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Zach Klaassen: Hi, my name is Dr. Zach Klaassen. I'm a urologic oncologist at the Georgia Cancer Center in Augusta, Georgia. Thank you for joining us for this UroToday discussion with Dr. Scott Eggener who is a Professor of Urology at the University of Chicago. Dr. Eggener, thanks so much for joining us today.

Scott Eggener: Yeah, thanks for having me, Dr. Klaassen.

Zach Klaassen: Awesome. We're going to talk about a very important topic, and I know this started a long time ago in terms of when you started talking about the emotional toll of surgical complications, but really it generated a ton of interest around the AUA. Let's just start off by how did you get into this topic? What was sort of the genesis to develop your interest in this really important topic that you can't find in textbooks?

Scott Eggener: I never kind of sought to be that person or be a public voice about it, but it was through suffering a bit through some complications and realizing that we need to do a better job as a community to take care of each other and also taking care of ourselves. You, me, and most others probably never had much training, if any, on this. No one ever spoke about it. And then I experienced it. I ultimately wrote an essay at some point and it got some traction.

Zach Klaassen: Yeah, I remember that. It was the New York Times article, I think, you're probably referencing from a few years ago that that was really powerful and something I have kind of bookmarked in my web browser. How did that invite come and what was sort of the background to that?

Scott Eggener: It's a semi-interesting backstory, but it was a case I had done. It was a big thrombus case and I did it with one of the vascular surgeons and the short summary is the patient died on the table, and it was the most traumatic thing I'd ever experienced, and I was just inconsolable and all the emotions that many of us have experienced when tragic things happen just by trying your best. And over the course of about six months I put pen to paper, more as therapy for myself, I never had any intent on publishing it. And then I showed it to the vascular surgeon I worked with and he's the one that said, "You've got to put this out there. We've all experienced it." And then I ultimately had it published and the response was eye-popping, just what I got through phone calls, texts, emails, from all over the world.

Zach Klaassen: You're right. I mean, I think anybody who does big time neurological oncology has bad complications, and we all have phenomenal intent and unfortunately we walk a very fine line. I tell the residents every day, a very fine line every single day. And 98, 99% of that time we're on the right side of the line, it's the one to 2% that really are the tough ones. I think that's where we all have that quiet place we go when those things happen, but it's hard to deal with it at times. And that topic of emotional toll of surgical complications at AUA really was bang on. Maybe you can just walk us through a little bit of the highlights of that, if it differs much from what we've already talked about with the New York Times article.

Scott Eggener: I don't know if they're highlights or low lights but-

Zach Klaassen: Fair enough.

Scott Eggener: ... I'm the sucker willing to-

Zach Klaassen: The key messages.

Scott Eggener: Yeah, I'm the sucker that's finally at a point in my career I'm willing to stand up in front of large crowds and share some of these experiences. And the main thing is hoping to kind of just break the seal and open it up so that everyone kind of acknowledges that we all experience this to one degree or another when patients have complications. Unless you're a sociopath, you hurt and you wish you weren't involved in it and you want to do better. And the cool thing is there's a lot of movement in individual programs and even societies and universities and in other countries trying to make this part of the curriculum with our trainees. I think there's a lot that can be taken from it, but step one is just acknowledging that it happens and steps that might help an individual get through it, heal, understand that it's a universal experience of surgeons.

Zach Klaassen: In terms of a curriculum, what would you envision for our trainees? I mean, I think they see us talk to patients in the clinic and when we mention these devastating potential complications to patients the patients are scared, and of course they are, but it's an important conversation. But when we're talking about it actually happening, what would you see as key components for a trainee?

Scott Eggener: I've wrestled with that and tried to think of it, and there's groups of people that have far more mature programs in it. I can tell you what I've done just recently with our group of trainees and residents and fellows is had them over to my house and we talked about it. We sat in a circle and they just needed to know that they're attending sometimes to struggle emotionally and whether we show it or not, and just acknowledging that you may be experiencing it. I try to have residents come with me when sharing bad news with patients' families. If we collectively have a complication I try to follow up with them afterwards to make sure they're doing okay.

There's universities like Ohio State that have a first responder unit when bad things happen to take care of the physicians, nurses and staff and check in on them and their mental health. And then probably the best in urology, in Bournemouth, England, there's been some resilience training that Kevin Turner has spearheaded and published about. And Jeremy Grummet in Australia has a program for USANZ trainees where he had a half day session on this topic and a very thorough curriculum on it and kind of piloting that.

Zach Klaassen: That's great. I think you're right. I mean, I think having them see us go talk to families, and not that we're experts in it but we're the ones responsible as the attending surgeon. I think that's a big part of it. And in those complications that maybe happen post-up day one through whatever, I think one of the important messages for trainees that are listening, and obviously you and I probably do the same thing, is it's easy to feel like you're guilty or you've done something wrong or something happened that you wish you could have changed, but it's important to bring those family members and the patients closer when you feel like you're pushing them away. The human nature is to back off, but you've got to even go further in. I mean, that's how you get these patients and families through it, even if the prognosis is dire.

Scott Eggener: Heck yeah, I couldn't have said it any better. You've got to lean in. Sometimes it's hard. Sometimes there's a lot of self-loathing and shame. You've got to become more available. They all get my cell phone number, email address, everything, and they take a lot of comfort in knowing that you're going to be with them throughout. I'm blown away in a very positive way from patients and families, if you look them in the eye and you're transparent, they often and typically understand and they're not pointing fingers and pissed off.

Zach Klaassen: Some of the greatest resilience I've seen is in family members of an ICU patient on, let's say, an anastomotic breakdown of a cystectomy, and they go back and it's like when you see their resiliency it almost makes you... it's hard to explain how that impacts us as surgeons, and they know that you're doing what you can and it's just their understanding level is incredible. Obviously, they're going to go through months and even years of introspection if the patient passes, and we don't know that and certainly we haven't been there, but that resiliency in those moments is incredible. I've seen that myself too. Let's see if there's somebody out there, I mean, junior faculty, they're coming in, they've done an SUO fellowship, they're trained to do all these big operations, and let's say they don't have that support system when they do have a bad complication. What's your recommendation for these folks, one to three, five years, in practice?

Scott Eggener: I suspect it looks different for everybody and there's no kind of recipe to get through it. Obviously, there's things you need to avoid like holing up, not talking to anyone, alcohol, drugs, I mean, those are real issues that happen. I can only speak for myself and having heard from others what works. Things to get your mind off things, whatever that might be, some activity, yoga, meditation, exercise, talking to people. I find solace and therapy in talking to folks and I think the single best therapy for me are talking to like-minded urologists who do similar cases, who have been in similar situations and they just listen and support and we check in on each other. I have a wonderful spouse who's super supportive, but under no circumstance can she understand what it's like to walk in those moccasins. It's a unique kind of band of brothers and band of sisters that we have, and I think that's the most valuable is don't be afraid to speak up and seek support and sometimes even professional support if needed.

Zach Klaassen: Yeah, absolutely. That's well said. I think you bring up a good point about the families and likewise of great family support, and they'll give you your space and they'll listen but you need people that truly understand and they've done this and they've gone through it to really be on that same wavelength, which is important for sure. Great conversation. Anything you want to just give our listeners that we haven't touched on?

Scott Eggener: I guess it's worth noting, I should have mentioned at the beginning, the glorious part of our job, Dr. Klaassen, and you know this, there's infinitely more wins than losses. You alluded to it. And I think we should also be doing a better job of celebrating the wins with your patients, their families, hugs, high-fives, your team members that you work with. I mean, we historically don't do that. We should, because there will be some hits and blows and losses at some point that are going to hurt like hell, but let's enjoy all the wonderful elements of our job.

Zach Klaassen: No question. There's such a victory when you get to clinic and you see those patients that are a couple weeks out and they've done well. And like you said, that's the majority. We do have the hits but the wins are awesome and we do need to do a better job with that. You're absolutely right. So Dr. Eggener, thank you so much. It's been a great conversation. I know people will find this valuable and I thank you for your time today.

Scott Eggener: Thanks so much for covering it.