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For surgeons who make a clinical error, the emotional effects can be deep and lasting. So much so, that they have been termed the 'second victim'. The MDU can help, as Dr Jerard Ross, medico-legal adviser, explains.
Surgical error and avoidable injury to patients are, quite correctly, a hot topic. Like all doctors, surgeons are encouraged to be open and reflective, and to constructively analyse error when it arises so that the likelihood of repetition is reduced.
In surgery, a practitioner's identity as a 'successful surgeon' is inextricably linked to their clinical performance. This is judged not only by peers and trainees but also those who may be distant from the process and not aware of the complexities of a given case. It is common to strive for perfection. Against this background, openly accepting and acknowledging failure may be very difficult.
Errors are not always the same as adverse events, although the latter may flow from the former. Sometimes a surgical error results in no external signs or problems; sometimes the outcome is 'suboptimal'. Occasionally, one slip of the scalpel or a poorly placed screw results in great harm to the patient.
The surgeon may also face consequences from the error. Complaints result, experts opine, coroners inquire, judges adjudicate and regulators may investigate any indications of impaired fitness to practise. There is an increasing appreciation of the impact of error on the clinician (the 'second victim') and calls for organisations involved in training surgeons to recognise it in their curricula.
The emotional reaction to adverse events can be profound. In a study of 7905 surgeons, 16% of those who reported a major error experienced suicidal ideation. In the same study, the perception alone of having made an error increased the risk of suicidal ideation three-fold.
Involvement in medical errors often provokes intense emotional distress that considerably increases the risk of burn-out and depression. Commonly this manifests as distress, self-doubt, confusion, fear, remorse, and feelings of guilt and failure.
Depression, anger, shame and inadequacy can persist for longer and all may be amplified by higher degrees of perceived personal responsibility. Worryingly, evidence suggests a continuous cycle of these symptoms is followed by increased risk of future suboptimal patient care and error.
Unsurprisingly, these can have a negative impact on the doctor's private life. In one study of 1318 doctors, of those involved in serious adverse incidents 17% reported a negative impact at home and 6% obtained professional help for the effects.
The emotional response to error has been described as coming in four recognisable phases. The initial 'kick' on realisation, involving feelings of failure and significant physiological effects (tachycardia, nausea). This is followed by 'the fall' of spiralling feelings of self-doubt casting a pall over everything. Often in this phase surgeons analyse whether there really is a link between their outcomes and the actions, resulting in significant rumination and concern about other people's opinions.
The first two phases may last a few days before the 'recovery' begins when surgeons need to talk to family, friends and colleagues about events. This can be significantly improved if the patient and family are understanding and often doctors hope to learn something from the event. The 'long-term impact phase' can be prolonged and significantly affect the doctor's personal and professional identity ('a piece of them being taken away with every complication').
Individually, doctors have coped with these issues by utilising three classic strategies, firstly denial ('that wasn't an error'), secondly discounting ('if the SpR hadn't forgotten too' or 'if the anaesthetist had remembered to check') and thirdly distancing ('we all make mistakes').
More constructively, talking and listening to colleagues seems to play a critical role in dealing with the experience of error and drawing constructive conclusions from it. Although it can be difficult to find such support (Fahrenkopf ref), some doctors suggest that they would only offer such support to a close personal friend, not just to any colleague.
Morbidity and mortality conferences and significant event analyses are organisationally absolutely essential but seldom offer much emotional support to surgeons.
A doctor may be judged as much on their response to the error as by the error itself. Taking an objective, rational and insightful stance and acting appropriately can be difficult when dealing with the aftermath of a bad outcome. Managing the process as an individual can be even more difficult.
This is where the MDU can be helpful, guiding you through the various medico-legal ramifications and helping you obtain the best result in what can be a challenging situation for clinicians at every grade and in every specialty.
The chance to talk to medically-qualified advisers may in itself help minimise feelings of guilt and self-doubt. We can talk you through appropriate professional responses to error and management of the daunting processes which can follow.
We can also discuss the impact it has had on you and what might be an appropriate response, such as making an appointment with your GP or with occupational health. Occupational health physicians have a key role to play in work-related illness. Many are on-site in hospitals and have significant skills in supporting colleagues in these circumstances.
The MDU is on hand to help members write appropriate SUI reports and coroner's statements. We can advise and, if necessary, organise representation for members giving evidence at a coroner's inquiry or Fatal Accident Inquiry. We have a huge organisational experience of responding to complaints, dealing with the coronial system and handling claims for clinical negligence against our members. Each year we rebut around 70% of all claims brought against members.
Any correspondence from the GMC indicating a desire to investigate an event is best discussed with us as soon as possible. We have long and successful experience of helping our members with the regulator.
In essence, surgeons and more generally doctors can suffer significant emotional and professional consequences of error. The MDU is here to help you manage the outcome.
This article originally appeared in the printed version of the April 2014 MDU journal entitled "Behind the mask"
For references for this article refer to the PDF version of the journal
This guidance was correct at publication . It is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.
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