As I reflect on my 17-year career since fellowship training, I can recall a dozen or more sentinel events. At least six were particularly devastating and profoundly eroded my mental health and contributed to my burnout. Four occurred during the first decade of my career, when I had no awareness about burnout or well-being. In the past seven years at my current health system, I have experienced two more. Serving in leadership roles as division chief and surgeon-in-chief did not shield me. I have only heard of the term “second victim” within the past two years.
Explore This IssueApril 2020
Second Victim Syndrome
First coined by Dr. Andrew Wu in 2000, “second victim syndrome,” as described in a KevinMD article (2019), involves “suffering that the healthcare 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.”
But it’s more than that. I have experienced what must be similar to post-traumatic stress disorder, even if I have no frontline military or war experience.
I received a call from an outside ED one Wednesday morning, around 8:30 during a busy clinic day with 30 patients scheduled. “Your patient, “xxx,” has been pronounced,” the person said. I remember repeatedly asking, “Excuse me, I don’t understand. What do you mean “pronounced?” The voice on the other line stated that a five-year-old, on whom I had performed a T&A two days prior, was brought in by paramedics, pulseless and unable to be resuscitated. “Are you sure?” I asked repeatedly. I knew this child very well. I had trached him at six months of age for severe laryngomalacia, and he had been decannulated for over three years. He had undergone routine T&A for sleep-disordered breathing from severe tonsillar hypertrophy. His grandmother, who was his legal guardian, had found him in bed, cold and breathless, without any signs of bleeding or reason for the inconceivable death.
I still remember collapsing with the phone in my hand, crying hysterically. The first person I called was the one partner that I was closest to in the group. He tried to console me over the phone. My nurse asked me if I wanted to cancel the clinic. My answer was simply “no.” After all, the idea of canceling patients was not acceptable to me, even when in shock. I managed through that day somehow, holding back the tears.
Two days later, I arrived by 6:45 a.m. to about 15 ambulatory cases. There were at least seven T&A cases. I remember sitting curled up in the corner of the small physician lounge, crying and shaking uncontrollably, unable to fathom how I could ever perform another tonsillectomy again. If death was possible after a routine operation, I was paralyzed by the reality and implications of the rest of my career as a pediatric otolaryngologist. My anesthesia colleague pulled me off the floor and gently asked me if I wanted to cancel my cases and go home. I chose to stay, again. Cancelling any patient was not acceptable; stopping for any reason, because I was not well, was at that time not a possibility I could understand. Patients and families can’t be let down. This was not their “problem.” I completed all cases that day but recall my hands shaking with every tonsillectomy. I attended the funeral of my patient that Saturday, and had the pastor and others come up to me and say, “Oh, you’re the surgeon.” Perhaps it was paranoia after days of insomnia, but I think I heard whispers as his family and friends pointed at me. I was numb for weeks, then months. I was afraid with every tonsillectomy case.
I can’t remember the exact timing of my next sentinel event. It was another routine outpatient T&A on a healthy 16-year-old who was the daughter of an acquaintance. About one week post-op, I received a frantic call from the father that she was bleeding so briskly that as they tried to get her in the car to go to ED, she lost consciousness. I instructed them to call 911 and to go to our children’s hospital, as I would meet them there. As I rushed onto the freeway, I received a call from the paramedics that they needed to go to the closest regional trauma center due to the severity of acute bleeding.
Three physicians transported her to the OR, with the ED physician using a tonsil sponge to apply direct pressure to her throat. The adult ENT who covered that ED and the anesthesiologist transported her quickly upstairs to the OR, while I watched helplessly next to her father. Within a minute, OR nurses came running out asking for me to scrub in.
Awake tracheostomy. Seven units of RBC transfused, with Hgb still at 4. Twenty-two units of platelets. Three doses of factor VII. Repeated attempt to suture left inferior fossa resulted in nothing but continuous arterial bleeding. There was blood everywhere. Finally, ligation of the external carotid (answer from one of my four oral board questions in 2002) stopped the bleeding. I rode in the back of the ambulance, holding on to her fresh tracheostomy during transport to the children’s hospital where I was staff.
She survived. I did as well, barely.
For months, I had nightmares every night. My husband and toddler daughter had someone who was not their mother or wife, but someone who left the house every morning and came home night after night. I can’t remember if I ate or lost weight. I was a zombie. I didn’t have help. I spoke to no one. I didn’t have time. The trauma, mixed with shame, guilt, grief, and intensified fear, consumed me.
Another event was the inadvertent burn injury through the oral commissure of one of three brothers scheduled for consecutive T&A cases. The surgery center had replaced the Covidien Bovi Teflon-coated cautery tip with a less expensive brand without telling me. The 2 mm gap unintentionally left by the surgical technician, who had inserted the tip to the handpiece, resulted in a lack of insulation where the handpiece made contact with the oral commissure. At the end of the case, when I finally noticed the injury, I was hysterical. I did pull myself together, tears and all, and then went out to apologize to the parents and accept full accountability for causing harm. I told them I fully understood if they wanted to cancel the next two brothers. They didn’t. I performed the next two T&As flawlessly, with intense fear and shaky hands.
About five years ago, I received notice of a lawsuit for a case that had occurred over eight years prior, alleging that I caused learning disability in a child who had a residual small eardrum perforation after tympanostomy tube extrusion. The perforation had been repaired by a colleague after I moved out of state, with normal post-operative hearing per audiogram. I had always dictated my own operative report instead of having a resident do it, but on this day, for this case, a resident had dictated the operative report, and there was an error. Luckily for me, I had practiced for a decade in two states but lived in the one with tort reform, a patient compensation fund, and a cap on noneconomic damages. For two years, I worked with an excellent attorney appointed by the state. On nights and weekends and during a few in-person meetings, we pored over thousands of pages of documents. Despite my insistence that I get my day in court, she advised me to settle. The county and state from which the suit was filed had a track record of 99% decision in favor of the plaintiff, regardless of the facts or science. Until we arrived at a final settlement, I felt an elephant sitting on my mind and chest on a daily basis.
I have a history of depression from losing my mother to breast cancer at age nine. That same year, my father remarried and we immigrated to the U.S. None of us knew English. Years of adolescence pained by harsh cultural and parental lack of affirmation resulted in low self-worth despite academic achievements. My early life provided enough pain and suffering and established a pattern of a lack of mental well-being.
The first time I experienced counseling was in medical school, after a long dysfunctional and damaging relationship. No one talked about mental health or counseling for medical students during my medical school years. The next time was during residency, after a broken engagement. I faintly recall hiding the shame and fear of stigma if others knew. I continued to work daily as assigned and hope no one noticed my flat affect or change in demeanor. I do recall OR staff commenting that I had lost a significant amount of weight. In retrospect I will always be grateful to my chair and PD who helped direct me to the mental health treatment I received. It was not until a few years into my career post training that I experienced counseling again. This time it was marital counseling, a result of my lack of awareness of the high degree of burnout I was experiencing after dealing with infertility, then a miracle pregnancy, and all the time working furiously to “achieve.”
Why We Need Change
I share all this not to garner sympathy, but to provide context for my passion and commitment to inspire and create change in my own health system and others. I am by no means the only second victim. In fact, every healthcare professional who is part of their patient’s journey of disease and healing, recovery, or death is a potential second victim. We are all at risk, because we simply can’t guarantee perfect outcomes, even when we give the best care possible.
Despite years of widespread academic and media acknowledgement of physician burnout, most health systems and hospitals likely still underappreciate the prevalence of burnout in their own medical staff and workforce. The competing demands and the ever-growing gap in revenue versus volume achieved continue and change our entire daily experience from one of joy to one of frustration, anger, extreme fatigue, and hopelessness. Despite increased awareness, effective systematic solutions for individuals and organizations are not obvious and typically slow to implement. Physician suicides are tragically still occurring, upwards of 400 or more annually (NAM Perspectives. 2016. Discussion Paper, doi: 10.31478/201606a).
I have observed that health systems have a blind spot for understanding the unique challenges and specific mental health support needed to adequately address the sentinel events physicians and healthcare workers may experience.
The Problems with Employee Assistance Programs
All employers, including academic centers and health systems, assume mental health is adequately addressed because human resources offers an Employee Assistance Program (EAP) as a benefit. EAP is a mandate by the U.S. Office of Personnel Management, described as a “voluntary, work-based program that offers free and confidential assessments, short-term counseling, referrals, and follow-up services to employees who have personal and/or work-related problems.” Most of you reading this article will likely never go to human resources and ask for mental health support through your EAP. Physicians generally have a negative bias against human resources, associating the department with receiving corrective action, being let go, or being fired. We all know about and fear the stigma of letting anyone know we need help. Who would share that they are in crisis with their employer and have that information get in the human resources file or be reported to the state board?
I have observed that health systems have a blind spot for understanding the unique challenges and specific mental health support needed to adequately address the sentinel events physicians and healthcare workers may experience. —Julie L. Wei, MD
Furthermore, the EAP service is often a third-party vendor, and while it provides several free sessions, often no one has vetted the list of mental health counselors it provides. The providers listed may no longer take new patients, sometimes don’t call back, and often do not have experience treating physicians. I have yet to meet a physician colleague who has ever utilized this service as a way to access mental health counseling. After using free EAP sessions, people who require ongoing counseling still need to find a provider who is in network for their insurance plan.
24/7 Mental Health Support
I am grateful that senior human resources and physician leadership at Nemours Children’s Hospital, where I work, listened when I brought these concerns forward. Our hospital now contracts with a dedicated psychologist who has treated physicians for more than 30 years. Last summer, when we welcomed the first class of pediatric residents, we implemented a Resident and Faculty Wellbeing Program. The absolute most impactful aspect of our program was the creation of a 24/7 immediate access mental crisis line for all residents and faculty. The psychologist rotates being on call with a team of three additional psychologists. When physicians call this line for acute crisis, the calls are answered live or within 30 minutes. There is immediate de-escalation counseling provided on call, followed by a session the next day. After the acute de-escalation, the psychologist identifies for the caller a mental health counselor from our EAP list who is also “in network” for our insurance plan. The psychologist has vetted a list of mental health counselors and has confirmed that the counselors on the list have availability and experience treating physicians and healthcare providers.
Last summer, our program also had our psychologist meet with every chief and chair, senior physician leader, and incoming resident, one on one, for an hour. The goal was to establish baseline assessments of their mental health. Physician leaders will be expected to do this program once, but residents will do it every year. The psychologist also provides monthly sessions with the entire class of residents.
Residents and faculty have activated our immediate crisis access line over a dozen times. Sometimes chiefs or chairs contact me, and we activate the line for the physician in need who refuses to call for help or isn’t able to. This dedicated resource for acute mental health crisis and direct facilitation for ongoing mental health support is critical to ensure that no physicians are at risk for suicide.
I intentionally designed our Resident and Faculty Wellbeing Program to focus on addressing mental and physical health. We encourage participants to use an app, Engaged Performance Advantage, that has been customized for our medical staff, including all advanced practitioners. Every day, the app updates with a short read: something inspirational, practical tips to manage well-being, or a hot topic in healthcare or self-care. One day per week, the app sends a three-question survey that assesses sleep, emotional health, and well-being. For physical health, last year, every surgeon, as well as every chief, chair, and senior leader, attended an energy management training at the Johnson & Johnson Human Performance Institute. This was a great investment by the hospital. Attendees shared positive feedback and felt it was valuable, but the reality is that as soon as everyone returned back to our daily grind and stress, many admitted to not developing the new routines they had planned in order to increase individual well-being. We’ll continue to try initiatives to keep well-being at the forefront of conversations and daily experience.
In addition, in April 2019, Nemours hosted the “Do No Harm” documentary by Robyn Simon on physician suicide. I moderated a panel with two psychologists, an ED faculty whose husband had committed suicide in December of 2018, and the PD for our new peds residency program. It was hugely attended and created permission for all to discuss mental health needs for physicians and providers.
To create a culture of wellness, it’s imperative that we are brave and honest. We need to speak out and call attention to our own sentinel events as well as those sentinel events that affect our colleagues. We must design algorithms to quickly appropriate mental health counseling during sentinel events and not just focus on risk management. My next endeavor is to get our hospital to implement the notable Schwartz Rounds program for second victims. This program gives healthcare providers a regularly scheduled time to openly talk about the social and emotional stress that comes with their work. As long as each of us come together and help ourselves and one another, we will be better able to heal ourselves while healing others. We will always be able to get up again the next day, and experience life and humanity at its fullest.
Dr. Wei is division chief of pediatric otolaryngology/audiology at Nemours Children’s Hospital and director of the Resident and Faculty Wellbeing Program at Nemours Children’s. She is also a member of the ENTtoday editorial advisory board.