You may recognize this image of a physician that went viral on social media. It depicts a grieving emergency physician whose 19-year-old patient had died. It gave the public an inside look at the anguish we often experience but feel uncomfortable expressing in front of patients, families, and staff.
Our culture dictates that there is no time to grieve. We are to pull ourselves together and proceed to the next patient as if nothing happened, a culture that in part contributes to second victim syndrome. You may not have heard of it, but you or a colleague likely suffered from it.
We all have cases that haunt us. We may have connected with a patient or his family only to witness him take an unexpected turn for the worse. We may, in hindsight, realize that we made a medical error and wish we had done something differently. We may learn about a negative outcome only after a complaint, legal action, or medical board inquiry is made, leaving us in a state of chaos. Tragically, there are two victims in these situations—the patient and the physician who is significantly traumatized by the experience.
Albert Wu, MD, created the term second victim to describe the negative experiences, emotions, and trauma of health care providers involved in an unanticipated adverse patient event, medical error, or patient-related injury. (BMJ 2000;320:726.) Another group of researchers outlined six stages that delineate the natural history of the second victim phenomenon. (Qual Saf Health Care 2009;18:325.)
The external and internal turmoil resulting from an adverse event mark the first stage. This is followed by intrusive reflections in stage two. Second victims replay the events over and over, analyzing and reanalyzing the situation. The physician may question his judgment about the care given, particularly if an error was implied or perceived. At stage three, the second victim seeks support, but he may feel isolated and unable to talk to his peers due to legal or privacy concerns. This isolation is further reinforced by the actual or perceived withdrawal of colleagues who have learned about the incident. This is, however, when the physician is most vulnerable and in need of support from his colleagues.
Inquiries take place shortly after the incident or over the course of several years if they are related to medical malpractice and conducted through the legal system. Stage four is enduring these inquiries. The physician is forced to re-experience the pain, self-doubt, and guilt of the original experience at this time. The physician will often obtain emotional first aid (stage five) during these inquiries from family, friends, colleagues, and therapists.
The sixth and final stage is moving on, which can be surviving and learning from the incident or negative outcomes, such as burnout, depression, persistent anxiety, self-doubt, substance abuse, and even suicide and early departure from the specialty or the place of practice.
Treatment for this syndrome is sympathy and support provided through a peer-to-peer support program. (Int J Obstet Anesth 2015;24:54.) The tragic outcomes of second victim syndrome can be significantly mitigated or prevented when an institution has a support system in place.
Second victims struggle to restore their personal integrity and experience self-doubt. Support from a respected peer can dispel the myths that a second victim is incompetent or that he has lost the respect of his peers. This support can remind a second victim that we all make errors and that negative patient outcomes are an unavoidable part of practice. Peer-to-peer support is part art and part science. It can and should be taught as part of a system response to an event, although it mainly requires a willingness to listen and provide nonjudgmental support.
Adverse events are unfortunate but unavoidable. We should remind ourselves that it is not a question of if but when this will happen to us, and we should practice self-compassion by being mindful that this does not define our career or identity.
Isolation is one of the first signs of this syndrome, and it should prompt us to reach out for help. There is hope and help for second victims that can come from the support of your institution, peers, or therapy. We can survive these incidents and even thrive after going through them. We can learn from the incidents and become supporters of our colleagues if they become second victims. Johns Hopkins Medicine (http://bit.ly/2ivYCIp) and the Center for Patient Safety (http://bit.ly/2iwPS4Q) have resources on second victims you can use to help yourself or your peers.