We are suffering from second victim syndrome

Not enough attention is given to doctors’ emotional wellbeing after they make clinical mistakes, says Dr Claire Davies

To err is to be human. We GPs are, for the most part, good people wanting to make a difference to others, working in a system that seems to increase day by day in its complexity and demands. Clinical mistakes are an inevitable part of our careers. 

Yet when a mistake happens, we can struggle emotionally. As good clinicians, we will reflect professionally on our performance and seek out an opinion on the situation from our colleagues. 

Emotions, however, can be more difficult to manage. Guilt – the feeling that we have done something bad – is an obvious one, often with an accompanying desire to make amends. Guilt is different from shame; it’s a more toxic emotion, where we may overidentify with the mistake and convince ourselves that we really are a bad person. Fear of litigation, dealing with upset patients and relatives and the GMC are also common concerns.

In 2000, the US professor and internist Dr Albert Wu coined the term ‘second victim syndrome’. While the term is not without its critics, the original article describes the individual’s sickening realisation after a medical mistake and the subsequent fear of punishment or criticism. And while the subsequent processes pay attention to the medical facts of the scenario, little attention is paid to supporting the emotional reaction of the doctor.   

Feelings of self-doubt, fear and distress are common, and these may persist long after the incident. In the long term, depression, anxiety and post-traumatic stress disorder may occur. Clinicians may start to practice defensive medicine and even leave the profession.

Figures vary but up to 50% of healthcare staff consider themselves to have some experience of being a second victim. Doctors and nurses in training can be at greater risk. Staff with higher self-esteem, less tendency to perfectionism and a more positive way of explaining events are likely to do better. 

A typical reaction can include a journey through the following responses:

• A chaos and accident response.
• Intrusive reflections.
• Restoring personal integrity.
• Enduring the inquisition.
• Obtaining emotional first aid.
• Moving on.

How, therefore, can we best support our colleagues when a significant clinical error has occurred?

Work done by the Yorkshire Quality and Safety Research Group and the Improvement Academy recommends: ‘Of the three possible outcomes after an adverse event, we believe the gold standard should be to support staff to be self-compassionate, self-accepting, hopeful and forward looking, rather than feeling isolated and just surviving, or that they should no longer practice.’

For ‘second victims’, talking to colleagues, family, friends and staff support services about difficult feelings around the incident can support healing, recovery and learning.

Various interventions exist as to how we can support a colleague going through this. These include:

• Offering a conversation to the clinician involved to include acknowledgement of the emotional pain experienced by the clinician involved. Active listening, acceptance of the difficult emotions involved and empathy are all important as are respect. Professor Wu recommends offering to share any stories of your own medical errors. This conversation should take place ideally before investigations take place. Note that some clinicians have stated they found such conversations draining – seek permission before going ahead. 
• Offering ongoing support from both peers and within the management team.
• Secondvictim.co.uk includes videos of healthcare staff telling their own stories of the syndrome.
• Visibility of psychological support services such as in-house staff support or resources such as the Practitioner Health Care Programme (PHP).
• Transparency and information sharing on any investigation process.
• Offering the clinician an opportunity to be involved in any subsequent system improvement(s) arising from the investigations. 

Anyone who appears to have any red flags, such as continuously re-experiencing the event (eg, flashbacks), avoidance/emotional numbing or hyperarousal/irritability should be signposted towards further professional help. Other red flags include somatic symptoms, using substances to cope or breakdown of working relationships. 

With stresses on the profession at an all-time high and the continual loss of valuable GPs to other workplaces, it is imperative that we learn how best to support one another during difficult times.

If a colleague appears to be struggling emotionally after an adverse incident, they are not alone, and their reaction is common. The support we can offer ourselves in-house can go a long way towards maintain an emotionally healthy career. 

Dr Davies is a GP and coach in Hackney, London. Follow her on Twitter @clairedocdavies or get in touch via her website