The idea of “perfectionism” in healthcare is not new. We have all heard and referenced the Latin phrase Primum non nocere: “First, do no harm.” Nonetheless, medical errors do occur, and harm does occur in healthcare. In fact, iatrogenic errors have been found to be the third leading cause of death in the United States. One of my attendings during training used to routinely say, “If you don’t have complications, you haven’t done enough surgeries,” implying that we will all experience bad outcomes, errors, and challenging complications during our careers. What he did not discuss, though, was how we would cope with such situations mentally.
Until last year, I thought I was a first-rate surgeon, with years of superb outcomes and happy patients and families. However, I had an aspiring athlete experience a terrible outcome after a routine soft tissue surgery. This patient’s family wrote a devastating complaint to our hospital, essentially asserting that I should never operate again. I read this complaint over and over. I started to think that I should not be a surgeon and that perhaps there was a way I could be a nonoperative clinician, sending anything operative to my partners. I then fell into what was probably clinical depression, although of course I did not recognize it at the time—and I certainly never saw a specialist about it. I was generally unhappy, did not have the energy or desire to do the 100 things I had to do every day, and expressed anger for no reason toward my husband and children.
After taking some time to consider the situation, I realized that I was experiencing what is known as “second victim syndrome” (SVS). “Second victims” can be physicians, nurses, or other healthcare providers who suffer mental and emotional distress from being involved in a medical error. Even though no actual “error” occurred in my specific situation, it was nonetheless a dreadful outcome which impacted the patient’s future. SVS includes feelings of guilt, shame, anxiety, and fear, with experiences of flashbacks, nightmares, or avoidance of similar situations. I still have absolutely no desire to perform this particular surgery.
It has been estimated that almost half of all healthcare professionals have experienced SVS during their careers. Research has shown that involvement in unintentional errors can have a lasting impact, including lack of concentration, burnout, depression, poor memory, decreased clinical confidence, and impaired work performance, with an increase in rates of errors in subsequent months. Post-traumatic stress syndrome can occur, along with a poor quality of life at work and at home. Physicians with SVS have increased their use of alcohol and/or drugs, have developed suicidality, and have left the profession.
Surgeons have reported physical symptoms after an error, including sweating, heart pounding, headache and physical tension, tremors, clumsiness, and low dexterity. A cross-sectional survey of 7,905 surgeons found that having made a major error in the previous three months was associated with a three-fold risk of suicidal ideation. In a study from the American Society of Anesthesiologists, 84 percent of respondents had been involved in at least one unanticipated death or serious injury of a perioperative patient, with 70 percent experiencing guilt, anxiety, and “reliving” the event. Many still had diminished appetites, continued guilt and sleeping difficulties, concentration issues, and symptoms of depression up to one year after the initial mistake. Approximately 90 percent required time to recover emotionally; 19 percent acknowledged never fully recovering, and 12 percent considered a career change.
Finally, burnout secondary to medical errors is directly correlated with reduced empathy toward patients, which adversely affects clinical performance and the doctor-patient relationship.
The World Health Organization declared Oct. 10 to be World Mental Health Day, with the objective of raising awareness of mental health issues around the world and mobilizing efforts in support of mental health. Sharing my experience is my personal step toward discussing mental health issues in my small sphere. There are many steps we can take to help alleviate some of the downstream effects of SVS, including: receiving support/counseling, analyzing/learning from the mistake, focusing on improving the system, enhancing provider wellness, and implementing culture changes.
Adequate support can reduce the distress of SVS. In a qualitative study at a Swedish university hospital, most informants expressed a need for support after an adverse event, including managerial/institutional support, peer support, and support through the investigation process. Reported barriers to obtaining support included a lack of awareness of the available support mechanisms, time constraints, concerns about discovery (e.g., lack of confidentiality, documentation, fear of legal consequences, negative impact on career), and stigma regarding mental health. Very few surgeons (<5 percent) were aware of potential support groups and few ever sought professional help.
In a survey regarding the impact of stress on surgical performance, all participants reported that they never received training on coping strategies. To cope with stress, surgeons reported talking with colleagues, friends, and families. Systems have also developed rapid response teams to contact affected surgeons within 24 hours of an event. Barnes-Jewish/Christian (BJC) HealthCare established a formal program called “Support Our Staff,” which consists of group staff debriefing, individual counseling, and root cause analysis. Our institution uses a similar program, titled “You Matter,” and we have also identified surgeon support staff who can be available for surgeons coping with SVS.
Analyzing and learning from mistakes not only help with coping, but also help to improve the system and future patient safety. Disclosing errors to patients may also help providers heal. I spoke with my husband (who is also a surgeon), other colleagues throughout my area, friends, and family. These conversations were incredibly helpful; oftentimes fellow surgeons would share their own stories, which all effectively minimized my mental distress.
Fostering an environment in which errors are openly acknowledged and systematically analyzed can help with continuous quality improvement. Physicians report that organizational responses to medical errors can be hostile, threatening, isolating, and fundamentally flawed. Morbidity and mortality conferences, peer review processes, and licensing and credentialing all traditionally single out the individual physician. Changing the culture should include fostering a nurturing, blame-free environment for openly discussing errors, promoting constructive discussions, and addressing the false notions of perfectionism.
Culture change can also include efforts to improve wellness, limit excessive work hours, establish mentoring programs, reduce stigma of mental illness among providers, and promote an environment of nurturing rather than humiliation. Focus must be placed on provider well-being to enhance patient safety. Work unit safety grades have been strongly and independently associated with perceived major medical errors. Exercise, meaningful activities, proper diet, adequate sleep, supportive relationships, and regular attention to personal health needs can minimize stress. Mindfulness training can reduce stress and increase empathy in surgeons in training and in practice. To learn more about how mindfulness may be a potentially useful tool for surgeons, see the article “What’s the Big Deal with Mindfulness?” published in the September issue of AAOS Now.
In hindsight, I wish I had sought counseling, but I actually did not recognize that I needed it at the time. In the end, my support system (including my husband, children, professional colleagues, parents, and friends) and wellness activities (staying physically fit, playing tennis, spending time with my family) were critical to getting me “back on track” emotionally. As I continue to practice medicine, I have been taught (and now recognize firsthand) that I will experience bad outcomes. Having done my research and learned more about these issues, my toolbox for coping is a little more robust. For the future, I hope my coping mechanisms will improve, my support system will remain steadfast, and my institution will remain compassionate.
Julie Balch Samora, MD, PhD, MPH, FAAOS, FAOA, is a pediatric hand surgeon at Nationwide Children’s Hospital in Columbus, Ohio, where she serves as associate medical director of quality for the hospital. She is also the deputy editor of AAOS Now.
References: (online only)
- Bergman B, Ahmad F, Stewart DE: Physician health, stress and gender at a university hospital. J Psychosom Res. 2003;54(2):171-8.
- Christensen JF, Levinson W, Dunn PM: The heart of darkness. J Gen Intern Med. 1992;7:424-31.
- De Boer J, Lok A, Van’t Verlaat E, et al: Work-related critical incidents in hospital-based health care providers and the risk of post-traumatic stress symptoms, anxiety, and depression: a meta-analysis. Soc Sci Med. 2011;73(2):316-26.
- Delbanco T, Bell SK: Guilty, afraid, and alone—struggling with medical error. N Engl J Med. 2007;357:1682-3.
- Denham CR: TRUST: the five rights of the second victim. J Patient Saf. 2007;3:107-19.
- Edrees HH, Paine LA, Feroli ER, et al: Health care workers as second victims of medical errors. Pol Arch Med Wewn. 2011;121:101-8.
- Fernando A, Consedine N, Hill AG: Mindfulness for surgeons. ANZ J Surg. 2014;84(10):722-44.
- Gazoni FM, Durieux ME, Wells L: Life after death: the aftermath of perioperative catastrophes. Anesth Analg. 2008;107:591-600.
- Goldberg RM, Kuhn G, Andrew LB, et al: Coping with medical mistakes and errors in judgment. Ann Emerg Med. 2002;39:287-92.
- Hilfiker D: Facing our mistakes. N Engl J Med. 1984;310:118-22.
- Hu YY, Fix ML, Hevelone ND, et al: Physicians’ needs in coping with emotional stressors: the case for peer support. Arch Surg. 2012;147(3):212-7.
- James J: A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf. 2013;9(3):122-8.
- Kauer AP, Levinson AT, Monteiro JFG, et al: The impact of errors on healthcare professionals in the critical care setting. J of Critical Care. 2019(52):16-21.
- Lander LI, Connor JA, Shah RK, et al: Otolaryngologists’ responses to errors and adverse events. Laryngoscope. 2006;116:1114-20.
- Marmon LM, Heiss K: Improving surgeon wellness: the second victim syndrome and quality of care. Semin Pediatr Surg. 2015;24(6):315-8.
- McClafferty H, Brown OW: Committee on Practice and Ambulatory Medicine. Physician health and wellness. Pediatrics. 2014;134:830-5.
- Panagioti M, Panagopoulou E, Bower P, et al: Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis. JAMA Intern Med. 2017;177(2):195-205.
- Plews-Ogan M, May N, Owens J, et al: Wisdom in medicine: what helps physicians after a medical error? Acad Med. 2016;91(2):233-41.
- Pronovost PJ, Bienvenu OJ: From shame to guilt to love. JAMA. 2015;314:2507-8.
- Robertson JJ, Long B: Suffering in silence: medical error and its impact on health care providers. J of Emerg Med. 2017;54(4):402-9.
- Rodriquez J, Scott SD: When clinicians drop out and start over after adverse events. Jt Comm J Qual Patient Saf. 2018;44:137-45.
- Sarsons H: Interpreting signals in the labor market: evidence from medical referrals [job market paper]. Working Paper. 2017. Available at: https://scholar.harvard.edu/sarsons/publications/interpreting-signals-evidence-medical-referrals. Accessed Sept. 28, 2021.
- Scott SD, Hirschinger LE, Cox KR, et al: The natural history of recovery for the healthcare provider “second victim” after adverse patient events. Qual Saf Health Care. 2009;18:325-30.
- Scott SD, Hirschinger LE, Cox KR, et al: Caring for our own: deploying a systemwide second victim rapid response team. Jt Comm J Qual Patient Saf. 2010;36(5):233-40.
- Seys D, Wu AW, Van Gerven E, et al: Health care professionals as second victims after adverse events: a systematic review. Eval Health Prof. 2013;36:135-62.
- Shanafelt TD, Balch CM, Bechamps G, et al: Burnout and medical errors among American surgeons. Ann Surg. 2010;251:995-1000.
- Shanafelt TD, Balch CM, Dyrbye L, et al: Special report: suicidal ideation among American surgeons. Arch Surg. 2011;146:54-62.
- Srinivasa S, Gurney J, Koea J: Potential consequences of patient complications for surgeon well-being. JAMA Surg. 2019;154(5):451-7.
- Tawfik DS, Profit J, Morgenthaler TI, et al: Physician burnout, well-being, and work unit safety grades in relationship to reported medical errors. Mayo Clin Proc. 2018;93(11):1571-80.
- Tumelty M: The second victim: A contested term? J Patient Saf. 2018. Online ahead of print.
- Ullstrom S, Andreen Sachs M, Hansson J, et al: Suffering in silence: a qualitative study of second victims of adverse events. BMJ Qual Saf. 2014;23:325-31.
- Ward S, Outram S: Medicine: in need of culture change. Intern Med J. 2016;46:112-6.
- Waterman AD, Garbutt J, Hazel E, et al: The emotional impact of medical errors on practicing physicians in the United States and Canada. Jt Comm J Qual Patient Saf. 2007;33:467-76.
- Wears RL, Wu AW: Dealing with failure: the aftermath of errors and adverse events. Ann Emerg Med. 2002;39:344-6.
- West CP, Huschka MM, Novotny PJ, et al: Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. JAMA. 2006;296:1071-8.
- West CP, Tan AD, Habermann TM, et al: Association of resident fatigue and distress with perceived medical errors. JAMA. 2009;302:1294-300.
- Wetzel CM, Kneebone RL, Woloshynowych M, et al: The effects of stress on surgical performance. Am J Surg. 2006;191(1):5-10.
- Wu AW: Medical error: the second victim. BMJ 2000;320:726-7.
- Wu AW, Folkman S, McPhee SL, et al: Do house officers learn from their mistakes? Qual Saf Health Care. 2003;12:221-6.
- Wu A, Cavanaugh TA, McPhee SJ: To tell the truth: ethical and practical issues in disclosing medical mistakes to patients. J Gen Intern Med. 1997;12:770-75.
- Wu AW, Steckelberg RC: Medical error, incident investigation and the second victim: doing better but feeling worse? BMJ Qual Saf. 2012;21:267-70.
- Wu AW, Shapiro J, Harrison R, et al: The impact of adverse events on clinicians: What’s in a name? J Patient Saf. 2020;16:65-72.
- American College of Surgeons: Chapter 8: Education: professional and community outreach. In: Optimal Resources for Children’s Surgical Care. 2021. Available at: www.facs.org/quality-programs/childrens-surgery/childrens-surgery-verification/standards. Accessed Sept. 28, 2021.
AAOS Continues to Advocate for Physician Mental Health Legislation
AAOS believes that clinicians must be able to freely seek mental health treatment and services without the fear of professional setbacks, so that their mental healthcare needs can be resolved rather than suffered through silently. AAOS has endorsed and is advocating for passage of the Dr. Lorna Breen Health Care Provider Protection Act (S. 610/H.R. 1667), which was introduced in March.
The bill is named in honor of Dr. Breen, an emergency room doctor who worked on the frontlines of the COVID-19 pandemic in New York City. She contracted COVID-19, recovered, and returned to work but had trouble making it through her sometimes 18-hour shifts. She was treated for exhaustion and later died by suicide.
If passed, the bipartisan, bicameral legislation will:
- help establish grants for training medical students, residents, and other healthcare professionals to reduce and prevent suicide
- identify and disseminate best practices for reducing and preventing suicide and burnout among healthcare professionals
- establish a national education and awareness campaign to encourage healthcare workers to seek support and treatment
- establish grants for employee education, peer-support programming, and mental and behavioral health treatment
- commission a federal study on healthcare professional mental health and burnout, as well as barriers to seeking appropriate care
Learn more and advocate for the legislation at www.aaos.org/advocacy/advocacy-action-center/physician-mental-health.
Listen to an AAOS podcast episode on the legislation at www.aaos.org/thebonebeat-advocacy-21.