Behind every kidney transplant is a surgeon who carries the weight of two lives at once. When something goes wrong in the operating theatre, that weight can become crushing. A new study from the University of Glasgow and Queen Elizabeth University Hospital has, for the first time, laid bare the psychological, professional and personal fallout experienced by kidney transplant surgeons after perioperative adverse events, revealing a hidden burden that shapes not only the surgeons themselves but the decisions that determine whether patients receive life-saving organs at all.
The research, published in Frontiers in Transplantation, used a mixed-methods exploratory sequential design to interview 15 consultant kidney transplant surgeons from seven UK transplant centres about adverse events they had experienced during their careers. Each participant underwent an individual, semi-structured qualitative interview lasting between 22 and 71 minutes, transcribed verbatim and analysed using Braun and Clarke’s reflexive thematic analysis framework. Alongside the interviews, participants completed two validated psychometric instruments: the 44-item Big Five Inventory, measuring the five-factor model of personality across extraversion, agreeableness, conscientiousness, neuroticism and openness, and the Domain-Specific Risk-Taking (DOSPERT) scale, which quantifies attitudes toward risk across ethical, financial, health and safety, social and recreational domains. Integration of the qualitative and quantitative datasets occurred at the analysis stage, allowing the researchers to triangulate how personality traits and lived experience interact in shaping surgeons’ responses to adverse events.
An adverse event was defined as an unintended event occurring during or following transplantation that resulted in patient harm, encompassing both preventable errors made during an operation and known procedural complications. This broad definition was deliberate, allowing the study to capture the full spectrum of harm that transplant surgeons confront. The stakes in transplantation are uniquely high: unlike most surgical fields, the surgeon is responsible for two patients simultaneously, the donor and the recipient, and must balance the imperative not to waste a scarce organ against the risk of implanting one that may fail. Outcomes are closely monitored, and once the operation is performed there is limited opportunity to rectify errors. A surgeon’s influence extends beyond the operating table to organ acceptance decisions, meaning that a shift toward risk aversion after an adverse event could translate into higher rates of organ refusal and fewer transplants performed.
The thematic analysis identified four main themes with nine subthemes. The first and most visceral theme was that adverse events have a profound psychological impact. Every surgeon described an immediate emotional response, sharing in the trauma of the patient with feelings of sadness, anxiety, guilt and frustration. One participant described being “devastated, devastated, obviously, really upset,” while another recounted mentally replaying the entire operation on the drive home, unable to stop. The long-term emotional response proved more varied: some surgeons continued to feel the same intensity of distress years later, while others reported a more subdued reflection over time. In both cases, the emotional burden faded from daily consciousness but remained accessible, resurfacing when the surgeon encountered the same patient’s name or faced a similar clinical scenario. One surgeon reflected, “You don’t forget about it. And it carries with you. And you still think about it. And every time you see their name, you shudder.”
The second theme centred on how the surgical environment shapes the response to an adverse event. Participants consistently emphasised that a cohesive, supportive unit was foundational in navigating the aftermath. Informal peer support, colleagues offering perspective and reassurance, was regarded as the most effective coping mechanism, often described as an inherent part of team culture rather than a formal service. This relational support was preferred over accessing structured support services, which surgeons said they would not routinely rely upon. Conversely, a fragmented team dynamic was found to add to the burden. The study also revealed a darker side of the surgical environment: scrutiny following an adverse event evoked doubt in surgical capabilities, with some surgeons admitting that their decision-making became governed by concern over peer perceptions rather than clinical reasoning. One participant noted that at times they had considered changing their mind not because they felt the decision was wrong, but because of “the perception of your peers in a heavily scrutinised environment.” Pressure from external bodies reviewing departmental metrics compounded this anxiety, with one surgeon describing fear that statistics would be processed “without knowing the context” in a way deleterious to the department.
Yet scrutiny was not uniformly destructive. A positive aspect emerged within the morbidity and mortality (M&M) meeting process, where surgeons found value in thorough, non-personalised review of errors. Participants distinguished this constructive accountability from perceived colleague scrutiny, which they described as harmful and associated with self-doubt. A well-conducted M&M process allowed surgeons to learn from mistakes and take responsibility in a manner that, as one put it, “you can’t be personal about.” This distinction reinforces the importance of psychological safety, an environment where staff are comfortable admitting mistakes and learning from them, which is shaped by continuous interpersonal interactions among co-workers and ultimately benefits patient outcomes.
The third theme concerned changes in practice following an adverse event. Surgeons commonly expressed a desire to improve, driven by surgical pride and a sense of responsibility to every patient who comes to harm. Some sought out colleagues to observe alternative techniques, such as reviewing how peers perform arterial anastomoses after their own approach failed. Critically, participants reported that changes to practice should be based on decision-making processes rather than outcomes alone, warning against overcorrecting based on isolated incidents while remaining alert to patterns suggesting systemic issues. Some surgeons reported formalising their consent process and risk explanation when counselling future patients. Perhaps most significantly, the study documented shifts in risk attitude: many surgeons described a natural, often temporary, move toward conservatism in the immediate aftermath of an adverse event, followed by a recalibration of risk appetite based on surgical confidence and patient need. One surgeon observed that a disastrous first case could have a massive impact on the rest of a career, making a surgeon “much more conservative and much less willing to accept risk.” Others noted that the easiest path is risk aversion, which they considered “very bad medicine because patients are not getting the treatment that they deserve.”
The fourth theme explored the influence of personality on responses to adverse events. Participants consistently believed there to be a link between personality and how they processed these events. The Big Five Inventory findings provided descriptive context: mean neuroticism scores were higher among surgeons reporting greater long-term emotional impact (3.28) than among those reporting lesser impact (2.08), though the researchers caution that given the limited sample size this comparison is descriptive rather than associative. DOSPERT scores were comparable across all domains. Two subthemes emerged as protective mechanisms. The first was “robustness,” the ability to draw a line after an adverse event, temporarily pausing one’s own emotional response to continue clinical tasks and process the trauma later. Participants described compartmentalising emotions, with one stating, “Frankly, your emotions, in my opinion, are in that situation, secondary. You just got to put them away somewhere, compartmentalise them.” The second was “purpose”: surgeons described a period of introspection that reinforced the fundamental values of their career, a duty to patients, to shoulder responsibility, and to perform to the standards their training has allowed. One participant asked whether their core purpose was to massage departmental figures or to act in the patient’s best interests, concluding that declining to implant a kidney would have served statistics rather than the individual.
The researchers also identified external factors that modulated the emotional response, including the severity of the adverse event, whether it involved an overtly technical error, the surgeon’s seniority at the time, and the reaction of the patient’s family. More severe events and technical errors were associated with greater and more lasting emotional impact, possibly because surgeons view complications as an inevitability of surgery while errors feel like personal failures. Seniority cut both ways: reduced clinical experience was perceived to increase vulnerability in surgical confidence, yet being among the most experienced surgeons in a department carried its own burden, with an expectation of emotional resilience and a perceived lack of peer reassurance. Antagonistic responses from patients’ families amplified the emotional toll, forcing surgeons to confront hostility while still processing the event itself.
The findings map closely onto the “Second Victim Syndrome” framework, a term coined by Albert Wu in 2000 to describe the harm clinicians incur from adverse events, encompassing guilt, fear, anger and concerns about professional reputation and confidence. The study’s authors situate their results within the Bowlby and Parkes model of grief, attributing interview responses across its four stages and supporting the concept that all surgeons experience an acute reaction while longer-term emotional impact varies. Notably, a recent systematic review co-authored by members of this study team found that over half of surgeons experience anxiety, guilt and sleep disturbance following an adverse event. What makes the transplant context distinct is that the psychological consequences may ripple outward: risk aversion following an adverse event could reduce organ acceptance rates, meaning the second victim phenomenon in transplantation carries implications not just for surgeon wellbeing but for patients on dialysis who may never receive the transplant they need. The researchers argue that avoiding surgery because of personal risk perception may be as paternalistic as proceeding based solely on belief in its benefit.
Perhaps the most striking finding is what surgeons did not rely upon: formal support services. Existing literature has highlighted the limited effectiveness of single-session psychological debriefing following traumatic events, and aspects of surgical culture, the expectation that surgeons should cope alone, act as barriers to engagement with structured support. Instead, the most effective mechanism came from collegial relationships within a cohesive team. The authors point to evidence supporting Schwartz rounds, which improve team cohesion, support staff wellbeing and encourage compassionate reflection, as potentially beneficial in the complex, multidisciplinary transplant setting. They also highlight emerging resilience-focused interventions, such as Enhanced Stress Resilience Training, which showed improvements in burnout, stress and mindfulness among surgical trainees who fully engaged with a five-week course. Whether such training could benefit transplant surgeons warrants further investigation. The study acknowledges its limitations, including its modest sample size concentrated across two centres, the interviews being conducted by a medical student introducing a potential power dynamic, and quantitative data serving only descriptive rather than inferential purposes. Nevertheless, the findings open a conversation long overdue in transplant surgery, suggesting that strengthening collegial support within units, and re-evaluating formal support systems that remain underused, could protect both the surgeons who perform these operations and the patients whose lives depend on their willingness to take calculated risks.
Subject of Research: Psychological and professional impact of perioperative adverse events on kidney transplant surgeons
Article Title: The impact of perioperative adverse events on kidney transplant surgeons: a mixed-methods study
Article References: The impact of perioperative adverse events on kidney transplant surgeons: a mixed-methods study. (n.d.). https://doi.org/10.3389/frtra.2026.1959604
Image Credits: AI Generated
DOI: 10.3389/frtra.2026.1959604
Keywords: kidney transplant, adverse events, second victim syndrome, surgeon wellbeing, surgical psychology, risk aversion, organ acceptance, Big Five Inventory, DOSPERT, thematic analysis, peer support, transplant surgery
