AAOS Now

Published 12/20/2023
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Casey L. Wright, MD; Harold A. Fogel, MD, FAAOS

Second-victim Syndrome Can Trigger Debilitating Psychological Responses

Editor’s note: This article is the third in a three-part series about physician mental health from the AAOS Committee on Healthcare Safety. Part one was published in the October issue, and part two was published in the November issue.

In contrast to the years of surgical training spent learning how to care for patients, orthopaedic surgeons spend almost no time learning to care for themselves when a poor patient outcome inevitably occurs. As a result, orthopaedic surgeons are particularly susceptible to a phenomenon known as “second-victim syndrome.”

Second-victim syndrome refers to the emotional trauma experienced by physicians and other healthcare professionals after a medical error or significant adverse event. Symptoms exist on a continuum of severity and encompass feelings of guilt, shame, anxiety, sadness, and anger.

Surgeons are particularly susceptible to second-victim syndrome, as they strive for perfection while working in a high-stakes environment in which adverse events can evolve rapidly with devastating consequences. Although these emotions may manifest after a medical error, sometimes they may be triggered simply by a perceived mistake on the part of the surgeon.

In addition to emotional distress, clinicians may experience cognitive symptoms such as decreased concentration or somatic symptoms, including insomnia and increased tension. This psychological response can be debilitating and contribute to feelings of burnout, especially when surgeons lack the time or support to process their response. In its most severe form, second-victim syndrome may manifest as posttraumatic stress disorder.

In the face of patient harm, feelings of “could have done more” are particularly distressing, as they are interconnected with concerns of not being enough for a patient. When a person is unable to process these emotions in a constructive manner, they risk losing self-confidence, experiencing increasing stress and anxiety regarding future patient care, and avoiding similar situations in the future. As a result, second-victim syndrome may have long-lasting implications. Younger clinicians—especially trainees—are particularly vulnerable, as they may have a less robust network of colleagues to lean on for support and have a smaller cohort of good outcomes to offset feelings of self-doubt after a bad outcome.

After adverse events
As described by Scott et al., healthcare professionals commonly experience six stages after an adverse event:

  1. experiencing chaos and accident response
  2. having intrusive reflections
  3. restoring personal integrity
  4. enduring the inquisition
  5. obtaining emotional first aid
  6. moving on

The first stage, chaos and accident response, refers to the event itself and the corrective actions taken by the healthcare team. This stage is followed by a period of intrusive reflections, when the clinician personally revisits the event over and over, asking themselves what they could have done differently. This can result in significant distress and ongoing distraction.

During the restoring integrity phase, they seek to reconcile their own actions and competence with the event. They may discuss the event with a colleague, often to seek affirmation that they are not to blame.

Next is the enduring inquisition stage, when clinicians may need to participate in a review of the event (e.g., a morbidity and mortality conference, licensing board review, lawsuit), resulting in further reliving of the event and stress about any potential consequences.

The clinician then progresses to seek emotional support, but they may struggle to find the appropriate person or resource. Loved ones outside of the hospital are often sought out, but privacy and legal restrictions may impede this connection. Thus, finding the appropriate emotional support may be challenging and add to personal trauma. At the conclusion of the process, the second victim “moves on” and may “thrive,” “survive,” or “drop out.” Those who thrive adopt a growth mindset and often utilize the experience to help their colleagues navigate similar experiences or improve the health system in which they work. Conversely, for some, the event may ultimately prove to be too traumatic, and they may decide to leave their position.

The role of peer support
The peer support program at the authors’ institution, PeerCare, is designed to provide peer-based support when medical professionals are involved in an adverse event or patient safety issue. The program is staffed by trained peer supporters from 11 departments who reach out to impacted staff following an adverse event to facilitate emotional well-being and provide guidance on available resources. In addition to being available on the institution’s intranet, the form to request a peer supporter is also available on the safety reporting site.

Clinicians who request peer support are contacted by a peer supporter within 24 hours, opening a channel of communication. The process is confidential and protected from peer review, which allows providers to speak freely. By educating staff on the significant psychological impact adverse events may have, peer support may mitigate distress, normalize the experience, and validate the staff member’s response. Additionally, by improving their knowledge regarding the manifestation of second-victim syndrome, providers may feel more empowered in the aftermath of an adverse event.

Orthopaedic surgeons will all experience adverse events over the course of their careers, and no one is immune to the ensuing emotional response. However, by understanding the natural history of second-victim syndrome and creating a robust network of supportive colleagues, surgeons can aim to decrease the severity and duration of symptoms. Perhaps, then, surgeons will be able to better care for both patients and themselves.

Casey L. Wright, MD, is an orthopaedic surgery resident at the Harvard Combined Orthopaedic Residency Program in Boston.

Harold A. Fogel, MD, FAAOS, is a clinical instructor of orthopaedic surgery at Harvard Medical School and specializes in spine surgery at Massachusetts General Hospital. He is a member of the AAOS Healthcare Safety Committee.

References

  1. Wu AW: Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ 2000;320(7237):726-7.
  2. 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(5):325-30.