The vast majority of births and deliveries are joyful ones. Families celebrate the wonder of the new addition to their families, and clinicians go home at the end of the day with a sense of pride, deriving meaning from their professional lives. This is one of the reasons that many of us chose obstetrics in the first place.
But unfortunately, that is not always the case.
As an obstetrician, I know firsthand that there is virtually nothing as emotionally wrenching as a baby or mother suffering an injurious complication or dying during childbirth. Unanticipated, bad, even horrific outcomes sometimes happen — even when all precautions have been taken. Even when things are progressing as planned. And even when the team does everything right to manage complications as they arise.
In the midst of and in the aftermath of these events, patients and their families are the first victims. We are trained — or hopefully, we learn over time — how to best support patients and their families in myriad ways when unexpected adverse events occur.
However, at the end of such a day, once I know the patient and family have been supported as best I can. As I leave the hospital and am finally by myself, I know I have never felt as desperately alone as I have felt in those times.
In many of these cases, we, as clinicians, are “second victims.”
Dr. Albert Wu first coined the term in 2000, when he stated, “Although patients are the first and obvious victims of medical mistakes, doctors are wounded by the same errors: they are the second victims.” Since that time, there is a realization that second victim experiences can occur in the absence of a medical error, even when everything is done right. This should not be surprising as it is unrealistic to think that we, as clinicians, can witness tremendous human suffering and not be impacted by it.
Unfortunately, an estimated 65 percent of clinicians who experience vicarious trauma deal with it alone. It presents itself in different ways and can include difficulty sleeping, flashbacks, a loss of confidence in our professional abilities, dread, overwhelming grief, anger, burnout, and depression. Some of us choose to stop practicing medicine altogether. Tragically, some of us even commit suicide.
As physicians, we are taught clinical detachment as a means of providing objective medical care — and, indeed, that detachment when combined with compassion yields better outcomes. But when unexpected and adverse clinical events happen, after management of the patient and family, we need to pause and recognize that we may also be suffering and recognize that we may also benefit from compassionate support.
In some cases, we may be coping well in the aftermath of a difficult event, but then we are retriggered by having to review the details of the event in quality assurance meetings, with risk managers, or when litigation arises. Authors of a 2010 study on the emotional impact of malpractice characterize it as being “much like running a movie scene over and over, but the coping strategy is self-defeating because the outcome of the event never changes.”
In most non-medical work environments, employees turn to their peers for support after a mistake. But most work outcomes don’t impact human life. Other than our clinical peers, we know no one else can possibly understand what we are feeling. So, we in medicine usually deal with our shame and grief alone, even though research has found that speaking with a colleague, specifically, about the experience was correlated with resilience and positive coping after adverse and other emotionally stressful events.
Three things must change to help physicians in the aftermath of these difficult clinical events.
First, we physicians must be able to recognize that we are also are impacted by the event. We must empower ourselves to ask for support without fear of reprisal. Peer support offers the opportunity to talk freely about the emotional impact of the event in a confidential non-discoverable atmosphere, where notes are not taken.
Second, we clinicians must offer our colleagues emotional first aid in a confidential, supportive, non-judgmental way, creating a space for healing, as opposed to an inquisition focusing on exactly what happened or an analysis of what went wrong. This non-stigmatizing approach simply offers clinicians an opportunity to talk through their emotions following a significant adverse work-related event, without fear of judgment. This is an uncommon path for peer physicians. But if we hope to be effective in this role, we must do more listening than talking and create a space that is safe for these conversations.
Finally, health care organizations should develop a structured peer program to support second victims in the aftermath of these events that we know will happen. While some organizations offer an assessment checklist or toolkit for clinician support, most do not offer wrap-around peer support.
We recently launched a support network called CARE: Clinician Assistance. Recovery & Encouragement. Peer supporters undergo a full day training on the second victim phenomenon and how to structure CAREgiver conversations by creating a safe space for second victims to discuss the emotional impact of the event. When needed, LifeCare Specialists facilitate appropriate referral to additional external resources to support the clinician to recovery. While our program is specific to obstetrics, this type of program can been replicated and offered in a variety of settings.
Florence Nightingale once said, “How very little can be done under the spirit of fear.” Those words were never as true to me as they were after my patient(s) suffered. I have suffered silently and shamefully for her for a very long time. According to Brene Brown’s research on shame, “If we share our story with someone who responds with empathy and understanding, shame cannot survive.”
I implore us, as a profession, to have the courage to walk alongside our colleagues when outcomes go inexplicably, tragically wrong and support our colleagues until they can find their way back to themselves.
Meredith D. Davenport is an obstetrician-gynecologist and helped launched Ob Hospitalist Group’s CARE program.
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