to avoid future complications may be needed. The morbidity and mortality (M&M) conference may have an important therapeutic effect by allowing the surgeon to share the facts of a case in an environment that is nonjudgmental and protected from discovery.

Then we consider the legal implications of the case. Appropriate consultation with risk management and legal counsel may be indicated.

Finally, we consider the safety of the surgeon. It is important to consider the potential for self-harm, including substance abuse and suicide. If there are any indications that the surgeon may be a danger to him or herself, early referral to professional counseling may be required.

Vascular surgery is a fantastic specialty. Hopefully, you will throw more touchdowns than interceptions. But when you are victimized by a pick-six, you need to have the support system in place that will get you back on top of your game.

John F. Eidt is a vascular surgeon at Baylor Scott & White Heart and Vascular Hospital in Dallas. Gabriela Velazquez, also a vascular surgeon is an assistant professor of vascular and endovascular surgery at Wake Forest University School of Medicine in Winston-Salem, North Carolina.

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