Suffering in Silence: Physicians as the Second Victim

Originally published by our sister publication General Surgery News

One morning in September 2022, Brittany Bankhead, MD, a trauma surgeon and an assistant professor of surgery at Texas Tech University Health Sciences Center, in Lubbock, turned down a hospital hallway to find a scene that sent her heart pounding: a ventilator and a few drips hanging outside a patient’s door. Memories came flooding back of ventilators and drips lining the hallways outside COVID-19 ICUs in the spring of 2020.

Dr. Bankhead had been midway through her fellowship in trauma and critical care surgery at Massachusetts General Hospital (MGH), in Boston, when the city was hit by one of America’s first COVID-19 surges. She’d helped intubate hundreds of patients. She’d whispered the names of their loved ones into their ears, afraid that an ill-fitting mask might lead her to share their fate. When schools closed and her two young children needed homeschooling, she flew them across the country to stay with their grandparents.

She couldn’t shake the fear and guilt of those first months. After she moved to Texas to start work as an attending, she felt the weight of those memories. One evening, as Dr. Bankhead was driving home from work, she considered driving her car off an overpass.

“Lucky for me, that scared me,” she said.

Dr. Bankhead saw counselors, took time off and learned about post-traumatic stress disorder. But even now, the sight of a ventilator in a hallway can bring the pain rushing back.

“I’d learned in the past to take deep breaths, to go slow, and mostly to acknowledge each feeling as it came over me,” she said. But the memories still come rushing back.

“Almost every shift I work is fraught with high-acuity, high-stress, intense pathophysiology where patients are actively dying, but had woken up that day thinking they’d have an entirely normal day. But this sight—just a ventilator and a few drips hanging outside an ICU room—that is what caused my mind to race,” she said.

Dr. Bankhead spoke during a panel titled “Patient Injury and Death: The Surgeon as Second Victim” at the American College of Surgeons Clinical Congress 2022, in San Diego. Surgeons at the session spoke candidly about their experiences dealing with traumatic events and discussed ways that surgeons can better care for themselves and one another in the aftermath of these events.

There is no simple fix, but acknowledging the long-term effects is part of the process of healing, Dr. Bankhead told the audience. “There’s only my story, our stories, our experiences, and sharing them with one another and allowing ourselves to feel whatever it is that we need to feel.”

PTSD Among Surgeons

Helen MacRae, MD, a professor of surgery at the University of Toronto, told the audience about a patient she’ll never forget. More than a decade into her work as an attending, she was referred a patient with ileocolic Crohn’s disease. The man worried about surgery and its impact on his ability to do endurance sports, and so he wanted a laparoscopic operation. Laparoscopy was difficult in his case, but Dr. MacRae persisted with a minimally invasive approach, despite the challenges. But after surgery, he developed complications, ended up with peritonitis and required a bigger operation.

Dr. MacRae said she lay awake in bed at night going over everything that she felt she did wrong. When she slept, she had nightmares about this patient. “I felt like a failure. I felt like everybody was going to be talking about this case,” she said. She sought support from colleagues but, even now, the case still pains her, she said.

She pointed out that studies from different countries have drawn similar conclusions: Surgeons are severely affected by complications, experiencing self-doubt, sadness, depression and anxiety; they feel alone, which can lead to profound mental health issues. In a 2010 survey of 123 surgeons (30.5% response rate), 12% believed a complication affected their ability to perform their job and 2% avoided or stopped doing certain procedures as a result of their experience with a complication (Surgery 2010;148[4]:824-828). Nearly 60% struggled to handle the emotional effects of complications, a trend unaltered by a surgeon’s years of experience. A Canadian study of 51 physicians, including 30 surgeons, found that nearly 55% met the criteria for clinically concerning PTSD in response to an adverse event (Curr Oncol 2019;26[6]:e742-e747). A Dutch survey of 4,369 healthcare providers, including 1,619 doctors, found that the more harm their patents experienced, the more the healthcare workers were affected long term. When patients died or experienced permanent harm, members of their healthcare team had a ninefold increase in lasting symptoms, including feeling hypervigilant, unable to provide quality care and uncomfortable within the team (BMJ Open 2019;9[7]:e029923).

“Because surgeons are both literally and figuratively more hands-on and make decisions, adverse events hit us hard. We’re at high risk of becoming a second victim,” MacRae said.

In a 2012 study, researchers found that physicians and nurses who believe they have contributed to a patient’s adverse event often go through four phases, noted Dr. MacRae (Med Educ 2012;46[12]:1179-1188). First, there is the kick, an immediate visceral reaction that is “almost like a body blow” with physiologic responses such as feeling sick and sleepless. This is followed by the fall, a feeling of spiraling that casts a pall over everything. In this phase, Dr. MacRae kept replaying her actions in her head, she said. The third phase is recovery, when surgeons become willing and able to actively reflect on the complication. This may be where they are more likely to turn to colleagues for advice and support. The final stage, recovery, is when surgeons reconcile themselves with what has happened.

Dr. MacRae echoed Dr. Bankhead’s comments that the effects of a traumatic event never wholly disappear. “As I was putting together this talk, just thinking about the whole case again made me feel upset and uneasy. I can still see the gray look on the patient’s face,” she said.

She closed her talk by quoting a surgeon who’d participated in one of the studies on traumatic events: “Each mistake I make or each complication I have or each patient I bury, I think has taken a little wee piece of me.”

Second-Victim Support

When Haytham Kaafarani, MD, MPH, was in his first few years of practice, he cared for a patient who’d been crushed by a forklift in a workplace accident. For three days, Dr. Kaafarani rarely left the hospital, operating on the man sometimes twice a day. When the patient woke after the last major operation, the injured man gave the surgical team a thumbs-up. Dr. Kaafarani went home, fell asleep and awoke at 3 a.m. to answer a call from his partner, saying the patient was deteriorating.

“I ran to the hospital,” recalled Dr. Kaafarani, an associate professor of surgery at Harvard Medical School and MGH, in Boston. He found the patient with severe necrotizing skin and soft tissue infection. The injury had led to a large inoculum of bacteria and cut off the blood supply to the pelvis. “He was gone. … There was nothing else to do,” he said. He had to tell the patient’s mother and children, who had, one day earlier, presented him with Christmas cookies as a thank-you.

Dr. Kaafarani said this case stood out among the hard ones because of a moment during the last operation. For a split second, Dr. Kaafarani thought that the fat in the wound looked a bit dull and pale compared with normal. After the patient died, he kept going back to that moment, wondering what else he should have done. “I terrorized my mind with that thought,” he said.

He felt that he couldn’t share his feelings with anyone. His colleagues and the patient’s family had seen him as someone heroic in his efforts to save this man. “But in my own eyes, I saw someone who actually failed that patient.”

Dr. Kaafarani now works closely with surgeons who have been involved in adverse events. The shift came from research, rather than his personal experience, he said. Kelsey Hahn, MD, at the time a medical student and now a surgical resident, suggested to him that they look at the effects of intraoperative errors on surgeons, as part of a larger research project on surgical errors. They surveyed 126 surgeons working at Harvard’s three major teaching hospitals and found intraoperative adverse events took an emotional toll: 84% said they felt the burden of errors, experiencing a combination of anxiety (66%), guilt (60%), sadness (52%), shame/embarrassment (42%) and anger (29%).

Surgeons told the investigators statements such as: “We all hide our grief, suffer in silence, the pain can be close to debilitating,” and “Everyone knows about an intraoperative adverse event within moments. There is no such thing as a support system—only criticism and condemnation.”

In response to the survey, Dr. Kaafarani developed the country’s first surgery-specific second-victim peer support program. He described it as a “walk with coffee” that is initiated by peer supporters when they hear about a surgeon affected by an intraoperative complication, adverse event, catastrophic outcome or lawsuit. Peer supporters are surgeons who’ve received specialized training.

“I strongly believe the value of a peer support program comes from a simple fact: being able to tell somebody that ‘I have been in your shoes. I know how it feels,’” Dr. Kaafarani said.

He offered advice for departments looking to start peer support programs:

• Create a sense of urgency, recognizing the need for a support system that is more formalized than just turning to colleagues for advice but less official than institutional assistance programs.
• Identify the individuals who will be good peer supporters. When the MGH program was started, the chair emailed everyone in the department to ask who their support people were when a complication happened, Dr. Kaafarani said. He then approached those surgeons to say they’d been nominated by their colleagues as peer supporters.

When a surgeon experiences an adverse event, the first priority for the supporter is to assess the clinician’s ability to continue safely caring for their patients, he said. Most surgeons can carry on with their day, but some may be so rattled that they need to go home. The supporters tell the surgeon to expect recurrent thoughts and flashbacks. They teach them techniques to help redirect their thoughts when they find themselves reliving the experience. This helps prevent against developing PTSD, Dr. Kaafarani said. Finally, they help address any systemic issues that contributed to the event.

Surgeons who find themselves in a peer supporter role should not try to fix things or pretend what happened is not a big deal, he said. “Know how to listen and resist the urge to find a solution.”

The peer support program at MGH is now in its fifth year. It is offered as an opt-out program to anyone associated with an adverse event—meaning the supporters initiate contact. To date, four out of every five surgeons opt for the support, Dr. Kaafarani said.

Employee Assistance Programs

Michelle McGovern, the director of strategic operations, people and culture at the American College of Surgeons, encouraged surgeons to check whether their institutions or insurance plans offer an employee assistance program (EAP) that can help when there is a traumatic event. EAPs are free but underutilized, with studies suggesting only 2% to 6% of workers use them.

She advised leaders in surgical departments and hospitals to advertise the availability of an EAP and highlight the confidentiality of these programs. “Individuals are more likely to use an EAP post-event if they’ve heard of it before,” Ms. McGovern said. Programs should promote the EAP during employee onboarding, and consistently advertise the program through online and posters in common areas that include phone numbers and websites.

Surgeons who do not have access to an EAP or want additional resources can find support online at Better Help (www.betterhelp.com), TalkSpace (www.talkspace.com), Cerebral (www.cerebral.com), Nobu (www.nobu.ai) and Psychology Today (www.psychologytoday), she said.