THE SECOND VICTIM: Collateral Damage In A Compromised Medical Outcome

A poignant scene in my memory is a colleague’s six year old son lisping a bedtime prayer “…..and please God, don’t let my father get sued” – His father happened to be an obstetrician practicing in Florida.

A reverberating slogan for this millennium is “to live to be a healthy hundred.” In this age of technological wonders, instant communication, precise testing and expectation of the perfect outcome, there appears to be no place for human falliability in medicine. “To err is human” does not apply to health care professionals.

Given this background, we still have the sobering statistic of medical errors occurring in 5-10%, and in some studies upto 50% of hospitalized patients; 34% of internal medicine residents report atleast one major medical error during their training and 16% of multi disciplinary residents report an adverse event related to their care in the previous week. These are self-reported statistics; no good data exists for attendings or physicians out in private practice, and most certainly there is no way of evaluating the “near misses”

The medical profession has taken cues from the airline industry in an effort to reduce such errors and both academic medicine and regulatory agencies have instituted a plethora of cautionary rules to improve patient safety. However we still work in a “Name, Blame, Shame” environment.

What is not often discussed is the impact of these adverse events on the physician and health care provider, now termed as the “Second Victim”, the first victim being the affected patient.  The second victim is defined as healthcare providers involved in an unanticipated outcome or in a medical error and or patient related injury and are now traumatized by the event. Frequently they feel personally responsible for the outcome; many feel as though they have failed the patient, second guessing their clinical skills and knowledge base.

The emotional impact ranges from loss of confidence (44%); reduced job satisfaction (42%), difficulty sleeping (42%), feeling their reputation has been damaged (13%). There is threefold increase in depression, burn out, and decrease in overall quality of life. The physician reenacts the events over and over again, is distracted and thereby prone to more errors, limits his practice and avoids certain procedures or refuses to implement new procedures. These effects are long lasting and occur regardless of number of years in practice.

Needless to say, there is a negative impact on interpersonal relationship with significant repercussion on close family members. The ultimate impact is the individual abandoning his profession or committing suicide.

The malaise is compounded by the invariable threat and inevitable commencement of litigation. The initial admonition the physician receives on reporting an adverse event to his malpractice carrier is “Absolutely, do not discuss this with any one,” thus losing the ability to obtain any solace from colleagues and peers.  A minority ethnic background or gender, where the individual may not be “one of the boys” adds to the feeling of desolation.

Great Britain celebrated the Diamond Jubilee of their Queen Elizabeth this year. What is mostly forgotten is the “Triple Tragedy of 1877” which changed the line of succession and changed obstetric practice to allow intervention in protracted labor. Princess Charlotte, the extremely popular and only child of King George IV, would have inherited the throne of England. She was married at age 17 to Prince Leopold of Saxe Coburn – Gotha. She suffered 2 miscarriages before carrying her third pregnancy to term; her personal obstetrician was Dr. Richard Croft who belonged to the non-intervention school. After a fifty hour labor she delivered a stillborn 9lb male. She appeared to be doing well but five hours later grew restless, had breathing difficulties, continued to hemorrhage and died despite all valiant efforts of a host of physicians. The country was plunged into mourning akin to what followed the death of Princess Diana. Three months later Sir Richard Croft shot himself, unable to live with the veiled criticism and feeling that he had been responsible for two deaths. Subsequently the King’s fourth son, the Duke of Kent, fathered Queen Victoria. Had Charlotte survived she would have been the queen and there would have been a Charlottan age instead of a Victorian age.

Cultural changes and coping strategies are needed to prevent the second victim tragedies. In a culture of blame, the thrust, whether it be in a morbidity/mortality meeting, or quality assurance or peer review committees, is to identify one or more individuals to hold accountable and impose sanctions. This leads to people trying to cover up, not report errors or near misses which could be learning opportunities and try to shift blame and grab on to a quick fix solution. Enlightened institutions are changing the emphasis to a “root cause analysis” and an effort to provide an opportunity for error acknowledgement, open discussion and mentoring. Dr. David Marx in his book “Whack –a – Mole –The Price We Pay for Expecting Perfection” states that professionals will make mistakes, and may develop unhealthy norms. There should be a distinction between a human error where we console, at-risk behavior where we coach and reckless behavior where we punish. He suggests an overhaul of our system, just as New Zealanders did more than 30 years ago, where they gave up the right to sue their doctor and chose to accept a national responsibility to take care of those who were injured.

Such a radical change is unlikely in our life time.

We need to focus on prevention, as the first key, understand and accept that we are human, and that a need for support is not a sign of weakness. Institutional support comes from educational curriculum, at times counseling, and above all peer support. The supporting individual needs to be one who is admired and respected, and has listening skills and can keep strict confidentiality A culture shift will be necessary to allow the appropriate healing of affected individuals so they can move on, learn, correct and remain productive physicians.

Those of us subscribing to an eastern school of philosophy may gain some solace from the feeling that our acts and outcomes are just predetermined manifestation of a karmic destiny. As an organization AAPI could look at establishing a “Second Victim Support Group”; comprising of committed multi-disciplinary  physicians from different scopes of practice willing to give of their time and energy for their anguished brethren.      Gynecology – Orlando, Florida

Acknowledgement – Patrice M. Weiss MD., Physician Recovery from Medical Error

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