Nearly 50% of healthcare providers face second victim syndrome (SVS) – the trauma after a medical complication or error – at least once, and experts are now urging more emphasis on improving access to services to help surgeons at risk of the condition.
Around 20% of hospitalised patients may experience a complication at some stage, with some specialties being particularly exposed to SVS, anaesthesia, paediatrics and obstetrics-gynaecology being among them.
The presentation varies, bringing prolonged emotional consequences for some and affecting the personal life and professional practice of others, reports Medscape.
The consequences can be psychological (shame, guilt, anxiety, grief, or depression), cognitive (lack of empathy, burnout, and post-traumatic stress), social, cultural, spiritual and physical. There are mainly quantitative data on the frequency of SVS; few qualitative studies are available.
Most published research does not focus on surgical specialties, even though surgeons face stressful situations and technical challenges daily, making them particularly susceptible to SVS.
Strength and emotional control are part of the typical surgeon stereotype. Consequently, the occurrence of a surgical complication is most often approached only from a technical standpoint without accepting its emotional consequences.
Study analyses data from 13 publications
An analysis by a team from Singapore examined published data on SVS in surgical settings. Thirteen qualitative studies, either cross-sectional or in the form of semi-structured interview reports, were selected.
The studies were conducted in the US, the UK, Canada and France. The analysis focused on a cohort of 1 069 surgeons from various specialities. The psychological, physical and professional impacts of SVS were distinguished, and the factors affecting the response to the causal event.
Psychologically, the most frequently described negative feelings were guilt, depression, anxiety, frustration and embarrassment. These had social, personal and professional repercussions, including self-restriction of leisure activities and insomnia.
Most lasted between a week and a month after the event and were more pronounced in female surgeons and those in aesthetic surgery.
Negative feelings
Guilt was the most commonly expressed feeling (18.1%-89.1%), because of the unique relationship between surgeons and patients.
It was also more pronounced in cases of patient death, especially among practitioners with close relationships with their patients and families. It was the most persistent negative feeling, and often coincided with depressive symptoms, which affected between 12.5% and 52% of surgeons.
Anxiety (18.1%-66%) was also frequently described as disturbing, invasive and restless, and associated with anger and frustration, sometimes manifested as rudeness toward patients or the operating room team. Beyond provoking negative feelings, an error or the occurrence of a complication affected judgment and self-confidence, leading to rumination, analysis and questioning of what could have prevented the complication.
This could sometimes result in excessively cautious attitudes that affect performance, with shifts to other specialties or even early retirement.
For some, SVS manifested physically as headaches, weight fluctuations, nausea, abdominal pain and palpitations – but these symptoms were often short-lived.
Professional impact
SVS impaired professional performance, led to avoidance behaviours, and often had medico-legal or disciplinary implications. Most surgeons believed their professional behaviour had not been optimal, and this judgment frequently resulted in the cessation of certain activities or types of interventions, with this conservative attitude sometimes being to the detriment of patients.
Similarly, surgeons became more meticulous in maintaining medical records and tracing consent. More generally, they were concerned about their reputation and suffered from professional dissatisfaction, especially given the prevalent criticism and condemnation in this highly competitive environment.
The perception of a lack of support from peers was amplified by the absence of support from institutions, with the fear of seeing their positions questioned.
However, surgical complications could sometimes be beneficial, forcing surgeons to rethink and reflect their roles, as well as that of their service and institutions. On an individual level, some became more cautious, more vigilant, and better understood safety issues.
At service and institutional level, improvements were noted in procedures (like computerised records), protocols (checklists, timeouts and equipment checks), and communication with administration.
Predictors of SVS
The factors influencing the reaction to a surgical complication depended on the circumstances and its nature, the surgeon’s personality, and the assistance received. A complication was better received if the patient were older, had comorbidities, or had an unexpected anatomical problem than would have occurred in a young, healthy individual.
A complication after emergency surgery was more easily tolerated than one after a scheduled intervention.
Conversely, a perioperative complication, due to a judgment error or technical problem, was poorly received. This was also the case for certain events (like death, infection, haemorrhage, anastomotic fistula, or unintentional injury) or sequelae (amputation or paralysis).
The individual response depended on personality and experience, which, while helpful, also exacerbated responsibility. Different personality types were observed within the cohort. Some were very close to their patients (e.g, showing empathy, listening and meeting expectations).
Others isolated themselves, repressed their emotions, moved forward, and tried not to be distracted in their future decisions. Conversely, others completely collapsed after the complication.
Culture of blame
This range of responses contributed to the variability in the intensity of SVS. Participants in these studies admitted their lack of skills to manage complications from a non-technical point of view. Younger individuals highlighted their isolation in this area and the lack of or poor quality of training.
In this competitive and reportedly unsympathetic environment marked by easy criticism, morbidity and mortality reviews (MMR) were experienced by some as an opportunity for public blame instead of a source of learning and improvement.
Thus, surgeons remained on the defensive, cutting the dialogue short. Even if the atmosphere could be constructive, the debate mainly focused on technical issues rather than on psychological consequences.
Finally, the lack of administrative support was emphasised, contributing to this culture of blame, with mainly punitive responses and without analysis of the underlying systemic causes.
Many practitioners would have liked standardised help in the form of a break from their activities, discussions with colleagues to facilitate communication with patients, and formal psychological assistance.
When this type of help was standardised, the atmosphere during MMR was much calmer. Exchanges with colleagues were considered the most effective help (81%), especially for younger individuals. Many would have liked to stop for a while, but few did, getting back on track immediately after the event.
A change in culture
This study contradicts the stereotype of surgeons being in control of their emotions. On the contrary, they can be affected by feelings of guilt, depression and self-questioning after a complication. These negative ideas can cause burnout, post-traumatic shock, and even suicidal thoughts.
A recent study of 622 academic surgeons, experienced or in training, showed that 15.9% were currently depressed and 13.2% had had suicidal thoughts in the past year. These destructive phenomena are self-perpetuating, and medical errors are clearly associated with depression, anxiety, post-traumatic shock, alcohol consumption, and burnout.
The authors advocate not only for information and programmes focused on SVS in training but also for a change in culture within the surgical environment. This change could benefit from the feminisation of surgical specialties because this study and other research show that female doctors (like junior doctors) are not only more prone to SVS but also more open to exchanges and assistance from their peers and the institution.
Note that quantitative studies are susceptible to inherent bias, either by over- or under-reporting, which can affect the evaluation of the prevalence and impact of SVS.
Study 1 details
Scoping review of the second victim syndrome among surgeons: Understanding the impact, responses, and support systems
Ryan Ian Houe Chong, Clyve Yu Leon Yaow, Hiang Khoon Tan et al.
Published in The American Journal of Surgery on 7 October 2023
Abstract
Background
It is thought that 50% of healthcare providers experience Second Victim Syndrome (SVS) in the course of their practice. The manifestations of SVS varies between individuals, with potential long-lasting emotional effects that impact both the personal lives and professional clinical practice of affected persons. Although surgeons are known to face challenging and high-stress situations in their profession, which can increase their vulnerability to SVS, majority of studies and reviews have focused squarely on nonsurgical physicians.
Methods
This scoping review aimed to consolidate existing studies pertaining to a surgeon's experience with SVS, by broadly examining the prevalence and impact, identifying the types of responses, and evaluating factors that could influence these responses. The scoping review protocol was guided by the framework outlined by Arksey and O'Malley and ensuing recommendations made by Levac and colleagues. Three databases (MEDLINE, EMBASE and Cochrane Library) were searched from inception till March 19, 2023.
Results
A total of 13 articles were eligible for thematic analysis based on pre-defined inclusion criteria. Effects of SVS were categorised into Psychological, Physical and Professional impacts, of which Psychological and Professional impacts were particularly significant. Factors affecting the response were categorised into complication type, surgeon factors and support systems.
Conclusion
SVS adds immense psychological, emotional and physical burden to the individual surgeon. There are key personal, interpersonal and environmental factors that can mitigate or exacerbate the effects of SVS, and greater emphasis needs to be placed on improving availability and access to services to help surgeons at risk of SVS.
Study 2 details
Unspoken Truths: Mental Health Among Academic Surgeons
Collins, Reagan; Herman, Tianna, Cunningham, Carrie et al.
Published in the Annals of Surgery in March 2024
Abstract
Objective
To characterise the current state of mental health within the surgical workforce in the United States.
Background
Mental illness and suicide is a growing concern in the medical community; however, the current state is largely unknown.
Methods
Cross-sectional survey of the academic surgery community assessing mental health, medical error, and suicidal ideation. The odds of suicidal ideation adjusting for sex, prior mental health diagnosis, and validated scales screening for depression, anxiety, post-traumatic stress disorder (PTSD), and alcohol use disorder were assessed.
Results
Of 622 participating medical students, trainees, and surgeons (estimated response rate=11.4%–14.0%), 26.1% (141/539) reported a previous mental health diagnosis. In all, 15.9% (83/523) of respondents screened positive for current depression, 18.4% (98/533) for anxiety, 11.0% (56/510) for alcohol use disorder, and 17.3% (36/208) for PTSD. Medical error was associated with depression (30.7% vs. 13.3%, P<0.001), anxiety (31.6% vs. 16.2%, P=0.001), PTSD (12.8% vs. 5.6%, P=0.018), and hazardous alcohol consumption (18.7% vs. 9.7%, P=0.022). Overall, 13.2% (73/551) of respondents reported suicidal ideation in the past year and 9.6% (51/533) in the past 2 weeks. On adjusted analysis, a previous history of a mental health disorder (aOR: 1.97, 95% CI: 1.04–3.65, P=0.033) and screening positive for depression (aOR: 4.30, 95% CI: 2.21–8.29, P<0.001) or PTSD (aOR: 3.93, 95% CI: 1.61–9.44, P=0.002) were associated with increased odds of suicidal ideation over the past 12 months.
Conclusions:
Nearly 1 in 7 respondents reported suicidal ideation in the past year. Mental illness and suicidal ideation are significant problems among the surgical workforce in the United States.
Annals of Surgery article – Mental Health Among Academic Surgeons (Open access)
Medscape article – How Does Second Victim Syndrome Affect Surgeons? (Open access)
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