Introduction

Knee replacement surgery is a discretionary, preference sensitive surgery that can improve quality of life for people with advanced knee arthritis. It has the potential to improve patients’ quality of life by reducing pain and improving function, but there is also potential for serious complications. Prosthetic joint infection (PJI) is a potentially life-threatening condition associated with severe pain, functional difficulties and poor quality of life [1–3]. If left untreated, PJI may result in limb amputation or death [4,5]. When PJI is identified, further major operations are often required to clear the infection, which reduces the need for subsequent joint removal or even limb amputation. Surgical treatment can be prolonged sometimes involving multiple surgeries and hospitalisations and prolonged antibiotic treatment. PJI and its treatment has a profoundly negative impact on all aspects of patients' lives, including physical, social, emotional and economic aspects and patients undergoing treatment can experience feelings of isolation and insecurity, and an inability to live independently [1,2]. Cahill and colleagues found that the profoundly negative impact on patients’ social functioning and mental health is notable with this group of patients rating their overall quality of life as poor with 12% of patients rating their current situation as equivalent to or worse than death [3].

Infection rates have been reduced by addressing contributory health system and surgical factors [6]. Recent evidence synthesis has shown that multiple patient related factors are associated with developing post-operative infection [7]. However, despite the small risk of adverse events such as infection, patients still have the capacity to benefit greatly from arthroplasty.

Although recent research has concentrated on the impact of infection on patients [1,2], little is known about how surgeons may be affected when patients whom they have treated have infection. Adverse events may have considerable impact on healthcare professionals, particularly if the professionals are seen to be accountable for the outcome [8]. For surgeons, adverse events and surgical complications are a major source of unpleasant emotions, cognitive dysfunction and negative feelings [9]. A growing body of evidence describes how adverse events and medical errors have a negative emotional impact on surgeons and other healthcare professionals [10–15].

Many surgeons uphold a “surgical ideal”, whereby surgery is seen as the only chance to cure a patient or improve their quality of life. When surgery does not achieve this goal surgeons report feelings of failure which may impact on their coping response to intraoperative complications [9]. Surgeons across all specialties are largely unprepared for the intense emotional responses that adverse events can elicit, which may not only affect clinical judgement, but also impact on surgeons’ personal and professional identity [10]. These emotional responses to adverse events can be associated with increased feelings of personal responsibility, guilt, self-doubt, anxiety and distress [12,13], but are dependent on factors including surgical experience, colleagues’ reactions and the preventability of complications [14].

There is an element of uncertainty in surgery where clear scientific evidence is lacking [15]. While adverse events can impact decision-making by affecting judgement or changing practice [14], the “second victim” [16] of medical mistakes or adverse occurrence–surgeons—can feel unique, vulnerable and isolated in their reactions to such events [9,10]. This “oppressive experience” [9] may help to explain surgeons’ tendency to become more conservative and more risk-averse following adverse events [14]. However, there is little literature that focuses on the impact on surgeons, where there is no obvious cause to adverse events such as prosthetic joint infection (PJI).

Approximately 1% of patients who undergo knee replacement develop PJI [17]. In 2015, just over 6,000 knee revision procedures were performed in the UK, of which nearly one quarter (1,420 (23%)) were for infection [18]. Although PJI has been described as “an orthopaedic surgeon’s worst nightmare” [19], relatively little is known about how PJI impacts surgeons professionally and personally. Identification and acknowledgement of the emotional impact of PJI may help in the development of support strategies and maintaining surgeons’ well-being [20], and a deeper understanding of the personal and professional impact of adverse events is needed [11]. Understanding how surgeons react to the occurrence of PJI is an important clinical question and has wider relevance to establishing how surgical teams can be supported during the management of this complication.

Qualitative methods are well established. They are used widely in health research and are recognized as the most appropriate method of understanding complex social interactions, behaviours and perceptions [21–25]. Previous qualitative research in surgery has focused on adverse events and “medical mishaps” [10,12,14, 26,27] and the emotional experience of being a surgeon [9]. To our knowledge, none has focused on adverse events that have no obvious cause, and the impact on surgeons personal and professional wellbeing.

Methods

Results

Eleven surgeons were interviewed. Experience as an orthopaedic consultant varied from one month to 20 years (mean 9.5 years). Our findings show the personal and professional impact of knee PJI on surgeons, and how, despite their expertise, surgeons remain vulnerable to cases of PJI, perceiving it as inevitable at some point in their career. Analysis of the data suggests that regardless of the variation in surgeons’ years of experience, knee PJI is a major concern, and is devastating for surgeons, as well as their patients. Three themes characterise surgeons’ views and experiences of treating knee PJI, and illustrative quotations are referred to throughout (Tables 1–3).

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Table 1.

https://doi.org/10.1371/journal.pone.0207260.t001

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Table 2.

https://doi.org/10.1371/journal.pone.0207260.t002

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Table 3.

https://doi.org/10.1371/journal.pone.0207260.t003

Discussion

Most patients improve after knee arthroplasty and do not experience any major adverse events, which makes it all the more difficult when something does go wrong. The surgeons in this study described how they are affected, emotionally and professionally when a patient they have treated develops a PJI, often without an obvious cause. Surgeons may experience ‘moral injury’ when their intention to help patients results in notable harm. While improvements in surgical techniques and health systems have greatly reduced the risk of PJI, surgeons still feel some level of personal responsibility despite being unable to completely control for its occurrence. Surgeons discussed how each case of PJI was memorable to them and described how important it is to come together as a team to discuss cases and support decisions around treatment. They acknowledged that this was not the case in all departments. Although surgeons worked with autonomy, they also relied on their team. Surgeons who experienced a strong and supportive team in which one could be open and honest with colleagues about a diagnosis of PJI, felt this enabled them to more effectively manage their surgical response to PJI.

Surgeons can feel vulnerable and isolated following an adverse event associated with surgeon error [9,10] or following an adverse event of multifactorial origin as shown in this study. The impact is shown to be greater when the complication is unexpected, results from elective surgery and leads to severe disability [14]. Such events can lead to intense emotional responses, impaired decision making, difficulty concentrating, a negative impact on clinical judgement and deleterious changes to practice [9,10]. The cumulative effect of these reactions may potentially impact upon surgeons’ personal and professional identities [10], and lead to a greater risk of error and suboptimal patient care [34]. Evidence suggests that surgeons may become increasingly conservative and risk-averse in response to these events [14], potentially reducing access to care for high-risk patients.

We suggest that uncertainty about the cause of PJI may greatly contribute to the impact on surgeons whilst increasing their vulnerability. The risk of PJI can be ameliorated, which explains why its occurrence is relatively uncommon, and this perhaps introduces a more profound level of disappointment when it does occur.

The findings of our study are important when considering the phenomenon of burnout syndrome [35]–a physical, emotional or mental exhaustion–that is common among surgeons [36–42]. One third of surgeons show high levels of burnout, regardless of their speciality [43]. Given the profound impact of PJI on surgeons, it is plausible to suggest that without adequate support, surgeons who treat PJI are at an increased risk of burnout and further adverse events [40].

Limited information exists about support interventions for health care professionals, in particular orthopaedic surgeons. Institutional support in the context of surgical complications has been described as inadequate, with a presence of strong blame cultures [14]. The surgeons in our study described the importance of accepting their role in the aetiology of infection, being honest with themselves and their patients, and reflecting on their practice. We suggest that the surgical response to PJI may be framed in a more positive light as a growth experience, and that a team and systems approach is crucial to ensure that surgeons support one another after adverse events. We also suggest this includes the wider surgical team. Providing teamwork and leadership training to clinicians, as well as educating clinicians about errors and adverse occurrence, are suggested as a means of primary preventative intervention to address clinicians’ increasing levels of stress, with secondary interventions including counselling and psychotherapy [44]. While the surgeons in our study did not express any concerns related to stress or burnout, the long-term impact on surgeons of a diagnosis of PJI suggests that these primary and secondary preventative interventions may be beneficial to orthopaedic surgeons. In January 2017, NHS England launched a health service for GPs with mental health concerns including stress and depression [45]. To our knowledge, there are no dedicated health services specifically developed to meet the needs of health care professionals. The Royal College of Surgeons provides “mentoring arrangements”, however, these are broad in remit and not specifically designed to support surgeons through adverse events or errors, although the college also provides a Confidential Support and Advice Service–a telephone helpline, where surgeons can discuss issues of concern [46].

Although we acknowledge the relatively small number of participants in this study, in keeping with qualitative methodology data saturation was achieved [47] and evidenced by the consistency with which all surgeons stressed the magnitude of the impact of knee PJI on themselves and their patients, speaking candidly about their experiences. Our team-approach in analysing the data ensured a rigorous analysis process [33]. On the basis of these two aspects of study design and conduct we are confident that the findings as presented here are an appropriate reflection of the dataset as a whole and will have relatively good transferability to other surgeons who experience PJI in patients whom they have treated [48]. Surgeons in this study were asked to describe how they are affected personally and professionally when their patients develop PJI. This was explored in the context of a wider interview exploring their experiences of treating knee PJI. It is possible that surgeons’ reflections were influenced by the passage of time, the support they may, or may not have received and the outcome of the patients they treated. We propose that Tables 1–3 provide a source of acknowledgement of the profoundly negative impact that occurrence of PJI has on surgeons, and that other surgeons may have shared similar experiences.

We believe that this is the first study to explore the impact of knee PJI on surgeons’ personal and professional well-being. Previous work has focused on major and minor adverse events, surgical complications, and medical error often across a variety of surgical disciplines [8–16]. While other studies have explored surgeons’ emotional reactions to a variety of adverse events and complications our study focussed solely on the occurrence of PJI. Similar to these other studies, our findings suggest that emotional reactions of orthopaedic surgeons to PJI are similar to surgeons’ reactions to a variety of other adverse events. PJI can be regarded as a major adverse event, which can be life-threatening. Previous studies have found that surgeons reactions to events are experienced more intensely when the outcome is major and the link of causality between surgeon contribution and event is more direct [10,14]. In most cases PJI cannot be attributed to surgeon error and this may mean that the personal impact on surgeons is less severe. In a qualitative interview study of vascular and general surgeons Pinto and colleagues found that inadequate institutional support and the existence of blame cultures also exacerbated the impact of complications on surgeons. While some surgeons in this study acknowledged that support may be lacking in some orthopaedic departments, based on their previous experiences, none suggested it was something they had experienced in their own current department. This may be because all of the participating surgeons in this study were from departments which specialised in treating PJI. Focusing solely on the personal and professional impact of PJI demonstrates the value of qualitative research for identifying areas for further research. We suggest that future studies should focus on identifying which aspects of PJI have the most impact on surgeons’ practice and personal wellbeing, and ways to further support surgeons to manage PJI.

Acknowledgments

The authors would like to thank all those surgeons who gave their time to be involved in this study and the study administration and management team: Simon Strange, Makita Werrett, Beverley Evanson for their support.