Second in a series
More than two decades later, Dr. Gary Brandeland still remembers the day his patient died after an anesthesia catastrophe during a delivery that was supposed to go normally. He remembers looking out the window and seeing nurses "literally running to their cars to escape the horror of what had just happened."
In a gut-wrenching essay in Medical Economics, Dr. Brandeland describes the days, weeks and months that followed: how his colleagues avoided him, how patients walked out on him, how he felt "like I was being beaten with a baseball bat, physically and emotionally."
They’re sometimes called the second victims – the doctors, nurses and other health care providers involved in an event that harms or kills a patient.
In a paper originally published in 2000 in the British Medical Journal and now considered a classic, Dr. Albert Wu of the Johns Hopkins School of Public Health writes about how health care professionals feel when something goes wrong:
Virtually every practitioner knows the sickening realization of making a bad mistake. You feel singled out and exposed – seized by the instinct to see if anyone has noticed. You agonize about what to do, whether to tell anyone, what to say. Later, the event replays itself over and over in your mind. You question your competence but fear being discovered. You know you should confess, but dread the prospect of potential punishment and of the patient’s anger.
A study that looked at the impact on doctors of medical mistakes found that physicians often remembered mistakes in detail, even after several years. Even the perception of having made an error left physicians with "significant emotional distress," the researchers found.
When Massachusetts General Hospital hosted a roundtable session to allow staff to share their own experiences about making an error, the topic struck a painful nerve.
The participants talked about feeling guilty, vulnerable, anxious. They often felt a strong sense of responsibility, and they agonized over what they might have done differently.
It was apparent that people could actively recall exactly how they felt at the time the error was realized and that these emotions can imprint a permanent emotional scar.
Some of them coped with it by rationalizing their actions, minimizing the harm or blaming the patient or the disease process. Others had a crisis of self-confidence in their skills and abilities.
One of the findings from the roundtable was that health care teams often pulled together when the patient was harmed in spite of high-quality care:
In situations when the right thing had been done but an unpredictable adverse outcome or a foreseen detrimental outcome occurred, staff often found solace in the fact that they had done or attempted to do the right thing to the best of their ability at that time. In such situations, teams often shared responsibility in a protective liaison.
Historically, however, health care professionals – especially physicians – who’ve been involved in an injury to a patient have often looked in vain for support from their colleagues. Here’s Dr. Wu again:
Sadly, the kind of unconditional sympathy and support that is really needed is rarely forthcoming. While there is a norm of not criticizing, reassurance from colleagues is often grudging or qualified… It has been suggested that the only way to face the guilt after a serious error is through confession, restitution and absolution. But confession is discouraged, passively by the lack of appropriate forums for discussion, and sometimes actively by risk managers and hospital lawyers. Further, there are no institutional mechanisms to aid the grieving process.
Nurses, pharmacists and other members of the team also are vulnerable to the fallout from medical error, Wu said.
Given the hospital hierarchy, they have less latitude to deal with their mistakes; they often bear silent witness to mistakes and agonize over conflicting loyalties to patient, institution and team. They too are victims.
What can be done to make the experience of error less harrowing for the health care professionals involved? Experts suggest the same approach as for the patients and families who are victims: bringing it out into the open so they can understand and learn from it.
The hosts and authors of the roundtable survey at Massachusetts General Hospital say this is "the first step in minimizing the emotional damage to both the patient and the doctor."
Expressing regret to the patient and trusted colleagues starts the process of learning from the error, taking measures to prevent recurrence and facilitating emotional adjustment. Hiding a "heart of darkness", soiled by guilt and fear, often causes a physician to harbor significant emotional distress.
Support also is important, according to Medically Induced Trauma Support Services, a nonprofit Massachusetts group that offers information and emotional support to clinicians as well as patients and families who’ve been involved in an error.
We come to work every day to provide the very best care for our patients, and when things go wrong we are not well trained to deal with the aftermath of these events, nor is the healthcare system designed to provide us with support. We are often left feeling isolated and with a sense of shame, guilt and incompetence. The fear of litigation discourages communication with patients, families and colleagues, and the involved care providers are expected to return to their routine patient care as though the event was absent of emotional impact.
Dr. Matt Anderson, a young Minnesota physician, learned lessons in humility and tolerance after being sued early in his career. In a prize-winning essay for Minnesota Medicine, he pleads with his peers to give each other the benefit of the doubt. "I tell them that all the best practices and all the risk-management protocols in the world may not protect them if they get a bad result," he wrote. "It happened to me."
Next: The hardest words