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When Things Go Wrong

The Surgeon as Second Victim

Bohnen, Jordan D., MD, MBA*; Lillemoe, Keith D., MD*; Mort, Elizabeth A., MD, MPH; Kaafarani, Haytham M. A., MD, MPH

doi: 10.1097/SLA.0000000000003138
SURGICAL PERSPECTIVES
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SDC

*Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA

Massachusetts General Hospital and Massachusetts General Physicians Organization, Boston, MA

Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA.

Reprints: Haytham M. A. Kaafarani, MD, MPH, Associate Professor of Surgery, Harvard Medical School, Department of Surgery, Massachusetts General Hospital, 165 Cambridge St Suite 810, Boston, MA 02114. E-mail: hkaafarani@mgh.harvard.edu.

The authors report no conflicts of interest.

Dr. S is a regular at weekly morbidity and mortality (M&M) conference, a well-known surgeon with excellent technical skills and a wealth of clinical experience. He shares his opinions freely, challenging others when warranted and supporting them when the situation calls for it. He owns up to his own complications too, admitting his mistakes and accepting when the unavoidable arises. Dr. S is a master surgeon. We all know him. His opinion matters.

One Thursday morning it was Dr. S's turn to describe a difficult case of his that went horribly wrong. Mr. P was an elderly gentleman with a mass that needed resection. The case started well but a technical error at a critical moment led to uncontrollable bleeding. Heroic efforts were attempted by a dedicated team, but Mr. P died on the operating room (OR) table.

Dr. S took the M&M floor to describe the case, his tone unusually subdued. His words were slow, humble, introspective. We listened in silence. His pain was palpable. It was hard to watch.

In a quiet moment, away from the crowd, we asked Dr. S if he was doing ok. Eyes distant, he said it would take him several months to fully move on. This was his usual “processing time,” his time for reconciliation. This was not his first major intraoperative adverse event, or patient death, and he knew it probably would not be his last.

As young surgeons, our senior faculty are our heroes. We learn from them—often through our own mistakes—that there is very little we can do that they can’t fix. We write down and emulate their techniques as we transition to become attending surgeons ourselves. It is strange to see our heroes grieving. But they are human, and like the rest of us they suffer when things go wrong.

The term “Second Victim” refers to a healthcare provider who suffers emotional distress following an adverse event or medical error. Originally described by Wu,1 the expression has been around for several years. However, our understanding of surgeons (and other physicians) as second victims remains limited, lagging far behind our general understanding of medical errors and their impact on patients.

In a recent study, we asked a cohort of academic surgeons in Boston to describe their experiences with intraoperative adverse events and the emotional impact these events had on them.2 The responses of over 125 surgeons provide alarming insight into the distress faced by many of our colleagues when things go wrong in their OR. Over 90% of respondents reported experiencing an intraoperative adverse event, most commonly within the last year. More importantly, almost every respondent admitted to strong feelings of anxiety, guilt, sadness, anger, shame, and/or embarrassment. A few sought professional psychological counseling. Most striking were the pages-upon-pages of free-text comments submitted voluntarily by our colleagues, as if finally given permission to discuss their feelings, so often left unsaid in our stoic surgical culture. As one surgeon stated: “We all hide our grief, suffer in silence. The pain can be close to debilitating.”

Some quick math illustrates the potential scale of the second victim phenomenon. With over 230,000,000 operations performed globally each year,3 the annual incidence of complications and deaths from surgery is estimated at 7,000,000 and 1,000,000, respectively, worldwide.4 Each of these events is experienced not just by a patient and surgeon, but by a surgical team comprised of physicians, trainees, nurses, technicians, and others. The second victim phenomenon is far from unique to surgeons. Second victims are all around us in healthcare: the first responder grappling with memories of a horrific mass casualty; the seasoned nurse whose patient decompensated overnight; the pharmacist who overlooked a medication interaction; the therapist whose patient relapsed and committed suicide. For surgeons, the impact is particularly palpable when decisions and actions in the OR cause direct and immediate harm. We replay and relive these moments, suffering quietly, wishing we had done better.

Following Mr. P's death in the OR that day, each member of the team was visibly affected. A minute of silence was observed, the air heavy as though carrying everyone's unstated grief. Unfortunately, we do not know who from that day is still grieving, because we never stopped to ask.

When we lose a family member or friend, our culture has developed long-held rituals to help us grieve and recover. Yet, when we lose a patient, we rarely stop for longer than a minute of silence, or a presentation at M&M, to process the loss. In the absence of accepted rituals for helping colleagues deal with difficult events, each of us is left to cope and heal alone.

Amid long-overdue national conversations surrounding physician burnout and well-being, we cannot continue to ignore the cumulative impact that the second victim phenomenon has on the mental health of our workforce. Each of us is at risk. Many develop mechanisms to cope with difficult patient interactions; some adaptations are healthy, but others are harmful and could put our careers and personal lives at risk. System-wide efforts are needed to better recognize the impact that challenging cases have on healthcare providers, and to identify colleagues who are struggling. This requires a culture that supports second victims as much as it promotes the safety of our patients.

Second victims most commonly turn to peers for help.2 To this end, peer support programs have been described as a means to support colleagues in times of need.5,6 We recently established a Second Victim Peer Support program in our Department of Surgery with the goal of identifying and supporting our own colleagues at risk following difficult cases. Through this program, surgeons and trainees are identified by peers following major intraoperative or other catastrophic adverse events, and a confidential outreach effort is made to each individual to let them know that they are not alone, and that a trained peer supporter (a surgeon) is immediately available to chat. Additional resources are provided when appropriate. The program is supported institutionally within the umbrella of “peer-review activities” and is therefore protected from litigation, similar to Morbidity & Mortality conferences. Indeed—and perhaps unexpectedly—most of the surgeons we reach out to accept the offer to speak with a peer supporter. Since the program's inception last year, we have conducted close to 50 outreach interventions (to residents and attendings), with the significant majority (82%) of those contacted expressing their willingness to speak with a peer supporter. Feedback from second victims after speaking with a peer supporter has been overwhelmingly positive. Most report feeling relieved to have someone to speak to, and to know that others have been in their shoes. In a short period of time the program's impact on our culture is being felt, and a collective sense is building that nobody should be left to struggle alone. Ironically, discussions with peer supporters tend to shift the focus of conversation away from failure and vulnerability, and instead toward personal resiliency and a sense of rejuvenation. In this context, we believe that a robust second victim peer support program provides a much-needed counterbalance to some of the negative forces in the workplace that lead so many physicians toward burnout. Table 1 lists the components of our Second Victim Peer Support program, and steps that can be followed to launch similar programs elsewhere.

TABLE 1

TABLE 1

It is time to accelerate our collective efforts to mitigate the widespread impact of the second victim phenomenon. As Dr. S continues to recover in the wake of his patient's death, we must be conscious of the many other second victims among us. They, too, may simply be waiting for someone to start the conversation.

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REFERENCES

1. Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ 2000; 320:726–727.
2. Han K, Bohnen JD, Peponis T, et al. The surgeon as the second victim? Results of the Boston Intraoperative Adverse Events Surgeons’ Attitude (BISA) Study. J Am Coll Surg 2017; 224:1048–1056.
3. Weiser TG, Regenbogen SE, Thompson KD, et al. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet 2008; 372:139–144.
4. World Health Organization. Safe Surgery Saves Lives: The Second Global Patient Safety Challenge. WHO Press, Switzerland. 2008; p. 9. Accessed 3/11/2018: Available at: http://apps.who.int/iris/bitstream/10665/70080/1/WHO_IER_PSP_2008.07_eng.pdf.
5. Shapiro J, Galowitz P. Peer support for clinicians: a programmatic approach. Acad Med 2016; 91:1200–1204.
6. Hu YY, Fix ML, Hevelone ND, et al. Physicians’ needs in coping with emotional stressors: the case for peer support. Arch Surg 2012; 147:212–217.
Keywords:

intraoperative adverse event (iAE); medical error; peer support program; second victim

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