How Surgeons and Surgical Leaders Manage Complications, Medical Errors, Malpractice, and Second Victim Syndrome

Abstract

Complications are inevitable for practicing surgeons, and when you lead surgeons, negative outcomes and consequences will result from some of their professional work. The implications of the undesired, unintended, or unexpected changes to a child's health due to surgical intervention can be either transient or permanent, ranging from minor to major, devastating, or even deadly adverse events. Just as surgeons strive to maximize their surgical knowledge and expertise before performing an operation, surgeons and their teams need to practice and learn how to improve their non-technical leadership and team performance skills. When an error occurs, surgeons and their teams need to resolve the complication as best as possible with their expertise, knowledge, and consultation(s) as needed. Leaders of surgeons and institutions need to support the patients, their families (first victims) and the surgeons and their care-giving teams (second victims) when a complication occurs. After a medical error, healthcare professionals should for their and the patient-parent(s) well-being: (1) acknowledge the error and its consequences; (2) take responsibility for the error; (3) express regret that the error occurred; (4) solve the problem as best as feasible with professional colleagues; and (5) strive to learn from this error and prevent such or related complication(s) from occurring to other patients in the future. There are partial and total apology (I'm sorry”) laws in 38 states protecting expressions of sympathy (partial) and admissions of fault (total) from admissibility in court. Institutional CANDOR/CANDOUR requirements do exist respectively in the US and UK. Malpractice or negligence litigation is a real risk when complications occur but interestingly occurs most often when patients and their families feel abandoned and deceived. Ultimately, all involved need to heal and this includes the surgeons who experience second victim syndrome. Providing individual and institutional support is imperative and essential for patients, their families, and the health care professionals involved in a serious surgical complication or medical error. Only then can we all cope and continue on as our best selves.

Certain truths exist in healthcare: if you care for patients, errors will happen. Complications are inevitable for practicing surgeons, and when you lead surgeons, negative outcomes and consequences will result from some of their professional work. The goal of course is to minimize risk to as low as feasible. The implications of the undesired, unintended, or unexpected changes to a child's health due to surgical intervention can be either transient or permanent, ranging from minor to major, devastating, or even deadly adverse events.

Leaders of surgeons, including department and division chiefs; program directors for graduate medical education for residents and fellows; hospital executives; legal teams; risk management coordinators; and physician support professionals need to be ready to assist and support not only the patient and family when a complication occurs, but also the surgeon and the surgical care team.

In best practices, as surgeons and leaders of surgeons, we do everything possible to reduce the risk of surgical complications and medical errors. Throughout our careers, we strive to expand our knowledge, enhance our technical skills, and build teams of healthcare professionals focused on achieving the best outcomes for our patients. We hope to work in and guide healthcare organizations that prioritize excellence. We all aim for complications in each surgical procedure to be a “never event,” while realistically understanding that our goal is to minimize the incidence of errors as much as humanly possible while continually striving for improvement. We must take risk mitigation seriously while recognizing that we cannot eliminate risk entirely. This is the inevitable uncertainty of our profession, which requires courage, as we face daily the challenge of making life-altering decisions with incomplete information. Communicating this professional reality to patients and the public is a leadership challenge that is best addressed through honest, compassionate, and interactive verbal and written communication.

Ideally, we and the surgeons we lead study, reflect, listen to patients’ expectations, and compare them to what is feasible. We consult professional colleagues as needed, plan surgery based on all the data available, and then, with patients and their families in shared decision-making, choose a treatment plan with all parties knowing and understanding the potential risks and benefits.

Surgeons and patients can then enter surgery well-prepared and equipped with the necessary personnel, resources, and tools for optimal outcomes. Ideally, appropriate contingency plans are communicated to the patient, their family, and the surgical team in advance. Surgeons, patients, surgical staff, and their leaders must anticipate changes to the original surgical plan and “expect the unexpected.” Most of the time, this careful planning and skilled execution benefit patients and organizations with uncomplicated, positive surgical outcomes, even in complex cases [1].

At-risk patients for complications

Minor and major complications occur in children at lower rates and are generally less severe than in adults. Surgical complications undoubtedly increase patient suffering, dissatisfaction, and the cost of care while decreasing quality of life in both the short and long term. A report from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) observational study on pediatric orthopaedic surgery patients indicated that the following procedural and patient characteristics were statistically more likely to be associated with adverse events: (1) patients undergoing spinal fusion or multiaxial external fixation; (2) obese patients; (3) patients classified as American Society of Anesthesiology (ASA) class 3 or higher; and/or (4) cognitively impaired patients [1]. Indeed, these patients (if they are of sufficient age and not cognitively impaired), along with their parents and family, should be informed of the increased risks in advance. Compared to white patients, NSQIP pediatric data reveal that African American children undergoing surgery across various subspecialties face statistically higher risks of postoperative complications (18% relative higher odds), serious adverse events (7% relative greater odds), and 3.43 times higher odds of dying within 30 days after surgery, a discrepancy not fully explained by racial variations in preoperative comorbidity [2]. The care delivery factors and social determinants of health that contribute to these elevated risks in African American children may remain poorly understood, unaccounted for, or inadequately communicated preoperatively. Additionally, immunocompromised children are also at greater risk of perioperative complications [3].

All surgeons, surgical leaders, and organizations must understand the risks and be prepared to act appropriately and swiftly when a complication or medical error occurs. To minimize complications and approach “never event” status as closely as possible, vigilant efforts are required from the individual surgeon and surgical team, along with a systems approach that integrates standard procedures and checklists into the daily practice of surgery [4]. Surgical leaders are essential in transforming the culture and behaviors within operating rooms. This goes beyond the surgeon and anesthesiologist simply engaging in patient safety thinking and planning. Leaders should encourage a team approach, establish safety protocols, and cultivate a psychologically safe environment for communication regarding patient safety. A standardized preoperative preparation and communication strategy is vital for effective surgery planning, including contingencies in case a complication arises.

Rates, types, and causes of complications

Leape et al. (1994) published in JAMA [5] that medical errors occur in 36% of hospitalized patients, and 25% of these errors are serious or life-threatening. In 2000, the Institute of Medicine published To Err is Human: Building a Safer Health Care System [6]. This comprehensive IOM report set a national agenda for reducing errors and improving patient safety, not by blaming individual professionals but by designing and implementing a better system. The report stated that the medical error problem is not caused by “bad people” but by “good people working in bad systems” that need improvement [6].

In 2009, Wong et al. [7] published a survey conducted by the American Academy of Orthopaedic Surgery (AAOS) featuring 917 surgeons, of whom 53% reported witnessing a medical error in the previous six months. The most frequent errors were related to equipment (29%) and communication (25%). The most serious harm errors involved medication (10%, including two deaths from incorrect narcotic dosing) and wrong site/patient/procedure errors (WSPEs) (6%). An American College of Surgeons survey [8], with nearly 8000 respondents, found that 9% reported making a major medical error in the previous three months. Interestingly, this survey showed that the reporting of complications was highly correlated with all three domains of physician burnout—emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment—as well as symptoms of depression and was negatively related to mental quality of life scores. Seventy percent of these surgeons attributed the errors to individual rather than systemic factors. From these references [7,8], it appears that the medical system, its processes, and the individual struggles of surgeons put patients at risk. Leaders of surgical and healthcare organizations need to pay attention to all aspects that contribute to the well-being of both patients and surgeons.

Some classify complications into the following categories: (1) predictable complications for that procedure, with a known frequency usually mentioned in the consent process; (2) unanticipated complications, typically not included in the consent, but possibly related to the complexity of the procedure; and (3) minor or (4) major errors. This perspective highlights the significance of both anticipation and planning, which includes contingencies and communication with the patient, family, and surgical team. Others view OR complications in terms of knowledge, technical skill, and experience relevant to any procedure, as well as non-technical skills such as leadership, situational awareness, communication, decision-making, teamwork, and task management (Fig. 1).

Figure 1.

Surgical Complication Classification with interplay between minor and major complications that can be either unanticipated or potentially predictable, and can be due to knowledge gaps, technical errors, non-technical skill deficiencies, or combinations thereof.

Regenbogen et al. [9]. through the Harvard Risk Management Foundation and the National Agency for Healthcare Research and Quality (AHRQ) studied medical malpractice claims from four liability insurers and noted that the majority (52%) of surgical adverse events were related to technical errors. In further examining these technical errors, 65% were manual errors, 9% were errors in judgment, and 26% resulted from a combination of both manual and judgment errors. They were surprised to find that among 444 malpractice claims, 73% involved experienced surgeons, and 84% occurred during routine surgeries rather than more complex procedures, which presumably carry a higher technical risk. Sixty percent occurred under conditions with greater patient or procedural complexity, such as emergency surgeries, increased medical co-morbidity, abnormal patho-anatomy, and previous surgeries resulting in abundant scarring. An index procedure in a routine elective situation is safer regardless of the procedure's complexity or the surgeon's experience. A crucial safety recommendation was for surgeons and their teams to concentrate on enhancing decision-making and performance in routine operations for complex patients and circumstances.

In another study of the same malpractice database, Greenberg et al. [10]. found that non-technical communication errors were instrumental in 60 out of the 444 malpractice cases (13.5%). The 81 communication errors that contributed to an adverse event were statistically equivalent across pre-operative, intra-operative, and post-operative settings. Most of these errors were verbal, often occurring during handoffs and transfers of care, and they were ambiguous, frequently involving the attending surgeon. The authors recommended implementing more structured handoffs, standardizing transfers of care, and using read-back techniques during attending-to-attending communications.

Of course, as highlighted by the occurrence of WSPEs (wrong site, wrong patient, wrong procedure errors), standardized protocols and practice guidelines will only lead to error avoidance if they are properly implemented. WSPEs continue to happen at troubling rates, despite the Canadian Orthopaedic Association's “Operate Through Your Initials” initiative launched in 1994, the American Academy of Orthopaedic Surgery's “Sign Your Site” protocol introduced in 1998, the North American Spine Society's “Sign, Mark, Xray” (SMaX) program, and the Joint Commission's mandated Universal Protocol. Within the decade following the launch of these programs aimed at reducing surgical errors, 21% of hand surgeons surveyed confessed to performing a wrong site surgery, while another 16% experienced a near miss [11]; up to 50% of spine surgeons admitted to operating on the incorrect level(s); and 8.3% of knee surgeons operated on the wrong knee. Santiesban et al. [12] concluded that “every orthopaedic surgeon, regardless of their orthopaedic subspecialty, is at risk for performing a wrong-site surgery during their career.” We concur. We all wish to avoid the feelings of regret and shame that come with a WSPE involving our patient or the patient of a surgeon we oversee. The data and concerns are similarly troubling regarding retained hardware and instruments. Complacency, especially in common or “routine” cases is dangerous, and surgeons need to hard-wire behaviors, procedures, and protocols to maintain vigilance and focus on patient safety.

To improve, surgeons should regularly “practice live” for technical execution using simulated surgeries [13], cadaveric procedure labs, and pre-operative surgical team conferences. Enhancing communication, situational awareness, task management, teamwork, decision-making, and leadership is essential [13]. This can be achieved through simulation; live observation (SCOPE= Surgical Coaching for Operative Performance Enhancement) or audiovisual recording of live surgery with debriefings (REAL – Real Event Analysis and Learning); regular, habitual post-operative huddles and reflections, including the use of (1) plus/minus/delta; (2) rose/thorn/bud processes to help you and your team focus on what was accomplished well, what was challenging, where improvements are needed, and what changes or developments are required (Fig. 2). We must all arrive in the OR prepared, communicate clearly in pre-surgery huddles, and respond professionally and promptly to the unexpected, both as a healthcare team and as individual professionals, each fulfilling our respective roles collaboratively to ensure the best outcomes for our patients. Senator John McCain, in his book on leadership “Why Courage Matters: The Way to a Braver life”, used the Navajo quote- “I walk like a chief now, so that when I become one I will already know how to behave” [14]- to illustrate how practicing leadership behaviors before they are required can be critical to success when a VUCA (volatile, uncertain, complex, ambiguous) crisis (such as an intraoperative complication) occurs and leadership is required. Planning and practicing calm responses to possible complications will allow the surgeon to be the calmest person in the room, directing the team to a safe outcome for the patient. It is always best to habituate these behaviors when it is easy in simpler, more routine situations, and then apply them when it is challenging, then start leading when it is complex and difficult.

Figure 2.

Simulation program in surgical subspecialty fellows leadership program with faculty, fellows, OR nurses, and anesthesia practicing “real” scenarios of wrong consent, disruptive professional behavior, drug reaction anaphylaxis, and incorrect or unavailable equipment with “patient” under anesthesia.

Dealing with complications

Complications are undesired, unintended, and unexpected. So, what should we do when one occurs, and equally important, what should we not do?

As Tony Herring advised [15], following a complication, the surgeon should ‘give yourself to the patient.’ Dr. John Hall offered similar but more detailed advice, which is not surprising since he was Dr. Herring's mentor, friend, and colleague. Hall recommended checking on the patient two or more times a day while they are in the hospital, even if they have been transferred to another service. Maintain vigilant contact with them throughout their recovery; listen, and explain as many times as necessary what occurred; demonstrate that you care and that you are sorry this has happened. Do not react emotionally or defensively when they are direct, confrontational, or even accusatory in their questions and communication. We have done the same throughout our careers, as discussed in a POSNA Peds Ortho podcast (Fig. 3).

Figure 3.

POSNAcademy: Peds Ortho: Wellness Special - Complications and Long Days.

You must assist that patient and their family in coping with their disappointment, even if the possibility of complications was part of the pre-operative discussion and consent. They likely never thought it would happen to them, believed you and your team were too skilled for it to happen, or maybe they did not fully absorb your explanations despite your best communication efforts. Never be dismissive, evasive, or impatient, especially in the case of a life-threatening complication. Never lie, be dishonest, or alter records. Mistakes occur; errors happen more frequently than we would like, but, as in all things, how we respond after a mistake defines us. “Do the right thing for your patient … for yourself and your professional team.” It takes courage to be a surgeon; undoubtedly, it is stressful to navigate complications. However, authentic, empathetic caregivers promote physical and emotional healing for their patients, families, partners, healthcare professionals, and themselves (Fig. 3). [16].

When a complication arises, your patient and their family still rely on you to perform your duties. You are their surgeon. They place their trust in you and need you to honor that trust. Seek consultation regarding the issue. Obtain additional medical and surgical assistance if needed. Hopefully, they will continue to believe in and trust you. If not, help them connect with the appropriate person to complete the necessary care. Openly offering to help them get a second opinion can enhance trust. Address the issue as effectively as you and your professional colleagues can, even in stages if necessary. Ensure they are moved to the safest and best possible location. Similarly, as surgeon leaders, you must pay close attention to the situation when a complication arises. Consider conducting a root cause analysis; determine how to resolve the current issue and reduce the likelihood of it occurring again. If you are leading a team, support your surgical staff while they care for the patient. Clearly communicate your accountability, condolences, and objective to the patient and their family to prevent similar incidents in the future. We all need to strive to perform our professional roles well and improve continually. Atul Gawande [17] noted in his Complications: A Surgeon's Notes on an Imperfect Science, “the moral burden of practicing on people is always with us.”

The Uses of Sorrow.

Mary Oliver [18]

(In my sleep I dreamed this poem)

Someone I loved once gave me

a box full of darkness.

It took me years to understand

that this, too, was a gift.

Apologies for medical errors

There are conflicting perspectives on apologies following a complication, whether from individual healthcare professionals, the healthcare organization, or both. Institutional and state policies vary. Apologies can facilitate psychological healing for patients, their families, the surgeon, and their care team. Enhanced psychological well-being can promote physical healing. Robbenoult [19] outlined that apologies after a medical error should: (1) acknowledge the error and its consequences; (2) take responsibility for the error; and (3) express regret that the error occurred. This often reduces blame and anger, increases trust, and improves relationships. There are challenges to apologizing or acknowledging a medical error, including personal discomfort in discussing failures with affected patients and their families, a medical culture that emphasizes “being the best” and fear of litigation. Apologies have paradoxically been seen as both increasing and decreasing the risk of malpractice following a surgical complication or medical error. The concepts behind “I am sorry” laws suggest they may reduce anger, and improve communication and understanding, leading to less litigation [20]. Data on malpractice suits indicate that patients and their families tend to sue when they feel there is a lack of information about what happened, no accountability for the error, and concerns that the error might happen to others in the future. One thing that is also clear is that a half-hearted or insincere apology can worsen the situation. Sincerity and authenticity are crucial.

Apology statutes protect healthcare professionals’ expressions of benevolence, sympathy, commiseration, condolence, or compassion toward patients and/or their families from legal admissibility [21]. However, not all states have “I am sorry” apology laws, and those that do vary. Thirty-eight states have apology laws that offer either partial or total protection. In the case of partial protection, statements that admit fault can be admissible. For instance, “I am sorry this happened to you (or your loved one)” is not admissible in court; however, “I cut the peroneal nerve while excising the osteochondroma” can be admissible in states with partial apology laws. Total protection means that both expressions of sympathy and admissions of fault are not admissible. Additionally, there are 12 states without apology laws [22]. It is wise to familiarize yourself with the apology laws in your state.

Communication around a complication

Setting aside concerns about liability risk, it's essential to recognize and acknowledge the complication, and to develop and execute a plan within a timeframe that yields the best possible outcome. Additionally, patients and their families want to know that their surgical team is “sorry” and sympathetic to their unfortunate situation. They expect their healthcare team to learn from the errors, regardless of the cause, and to minimize the risk of it happening to others in the future. They seek assurance that the surgical team and institution will enhance future care based on their negative experience.

Training aimed at improving post-medical error communication with patients and families in a standardized way is encouraged and is a policy in many institutions. Since the Health and Social Care Act of 2008 in England, there has been a professional “duty of candor” that ensures healthcare providers are open and honest with their patients when things go wrong with their care and offer an appropriate remedy. [23]. In the US, the Agency for Healthcare Research and Quality (AHRQ) offers a CANDOR [24] 8 module toolkit for institutions and healthcare providers to respond in a timely, thorough, and equitable manner when unexpected events lead to patient harm. Unfortunately, when this empathetic communication does not take place, the risk of litigation increases following a medical error or surgical complication.

Transparency, Compassion, and Truth in Medical Errors: Leilani Schweitzer at TEDxUniversityofNevada [25].

https://www.youtube.com/watch?v=qmaY9DEzBzI

A summary of Leilani Schweitzer's MUST WATCH TED Talk about lessons learned on medical errors, apologies, and transparency after a compassionate nursing act contributed to the death of her son Gabriel in a pediatric academic medical center hospital.

Her words as a spokesperson for first victims, survivors, and second victims include …

We want:

• An honest, transparent explanation of what has happened

• A full apology

• To know that changes have been made so that what happened to us does not happen to anyone else.

On Liability and Litigation:

• We want answers not money

• “People hire lawyers because they feel deceived and abandoned”

• About health professionals:

• We trust them with what we value the most, our lives and our loved ones.

• About lawyers, executives, doctors, and nurses' communications after the event:

• We do not want a legal ‘Deny and Defend form of Flight and Fight behavior’

On Expectations and what she received:

• They did not prey on my vulnerability

• They

  • Investigated
  • Explained
  • Took responsibility
  • Apologized
  • And then asked me what else we can do?

On The Survivors, including doctors and nurses, after a death of her son:

• I needed an infusion of truth or compassion.

• The nurses and doctors who took care of him, they needed it too.

Malpractice - negligence

The rate of adverse events and surgical complications that result in malpractice suits among all surgeons, including orthopaedic and specifically pediatric orthopaedic surgeons, is higher than the medical malpractice rate. Orthopaedic surgeons are more likely to be sued than other medical specialists. According to the Westlaw legal database, spine, hip, and knee surgeries are the most frequently litigated areas in orthopaedics [26]. Procedural error and negligence were identified as the two most common reasons for plaintiff actions, as reported in the Rynecki study [26] of 81 medical malpractice cases against orthopaedic surgeons. In 61% of the cases that went to trial, the verdict favored the defendants. Notably, when plaintiffs did win their suits, the jury awards were nearly double the amounts settled in payments.

In a review of 120 appellate and jury cases involving medical malpractice suits against pediatric orthopaedic surgeons, the most common cases involved diagnostic errors related to developmental dysplasia of the hip and fracture care. 51% of cases were found in favor of the plaintiffs, with high indemnity payments [27]. Most cases found in favor of the defendants were upheld in appeal.

To be successful in a malpractice (implies intent to harm) or negligence (patient is harmed unknowingly) claim by the plaintiff, four key elements must be present: (1) identification of the legal duty owed by the defendant physician to the plaintiff patient; (2) documentation of the breach of that duty; (3) a clear connection between the breach of duty and the patient's current condition; and (4) evidence of loss (economic or otherwise) resulting from that breach of duty. The process involves comparing the defendant physician's professional behavior and standard of care to what a doctor with similar background and training would have done in that situation [26].

For surgeons and healthcare professionals, managing their complications is stressful and challenging. The added anxiety of discovery, pre-trial and courtroom scrutiny, necessary disclosures, and potential litigation losses complicates the situation, causing emotional and physical strain, along with real financial risks for the individual healthcare providers and their organizations.

Things you hope to never need to know … but probably will

James J. Horgan, Esq

Deputy General Counsel, Senior Vice President, Boston Children’s Hospital

It is a cold, hard fact that in the course of a surgeon's career, they are more likely than not to be sued for medical negligence. You should take comfort that your mentor, the senior surgeon you admire, and even your Chief have probably been sued. Lawsuits are less an indication of a poor surgeon than they are a result of being actively engaged in a complex profession in a litigious society.

For nearly 30 years I have represented medical professionals on claims of medical negligence, first as a trial lawyer and now as lawyer within an academic medical center. No matter how talented or experienced a surgeon is, being sued can be very disorienting. The legal world is filed with language and processes that are unfamiliar.

What do you do when you receive a notice that you are involved in a lawsuit? For those in hospital-based practices, contact the hospital Office of General Counsel (OGC). Do not speak to friends, colleagues, or anyone else before calling the OGC. Moreover, do not go into the medical record, perform any research, literature search, or do anything to inform yourself about the subject matter of the case before speaking with your OGC. If your malpractice insurance is not provided through a hospital, promptly notify your malpractice insurance carrier. Not providing prompt notice can result in insurance coverage being denied.

If you are working through an OGC, the attorney will do several things:

• •Get you YOUR lawyer: The OGC attorney will provide notice to the malpractice insurance carrier and the carrier in turn will have counsel appointed free of charge to represent the interests of the surgeon above all else in defense of the suit;
• •Instruct you NOT to talk about the case: The OGC attorney will instruct the surgeon not to talk about the case with friends, colleagues or anyone but a select group of legally privileged people (lawyer, mental health professionals, religious officials, etc.)
• •Provide information on how to access mental health supports: If your hospital is like mine, the surgeon will be referred to mental health supports either through the hospital or insurance company or both. These are privileged spaces where the surgeon can speak about the litigation process. Whether or not you need them immediately, retain the contact information for these resources so you can access them if ever the process begins to weigh on you. It is important that you not try to “gut it out.”
• •Reassure you that the nightmare stories you have heard are false or extremely rare. While every case is different, the vast majority of cases that go to trial are found in favor of the surgeon. Moreover, most truly problematic cases generally settle early and within the insurance coverage limits. Examples where a surgeon loses their personal assets are exceedingly rare.

Lawsuits are a somewhat random event. Rest assured, there are systems and professionals prepared to shepherd you through the experience and ensure that you come out the other side intact.

Second victim syndrome

To quote the classic IOM report [6] with emphasis, “To Err IS Human.” It is not surprising, Han [28] and others [29,30] found that surgeons experience anger, frustration, anxiety, sadness, embarrassment, guilt, or even shame following a medical error. In the study by Han et al. [28] of Harvard surgeons’ attitudes and behaviors after a surgical complication or suboptimal result, many surgeons were hesitant to discuss the case, partly due to fear of litigation. Pinto et al. [31] noted that UK registrars felt that morbidity and mortality conferences were too defensive and lacked openness regarding the causes of adverse events, their impact on patients and caregivers, and support systems following an error. Orri et al. [32] noted that even in their day-to-day practice, surgeons experience significant stress, which some described as “oppressive.” Other studies [33,34] of surgeons in the US and UK indicate that the emotional impact of complications begins in residency and can intensify as they become attendings. Surgeons may feel “devastated” and personally accountable for complications [31,34]. The effects have been shown to be long-lasting. Burnout (emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment) and depression are found to be more prevalent after complications [35,36]. Professional intervention, including counseling and medication, may be necessary. There is a genuine risk of suicide. Herring [15] advocated for education, research, and interventions for surgeons facing the long-term adverse effects of surgical complications and medical errors.

Scott et al. [37] described six stages of provider recovery after an adverse event: (1) chaos and event response; (2) intrusive reflections; (3) restoring personal integrity; (4) enduring the inquisition; (5) obtaining emotional first aid; and (6) moving on. Rassin et al. [38] equated this experience to acute and post-traumatic stress disorders. Ozeke et al. [39] felt that Scott's stages five and six of second victim recovery are critical for professionals to thrive rather than merely survive or, worse, drop out. Trained peer support and mental health professionals may be necessary for a successful, thriving return to practice after a devastating adverse event. Notably, in the report by Berman et al. [40], only 11% of surgeons did not want to be contacted after an adverse event; just 5% reported being “very satisfied” and 22% “satisfied” with the institutional support they received in dealing with the aftermath of an error. The Peer Support Service at Brigham (https://cdi.brighamandwomens.org/peersupport/), the Office of Clinician Support at Boston Children's (https://www.childrenshospital.org/clinician-resources/boston-childrens-staff/office-clinician-support), and the “You Matter” program at Nationwide Children's (https://www.nationwidechildrens.org/careers/you-matter-program) are examples of effective programs that mitigate the effects of second victim syndrome [41].

We truly need to support one another when complications arise. Check-in with your practice partner at home to ensure they are okay. Visit their office or operating room regularly. Suggest taking a weekend walk together. Reach out to their spouse or partner if appropriate. Encourage them to seek professional help, whether in-house or external, if the burden becomes too heavy. We all encounter complications that vary from minor to major. Fellow surgeons understand these experiences better than anyone else, and creating environments of peer support is as critical as having environments of peer review. Taking care of each other and helping our colleagues care for themselves is crucial for all of us to cope and transition from the past into a healthier present and future.

The doctor who makes a mistake needs help too.

David R. DeMaso, MD

Director Office of Clinician Support

Department of Psychiatry & Behavioral Sciences

Boston Children's Hospital, Harvard Medical School

George P. Gardner & Olga E. Monks Professor of Child Psychiatry & Professor of Pediatrics

In 2000, Albert Wu wrote in the British Medical Journal that the “doctor who makes a mistake needs help too”. The surgeon involved in an unanticipated adverse patient occurrence and/or malpractice suit who experiences psychological and/or emotional trauma related to the event or suit is considered a second victim.

A range of traumatic stress symptoms experienced as a second victim commonly include a sense of isolation together with intrusive thoughts of shame, anger, and self-doubt which may be accompanied by physiological hyperarousal. These symptoms can range from transient difficulties all the way to a formal psychiatric disorder based upon an individual's circumstances and vulnerabilities [45]. These symptoms are generally further impacted by a long timeline that begins with internal and external hospital reviews that may last days to months only to be potentially compounded by a lawsuit that may last years with intermittently experienced stress points (e.g., suit notification, answering interrogatories, depositions, and trial). Unaddressed second-victim responses may increase susceptibility to “burnout,” which is characterized by emotional exhaustion and depersonalization which can lead to poor work performance and reduced quality of patient care. In this context, management of the second victim syndrome is critical.

Psychological first aid for an adverse event includes supportive listening and facilitating connections (Gispen & Wu, 2018 [46]). Surgical leaders (and colleagues) are well positioned to support their faculty (and a colleague) by acknowledging the process and committing to support them through the process. For example, countless physicians have spoken of the helpfulness at the time of adverse event and/or notification of a malpractice suit after hearing from a respected colleague that they too have faced a similar situation and understand personally the toll experienced. This sharing immediately helps reduce the sense of isolation and conveys one can get to the other side albeit it will take time [47]. Leaders can help by ensuring that ongoing support for the surgeon is mobilized. Besides confirming they have assigned legal counsel (if needed), they should encourage the surgeon to take advantage of all available support resources that may include hospital-connected health and wellness programs, peer support programs, ombuds/HR offices, and/or medical professional liability insurance provider support programs.

Staffed by experienced mental health professionals, the Office of Clinician Support is a confidential wellness program at Boston Children's Hospital (DeMaso, 2010 [43]; DeMaso 2018 [44]) that is designed to provide protected support to these physicians in coping with the chronic fluctuating stress that they will experience over time. Strategies to help them identify and manage dysphoric feelings as well as help enhance preferred coping strategies are provided. Common destructive cognitive distortions (e.g., All-or-nothing thinking – “There is nothing rewarding about practicing medicine anymore”; Jumping to negative conclusions – “I will definitely be found guilty”; Emotional reasoning without objective evidence – “I am a terrible physician”; or Magnification – “I will lose everything I have”) are countered. Most likely, your hospital has similar resources.

The norm of most surgeons is to ignore and keep silent. This is not the answer to responding to the second victim facing the impact of an adverse event and/or malpractice suit that you, your partner, or your staff lead. The answer is supporting them in getting the help they need.

Conclusions

Complications are an unfortunate aspect of surgical interventions. Health care professionals and institutions must strive to improve every day for every operation, for our patients and ourselves to lessen the risk and consequences.

When complications arise, our primary responsibility is always to our patient(s) and their families to resolve the issue and support their healing. However, this is not merely about “fixing” the physical problem. We must be empathetic, present, and accountable. Everyone—including patients, families, the surgical team, and ourselves—must navigate the disappointment, frustration, doubt, uncertainty, and at times shame [42] that can occur with a complication or medical error. These are life-changing events; they leave a lasting impact on you, your care team, and the survivors of that complication. As leaders in surgery, we should establish processes, systems, and professional teams to ensure everyone can recover in every aspect. With grace, we can all learn and move forward to perform our jobs again, hopefully even better.

Declaration of competing interests

None of the authors have conflict of interests for this manuscript.