Editor’s note: In the April 2023 issue, we looked at medical mishaps and how physicians can deal with them. But sometimes a medical error affects a physician so much that it becomes extraordinarily difficult to move on, making them what experts call a second victim. This month, ENTtoday spoke to Karen Kost, MD, a professor of otolaryngology–head and neck surgery at McGill University in Montreal, Canada, who has studied the phenomenon closely and given several presentations on the subject, and Hillary Newsome, MD, an assistant professor of otolaryngology at the University of Connecticut Health, who shared her own story of a medical mistake that she made during residency and that has haunted her ever since.
Explore This IssueSeptember 2023
Karen Kost, MD
Q: Tell us a little bit about the term “second victim” and what it means, particularly for physicians.
Karen Kost, MD: Actually, you’d be surprised to know how few people know about the second victim syndrome. The term itself was coined by Albert Wu back in the year 2000, and it has, in recent years, deservedly received more attention from the medical community.
Basically, Wu described how adverse events occuring in healthcare settings impact more than just the injured patient. Obviously, the injured patients and their families are at the center—the first victim(s), as it were. The second victim, on the other hand, is the surgeon or physician (or caregivers) who may feel responsible for the event. Although second victims have gone largely unnoticed for decades, the impact of intraoperative adverse events on surgeons is profound and can be life changing.
One of the reasons the issue of second victims hasn’t been discussed much is that people don’t like talking about mistakes or adverse events, especially if they feel responsible. This is especially true for surgeons, who feel enormous pressure to be perfect because you’re talking about people’s health and well-being.
Surgeons may feel entirely responsible for an adverse intraoperative outcome, whether or not they actually are. There are many descriptions of surgeons/physicians who weren’t responsible and yet either felt that they were or were made to feel that they were. The impact on their lives was profound, leading in some cases to post-traumatic stress disorder or even suicide.
Q: How prevalent are second victims? Are there any data on the phenomenon, as it was described more than 20 years ago?
KK: I scoured the literature to see what’s out there, and there aren’t yet a lot of data. But what is published shows that adverse events and medical errors are certainly not rare.
A study from the Annals of Surgery in 2008 looked at almost 8,000 surgeons and found that almost 9% of them had reported a major medical error in the prior three months. Individuals who reported these errors frequently experienced depression, burnout, and a lower quality of life. Another study published in 2017 in the Journal of the American College of Surgeons looked at the effects of adverse events on surgeons from three teaching hospitals in the Boston area. Researchers found that 84% of the surgeons had experienced at least one adverse event (mainly intraoperative events) in the past year. They reported feelings of anxiety, guilt, sadness, shame, and anger. Residents can also be second victims. In a study from 2021, 88% of residents reported having been part of a medical error and went on to experience emotional sequelae including guilt, anxiety, and insomnia.
Q: In what ways does the second victim phenomenon affect physicians?
KK: It can happen to anyone in healthcare—otolaryngologists, internists, cardiologists, nurses, and all caregivers. More specifically, as surgeons, we’re trained with the expectation that nothing less than perfection is acceptable. Consequently, when medical adverse events occur, we feel like failures: diminished, depressed, inadequate, or simply not up to the task. We feel like we’ve failed the patient. We second guess ourselves.
The impact on a surgeon’s quality of life, and those around them, can be enormous. One surgeon said it very well: “We all hide our grief, and we suffer in silence.”
The pain can be debilitating because you feel like you can’t talk to anybody about it—second victims feel ashamed and are worried about being judged by friends and peers, and so they retreat, withdrawing from friends and colleagues, and the effects from that are enormous. Some people turn to drugs and alcohol. There are so many descriptions of individuals suffering from post-traumatic stress disorder-type illness, quitting the field, and even committing suicide.
Q: What kinds of support systems are in place for physicians?
KK: Historically, when a medical error occurred, the easiest thing to do was, and unfortunately often still is, to pin the error on somebody. Many institutions still tend to have a policy that automatically blames a physician after an error occurs; the physician is dismissed and the problem is “solved.”
But the problem isn’t solved because there are countless reports of errors that occur over and over because of failing or inadequate systems. For instance, one case involved an anesthetist who, in a moment of crisis as a patient crashed, set up a bag of what they thought was Hespan but was, in fact, a bag of lidocaine. The patient died.
We might say, how could they make a mistake like that? But the bags have the same shape and size, and the lettering is the same color: red and blue. It’s extremely easy to confuse them, especially in a tense moment.
My colleague, David Eibling, MD, from the University of Pittsburgh, has spent a good part of the last decade looking at these system errors. His group did a study looking at IV bags of Hespan and lidocaine that look so similar. In a simulation setting with a patient crashing, residents were asked to rapidly resuscitate the patient with IV fluids; bags of both lidocaine and Hespan were present. As it turns out, 30% of the residents erroneously reached for the wrong bag (lidocaine) instead of the Hespan bag.
So, here’s a clear example of similar labelling essentially “setting up” physicians to fail. Assigning blame does nothing to fix the problem. Ultimately, a better, more productive, approach is to examine why an error happened and ask, ‘What can we do to prevent this from happening again?’
At the moment, I would say most institutions have no formal support systems in place to help second victims. There are probably a variety of reasons for this, including the fact that it has only relatively recently been recognized as an important problem, and for institutions, there might also be challenging liability issues to navigate.
There is, however, increasing recognition of second victim syndrome, and some programs have led the way in developing strategies to help support second victims while still being able to cope with liability issues. The University of Missouri is one of the pioneers in this area; their forYOU team program was one of the very first and serves as a template for others. Johns Hopkins also has a program called RISE (Resilience In Stressful Events) that offers peer support to employees in distress.
I think the first and most important level of intervention involves, very simply, being able to connect with somebody else who has had a similar problem—and there are many of us! Within a department, it can be useful to identify two or three senior surgeons in advance who can be reached at short notice. In private practice, that individual might be a close colleague or mentor. Whoever it is should be able to listen, be empathetic, and understand that the second victim needs to talk in a setting that’s completely safe and confidential. I’m not a psychiatrist or a trained counselor, but I certainly can listen, be compassionate, and, very importantly, not judge. I can check in on them, and maybe help organize their schedule for the next few days so they can take a breather.
Offering help also means being able to recognize when professional assistance may be needed.
KK: Physicians/surgeons also need to be encouraged to overcome their reluctance to talk to somebody—we’re notorious for that because we feel ashamed, inadequate, and think we’re alone. It can be so comforting to know that you aren’t alone—others around you have, at some point, themselves experienced adverse events. And this, I think, holds true whether you’re in private practice or are a member of a department. When people in crisis talk to me, I tell them, “You know what? You’re not alone. This has happened to me too. And it has almost certainly happened to the majority of surgeons around you.”
The impact of being a second victim is so great that some people leave medicine altogether, and that’s a big loss to us. We’re taught to strive for perfection and we set very high standards for ourselves. We want to deliver the very best care every hour of every day—nobody wants a patient to have a poor outcome. But at the end of the day, we can’t be perfect. Adverse events are our worst nightmare. When they happen, we need to be able to reach out and accept the helping hand of a colleague.
Hillary Newsome, MD
Q: Please tell us your story.
Hillary Newsome, MD: Five years ago, I was at the end of my second-year residency, and that’s the first year you start taking calls by yourself. I got a call from the emergency department in the middle of the night about a woman who they said couldn’t lie flat but was okay otherwise. For us in otolaryngology, though, that’s a pretty big red flag—those two things together don’t make sense.
I hurried to go see her, and she was definitely not okay. She couldn’t really follow any commands, and I found out she had been on an oxygen requirement earlier. I thought, “Why didn’t they tell me that part?” I had been told that she was on room air.
I’m willing to admit that I’ve made a mistake and potentially hurt a patient just so that other people don’t feel like they’re the only one it’s happened to.—Hillary Newsome, MD
I recognized that this patient needed a secure airway, as she wasn’t going to be able to breathe by herself much longer. I had alerted my chief resident about it, who alerted the attending. Everything was being readied to get this patient in airway, either via intubation with a breathing tube or with a tracheostomy.
But, before everyone got there, the patient coded, and I was the only person from the ENT team there. It was up to me to give this patient a surgical airway, and I would say I was unsuccessful. My chief resident didn’t make it in, and although we did get the patient an airway, she was already deceased.
Q: I can hear in your voice how much it still affects you today.
HN: Yeah. I was so affected by that. I try to spread awareness about second victim syndrome, but in turn, I keep recounting my story. And it’s really easy to just go back there and feel helpless like that. I still question if I’m supposed to be doing this.
Q: What happened after the event, and what help did you receive?
HN: In the immediate aftermath, we obviously had things like the morbidity and mortality conference, where we essentially did a root cause analysis on the issue. I had to see a psychiatrist, and I also did some therapy. I started on an antidepressant.
But I almost quit my residency. I had a lot of meetings with my mentors and program director to see if I should continue or not. I have no idea what made me decide to continue, other than I [had] put a lot of time and effort into medicine. I don’t think of myself as a quitter; you can’t go this far and quit when it gets hard.
And I made other mistakes later, potentially because of that first one. Five years later, I still have a physical reaction to telling the story; I’m emotionally transported back to that night.
Q: What have you been doing to try to spread awareness about second victims?
HN: When I would talk to my mentors and program directors behind closed doors, they all said they’ve been in the same situation—they have a patient that they can’t get out of their head. But no one really broadcasts that. I’m willing to admit that I’ve made a mistake and potentially hurt a patient just so that other people don’t feel like they’re the only one it’s happened to.
Q: What advice would you have for others who may be in a situation like yours?
HN: Well, the first thing they have to know is how they respond to help. For me, talking things out can be cathartic, but for other people, that might not actually be the best thing.
I do think there should be some kind of debrief at their own convenience, but I also think it’s important to not necessarily pressure someone into what you think can be helpful as an outsider. They have to kind of be the ones to determine what is or isn’t going to work for them.
Our institution started a peer support program where if someone had a traumatic event, leadership would find someone with an equivalent role within the academic program who has the same temporal relationship with the training programs to reach out to that person. I was a resident peer supporter, and I remember talking to an OB/GYN resident who had made a mistake during a C-section that caused an adverse event.
Program leaders should let the person know that they’re there for them. Never once did my program make me feel like I was bad, or even that I had done something wrong—they never, ever gave me that impression. They only wanted me to feel supported, to carry on if that’s what I chose to do, and to get the help that I needed.
Amy E. Hamaker is the editor of ENTtoday.