“By Apollo the physician . . . I will keep this Oath. I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous.”
The Hippocratic Oath
During medical training, physicians learn the cardinal rule that they are to do no harm to patients. Errors cannot be tolerated. The culture within medical education demands that physicians set high standards for themselves and strive for perfection. Physicians complete their residency armed with the most current and the best training, and many believe that they will be immune from making clinical mistakes in their practice.
In concert with this assumption are patients’ expectations that everything will always go well and that, with the advances and discoveries they’ve heard about so often in the news, bad medical outcomes will not occur. Many patients have developed the perception that complications and errors in the medical system are so rare that they are unlikely to happen to them. But, in spite of our best efforts, at some point in every physician’s career, a patient will suffer an adverse outcome. Although much of the practice of anesthesiology has become evidence-based with great improvements in patient safety, daily practice still requires technical skills and judgment, and at times, decisions are made based on imperfect or missing information. A portion of the practice of anesthesiology remains an art, and it is not unexpected that errors, complications, or unexpected outcomes, although unintended, will occur, and the patient may suffer.
When this happens, the anesthesiologist or nurse anesthetist may become a second victim.1 He or she must cope with the knowledge of having inadvertently brought harm to a patient. Several reactions are common. There may be feelings of guilt, loss of self-esteem, and depression. Professional abilities may be questioned, and there may be the realistic fear of litigation. Doctors have been taught how to counsel patients when an adverse outcome takes place, but unfortunately, they have not learned what to do for themselves under these circumstances.
Then, there is the unavoidable situation of discussing the adverse outcome with the patient or the patient’s family. What should be said? How will the injured patient or family react? Physicians may be afraid to admit that an error was made for fear that the information could potentially be used against them during future litigation. This creates an internal conflict forcing the anesthesia provider(s) to hold in any feelings of remorse or empathy for the patient or his or her family. Any open display of emotions will likely be stifled.
Likewise, it is difficult to talk to colleagues about the situation because of the fear that they will question the anesthesia provider’s competency or ability to practice. The case will certainly be discussed at a departmental performance improvement conference to identify what went wrong and to make changes to prevent it from happening in the future. But usually this process takes place in a sterile, professional atmosphere without attention to the emotional needs of the affected physician.
Not knowing where to turn and not having a readily apparent venue to openly share feelings, the provider may turn inward looking for solutions. At times, the provider’s mechanism for dealing with these complex and strong emotions may be dysfunctional and contribute to depression, substance abuse, or even suicide.2
Recent work has revealed that depression and psychiatric disorders are present more commonly than realized among physicians. Surveys of medical students indicate that one-fourth may already suffer from depression.3 Depression may continue into residency and contribute to burnout during training.4 Physicians may fail to recognize when they are depressed, or if they do, be resistant to referral for treatment. There are many possible causes for this including concern that action would be taken by state medical boards, insurance companies, or hospital administrators. Additionally, apprehension arises regarding the stigma of a diagnosis of depression and the need for treatment.
Data from centers treating anesthesiologists with addiction indicate that the coexistence of mental disorders is not uncommon.5,6 Although an association exists between addiction and mental disorders like depression, the attributable risk for substance abuse due to psychiatric conditions has not been determined.
Decades of research have documented that physicians’ risk of suicide is greater than for the general population.7 In 1968, Bruce published data indicating that the rate of suicide in anesthesiologists was 2.7-times greater than for a sample of male insurance policy holders.8 A more recent mortality study compared causes of death in anesthesiologists to a cohort of internists.9 The rate of suicide in anesthesiologists was 1.45-times that for the internists, while the rates for drug-related suicide and all drug-related deaths were 2.2- and 2.8-times greater, respectively. A significant proportion of physicians who attempt suicide have coexisting psychiatric disorders, substance abuse, or alcoholism.7
Undoubtedly, there are multiple factors responsible for the increased rate of suicide in anesthesiologists and for the cases of depression and addiction. Multiple stresses are present in the professional life of anesthesiologists and nurse anesthetists including the events associated with an adverse patient outcome. Future studies should be directed at determining the extent to which a clinician’s reaction to the stress of an adverse patient outcome contributes to depression, substance abuse, and suicide. A better understanding of these relationships will permit more effective prevention and treatment.
But what can be done to help the second victim, the anesthesia provider, when a medical error or an adverse outcome occurs?1,10 Creation of an open, understanding environment for colleagues to discuss mistakes will reduce the anxiety and shame felt by the individual. Senior staff should be supportive of the affected physician and should encourage dialogue regarding the events that took place as well as the resulting emotions. Departmental and institutional policies and procedures, which are not punitive to the individual, should be in place to facilitate formal psychological counseling when indicated.
The error or the circumstances surrounding the adverse event should be discussed with the patient or the patient’s family including an explanation of what happened and an assurance that changes have been made to prevent the event from happening in the future. On an emotional level, an apology or an expression of empathy from the anesthesiologist and/or nurse anesthetist may help assuage the patient’s anger to an extent that litigation would not be contemplated. The act may also facilitate resolving the provider’s emotions and feelings of guilt regarding the error or adverse outcome. Several states have passed legislation that prohibits apologetic expressions of sympathy from being admitted as evidence of an admission of liability in a civil action. In our legal system that emphasizes adversarial relationships, physicians may be counseled against any stat
ements of apology by their institution’s risk management department or legal staff. Until there is universal legislation or widespread court rulings that permit expression of empathy or a formal apology, caution should be taken to weigh the possible value versus the risk of making an apology.
To implement these strategies there must be institutional policies outlining what can be discussed among colleagues and how and what information should be transmitted to the injured patient or family. There should be educational programs to inform physicians of these policies and the availability of legal counsel when patient issues arise. More importantly, we must be sensitive to the emotional needs of our colleague, the second victim, when a patient suffers from an error or adverse outcome.
Dr. Berry is a Professor of Anesthesiology at Emory University School of Medicine, Atlanta, GA.
- Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ 2000;320:726-7.
- Birmingham PK, Ward RJ. A high-risk suicide group: the anesthesiologist involved in litigation. Am J Psychiatry 1985;142:1225-6.
- Rosenthal JM, Okie S. White coat, mood indigo–depression in medical school. N Engl J Med 2005;353:1085-8.
- Thomas NK. Resident burnout. JAMA 2004;292:2880-9.
- Angres DH, McGovern MP, Rawal P, Shaw M. Psychiatric comorbidity and physicians with substance use disorders: clinical characteristics, treatment experiences, and post-treatment functioning. Addiction Disorders and Their Treatment 2002;1:89-98.
- Domino KB, Hornbein TF, Polissar NL, Renner G, Johnson J, Alberti S, Hankes L. Risk factors for relapse in health care professionals with substance use disorders. JAMA 2005;293:1453-60.
- Schernhammer E. Taking their own lives–the high rate of physician suicide. N Engl J Med 2005;352:2473-6.
- Bruce DL, Eide KA, Smith NJ, Seltzer F, Dykes MH. A prospective survey of anesthesiologist mortality, 1967-1971. Anesthesiology 1974;41:71-4.
- Alexander BH, Checkoway H, Nagahama SI, Domino KB. Cause-specific mortality risks of anesthesiologists. Anesthesiology 2000;93:922-30.
- Vincent C. Understanding and responding to adverse events. N Engl J Med 2003;348:1051-6.