Johns Hopkins research center director Albert Wu, MD, was a San Diego house officer when a fellow resident "failed to appreciate the significance of a patient's test result. An urgent problem became an emergency in the middle of the night" and the patient had to be rushed into surgery.
The staff turned on the resident, who "bore the brunt of finger pointing and criticism" for his lapse in medical judgment, Wu recalls.
"It became a bit of a mob, [with] bullying, with gossip, and [with] criticizing and castigating," Wu says. The way the resident was treated, "was wrong, because he shouldn't have been the only one seen as responsible for every aspect of this patient's care. More importantly, it wasn't a good way to handle the problem."
In fact, it was quite destructive.
That was in 1987, but the incident nagged at Wu as he realized that healthcare organizations are missing an opportunity to help caregivers grapple with the emotional distress of errors and bad outcomes they see so often.
"Although patients are the first and obvious victims of medical mistakes, doctors are wounded by the same errors; they are the second victims," he wrote in a British Medical Journal article in 2000.
Constructive intervention with respectful empathy can prevent future errors, salvage careers and self confidence, avoid burnouts and breakdowns, and create a much more functional system all around, Wu says.
What should always happen after such an incident is that the medical staff should make the incident widely known, so that everyone can benefit from the knowledge of what happened, instead of just one person, Wu says. "System flaws underlie the problem and allow it to happen."
"If people are consistently beaten up when there's a bad outcome, you create a climate in which no one talks about anything, and a conspiracy of silence leads to mistakes being repeated."
Most people in healthcare realize there's a problem with second victim psychological sequelae, but they think of it as a case-by-case thing. "There's been no organized recognition, no policy or support services for people with these problems."
Now, surveys that ask providers these questions are finding that as many as half of certain high acuity doctors and nurses "can think of an incident in which they would describe themselves as being the 'second victim,' " Wu says.
It's been more than a decade since Wu wrote his piece, but organized institutional structures are finally emerging to help providers grapple with the emotional turmoil they experience, whether or not their actions have caused a mistake.
Among the first such programs started in 2009, the forYOU Team, is the brainchild of University of Missouri Healthcare's patient safety officer Susan Scott, RN. Scott says she got the idea from Wu.
As the new patient safety officer, she says, "One of my jobs was to work with physicians after an anticipated event, talk about what transpired, and see if there were lessons we could learn about keeping future patients safe."
She heard caregivers give "incredible details (of the incident), and at the end of the conversation I would ask, 'Well that had to be really tough. How are you doing?'
"What I wasn't prepared for was the responses. Many would just break down in tears. 'I'm not sure I even want to be a doctor anymore,' said one. 'I should go be a WalMart greeter, I can't mess that up.'
Those kinds of demeaning phrases, and you could tell they just had real visceral pain from their experience. Their whole psyche was destroyed."
Very frequently these second victims were told by hospital lawyers not to discuss what happened except to investigators. "They'd go home, pick at their food, have restless nights and many suffered from marital stress because their spouses thought their marriages were in trouble," Scott says.
Traditional employee assistance programs (EAP) are staffed by professionals who don't work in a hospital. The emotionally devastated caregiver, she found, "really wants to talk with someone who actually knows what it's like."
With help from the EAP, Scott's project has trained 99 volunteers who have helped 639 members of the staff cope with second victims. She calls it a "rapid response team for clinicians," or "emotional first aid."
It's not always the caregiver who does something wrong to a patient who needs help. Often, it may be the impact of the unexpected death of a patient that someone got close to.
The volunteers try to cover every shift or unit within the seven-facility system through a 24-hour pager number, especially in "high-risk areas" such as intensive care units. Many have been second victims themselves.
Scott found that unexpected deaths of other hospital workers hit many of their colleagues hard. There was the young surgery tech who had leg pain in the morning, a pulmonary embolism in the afternoon, and was brain dead the next day. The tech's own team harvested her organs for transplant.
Or when the hospital helicopter crashed, giving two crew members that the staff knew well "career-ending injuries."
There were grief-stricken staff left behind, one lamenting that he had traded his shift with one of the victims, she recalls.
In mid 2011, Wu launched a similar program called the RISE (Resiliency In Stressful Events) Team, a crew of about 30 volunteers at Johns Hopkins. It started out as strictly a program for pediatric caregivers, and got some funding from the Josie King Foundation.
Wu says that Brigham and Women's Hospital and Beth Israel Deaconess in Boston are developing similar programs, as is Stanford University Hospital. A few others are in the works.
I asked Wu and Scott if healthcare workers, especially those working with daily life and death hospital dramas, shouldn't be capable of dealing with these events. I'd always been told that that nurses and doctors, especially those working in medical and surgical intensive care units, had to be "hard core" because that's where many patients die.<
There are just some cases that hit too close to home, they replied, "Like when you're in a unit where someone bleeds to death in front of you, that could be upsetting," Wu says.
He likens the scenario to that of a train operator who, as many do, sees his train running over someone on the track. "The operator just sits there; it's not his fault; he shouldn't feel badly that someone got mangled."
But he does.
Bob Wachter, MD, director of the division of Hospital medicine at UCSF and a friend of Wu's, says he "loves the concept of a structured program for second victims, and the evidence is strong that they work."
But he says they're tough to do because so many people need to be trained to make sure someone is available every shift in case an intervention is requested. "It's also resource-intensive, so it tends to fall to the bottom of the deck."
But Wu says the business case is easy to make, in part because a burned out second victim is expensive, typically costing between $100,000 to $200,000 to replace.
Besides, Wu suggests that hospitals have an ethical obligation to start these programs when they strongly encourage their doctors to report their mistakes to their supervisors, as well as the patients and their families.
"That's likely going to make the doctors feel even worse about themselves. And you're really being irresponsible if there's not an organized system of support."