In your words

Second victim syndrome: A doctor’s hidden struggle

When medical errors occur, the first victim is the patient and the second victim is the health care provider. The emotional effects of second victim syndrome should not be understated.

Editor’s note: This story was originally published by KevinMD.com and has been edited for The DO. It has been reposted here with permission. This is an opinion piece; the views expressed are the author’s own and do not necessarily represent the views of The DO or the AOA.

As physicians, we have embraced a calling where we help others. A commitment many of us fully relish. We are grateful for our patients and the families who put their trust in us as we diagnose and treat their sometimes incredibly complex illnesses. I have been genuinely inspired by the stories I have heard from patients and my colleagues on the work we do.

Yet, in spite of the incredible advancements in medications and diagnostics, mistakes do happen. Why? Because at the center of all this technology is a human — a physician. A physician who likely spent the better part of his/her early adult years learning and deciphering the mysteries of the body.

Many of us have read the Institute of Medicine’s report To Err is Human, which placed a big spotlight on the estimated 98,000 preventable annual deaths that occur from medical errors. This project asserted that this staggering projection stems not from bad people in health care; instead, it is from good people working in a bad and complex system.

Fatal errors and mistakes that cause harm to our patients will, undoubtedly, plague that patient and their family. This fact cannot be minimized. In our zeal toward creating systems and stopgaps toward patient safety and “patient first” campaigns, we have forgotten about tending to the physician.

Virtually every physician knows that sickening feeling when he realizes that he made an error, especially if it caused harm. He agonizes and replays the event over and over in his mind. It takes a mighty emotional toll on the doctor’s personal and professional life; there’s a sense of embarrassment, isolation, and failure.

What is second victim syndrome?

Dr. Andrew Wu in 2000 initially coined second victim syndrome. In cases of any medical error, the first victim is always the patient while the second victim is any health care provider (i.e., physician, nurse, patient care technician, paramedic, etc.) who was involved in that error. Second victim syndrome describes that suffering that the health care provider experiences as a result of the psychological trauma the event causes.

The emotional effects of second victim syndrome should not be understated. Symptoms of anxiety, depression, guilt, and loss of confidence are commonplace. There can be feelings of incompetence, self-doubt, and misery. Ultimately, this is a recipe for physician burnout. While the hospital organization is diligently performing root cause analyses and identifying the prevention of future errors, the physician is left in solitude.

Stages of second victim syndrome

Similar to grieving for the death of a loved one, there are specific stages that a health care provider suffering from second victim syndrome undergoes. As the authors of this paper clearly and succinctly describe in their 2009 study, each provider undergoes a six-stage recovery trajectory.

1. Chaos and accident response

Once the event happens, a flood of external and internal emotions arise. During the chaos and confusion, the physician must first attend to the patient and treat the potentially unstable patient, while simultaneously battling guilt and self-doubt. Many times, a peer or consultant is needed to assist with the patient, and the physician is further berated for the error.

2. Intrusive reflection

This is the stage of self-reflection and re-enactment of the scenario. This stage is filled with periods of isolation and internal questioning of oneself. The victim begins to doubt his ability to be a competent clinician. Daily work and patient care become increasingly challenging.

3. Restoring personal integrity

This stage is when the physician seeks the support of a trusted colleague if there is one. Many physicians do not know where to find help. At this stage, many physicians describe the inability to move forward, especially if there was no support from a colleague or attending physician.

4. Questioning

After the initial aftermath of the incident, the victim begins to wonder of the repercussions. Questions about job security, future litigation, and state licensure start to creep into the psyche of the physician. Equally challenging for the physician is the challenge imposed by HIPAA, which is poorly understood by many. Inquires such as “Can I talk about the case with a colleague?” or “Can I tell a family member or friend?” arise.

5. Obtaining emotional first aid

Everyone has their coping styles and mechanisms, but physicians in this stage express concern that they are unsure who (or where) to receive the support that is so desperately needed. Many are uncertain who is “safe” to confide in while being mindful of maintaining confidentiality. Some will reach out to family members but will provide a short or truncated version of the incident. Even attempts at formal professional support such as an employee assistance program can fall short.

6. Moving on — dropping out, surviving or thriving

In spite of the internal and external pressure to “move on,” the physician will enter one of three unique and specific pathways. Dropping out involves the physician leaving the current work environment or leaving the profession altogether. While many have their reasons for doing so, the intense and possibly haunting re-enactments drove them away.

Another conclusion involves merely surviving. The physician continues to provide appropriate care and meets expected professional performance levels but continues to be preoccupied by the event.

Finally, a physician can learn and grow from the event. The incident has changed their current practice patterns and allowed them to make long-term, sustainable changes for future patient care.

Many of us suffer alone. There is an incredible amount of shame, guilt, and self-doubt that engulfs the physician. As an emergency physician, the reality of this is a constant threat. Second victim syndrome is real. Many physicians who grow and thrive after an adverse event universally mention the need for a reliable support system. While the formal programs such as an employee assistance program can help, the support of a colleague cannot be understated.

‘Be an empathetic listener’

Be an empathetic listener. Remove any hint of judgment or blame. Share your personal experiences. The long and winding road of medicine is complicated and sometimes lonely. Let’s remember that we are not alone and that mistakes do happen. These do not define us — not as a person or a clinician. Seek the support of others so we can all learn, grow, and thrive in this incredibly wondrous and humbling career.

For further reading:

Medical mistakes happen. Here’s what helps.

New book says better communication is the key to reducing medical error

1 comment

  1. I teach the concepts of the medical provider as a “second victim” when medical errors that harm patients occur in my course on Health Quality. However I was recently informed by some experts and consumer advocates that the term, “second victim,” is controversial and indeed offensive to some consumer groups. There have been a number of papers on this topic recently:

    Tumelty ME. The Second Victim: A Contested Term? J Patient Saf. 2018 Dec 18. doi: 10.1097/PTS.0000000000000558. [Epub ahead of print]

    Wu AW, et al. The impact of adverse events on clinicians: what’s in a name. J Patient Saf. 2017; Nov 4. doi: 10.1097/PTS.0000000000000256. [Epub ahead of print]

    The most scathing paper I have seen is very recent:

    Arthur L. Caplan. No, Doctors Who Make Errors Are Not ‘Second Victims’ – Medscape – Apr 25, 2019. Available at: https://www.medscape.com/viewarticle/912206?src=WNL_infoc_190619_MSCPEDI_doctorError&uac=96100MR&impID=1999949&faf=1

    So, while all of the issues discussed in the article in The DO are true – providers do need support and do go through stages of recovery (there are well documented episodes where providers have committed suicide) – be cautious of using the term “second victim” with patients or around consumer groups.

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