Second victim syndrome in the time of COVID-19

Every physician I know has a story about an unanticipated patient event.  A story that was traumatic at the time and easy to now recall in fine detail.  A story that was so impactful that it still haunts them.  When a patient suffers an adverse event, many people are affected — the patient, his or her family, and the health care providers. The physicians and their team who are most impacted by the event become the “second victims.”

When I was a resident in the medical ICU, I had a second victim experience that changed the course of my career.  There was a physician assistant, Sam (name changed), who worked in our ICU for nearly 20 years.  Sam was intimately involved in training and supporting the residents, and consequently, every resident, fellow, and attending knew him well.  On his way into work one morning, he collapsed in front of the ER.  He was triaged, treated, and admitted.  I was the resident on call who admitted this mentor to our service.  Despite our heroic efforts, Sam died quickly under the care of the people who knew him and loved him well.

After his death, our team went back to our ICU to round.  We did not discuss the code, we did not acknowledge what happened, and we did not acknowledge our feelings.  I was exhausted and overwhelmed with emotion, and I became angry during rounds.  “We are not even going to talk about this?” I screamed.  “Kara, we have work to do,” the attending replied.

I know that our attending physician was clearly in shock.  My experience with him was that he was compassionate and deeply cared for his patients and their families. In fact, he modeled communication and end of life care in a way that I still emulate. However, that day, he did what he was well trained to do – compartmentalize his feelings, get his work done, and move on.  I have no doubt that he grieved, but as a learner, I internalized his outward silence as what was expected of me.

Sam’s funeral was four days later and attended by hundreds of people from our hospital.  Unfortunately, I was unable to attend, to grieve, and to process my own experience because I was again on call.  Working 80-hour weeks in the ICU left no time to seek professional help for this traumatic loss.  I did what many of us do after unexpected patient events.  I silently blamed myself, I told no one, and I tried to move on.  Now, as a mid-career physician, I recognize the long term effects of this event as second victim syndrome.

There were three lessons I learned from Sam’s death.  First, I internalized that it was not acceptable to have feelings about our patients, particularly during unanticipated events.  If we couldn’t acknowledge the weight of our colleague’s death, why should we have feelings about the rest of our patients?

Next, as an internal medicine resident, I was weighing my future as a primary care physician, a hospitalist, or a specialist.  I felt that if I could not suppress my experience in the ICU and avoid my grief, I clearly should not pursue a career in the hospital.  Despite being resident of the year twice, being invited to be chief resident, and receiving unsolicited letters of recommendation for my performance in the ICU, I could not reconcile these accolades with the very real feelings that these high acuity patients provoked.  Due to the fear, shame, and grief of second victim syndrome, I ultimately chose a career in primary care, hoping to avoid the feelings I associated with the ICU.

Lastly, I questioned my ability to be a physician.  Physicians are strong, resilient, and capable, and I clearly was not if my grief and anger intruded into my work. I questioned my decision making in Sam’s care: “What could I have done differently? I should have known this might happen! If I had only been smarter! If we had gotten there sooner!”  This experience imprinted uncertainty on my practice that I overcame with compulsive workaholism that contributed to my burnout years later.

This year, as a coach for physicians struggling with burnout, I was invited to give grand rounds on burnout at my alma mater.  I was simultaneously excited and nauseated.  Nausea is my fear response, and on introspection, I recognized that I was not nervous about the talk, but rather I was nervous about returning to the hospital and walking past that ER and ICU.  I ultimately did exposure therapy to overcome this fear – I literally walked the halls of my old hospital to recall Sam’s death and safely process my trauma.

My experience after Sam’s unanticipated death is not unique.  Nearly 80 percent of physicians report second victim trauma.  Many organizations, including the Joint Commission, recognize the profound impact of second victim syndrome and offer system-wide guidelines to address this epidemic.  Effective interventions for second victim syndrome primarily involve immediate recognition of the trauma, time, and ability to safely discuss the event, and peer support.  Cultural change in the form of access to mental health services, tort reform, and creating realistic expectations between doctors and their patients are also relevant.

Thus far, in the era of COVID-19, we have witnessed 136,000 COVID-related deaths.  As ICUs are overflowing with COVID losses, burnout and demoralization amongst physicians are rising. Do we, as individuals, communities, and organizations, recognize the immediate need to address our traumatic patient experiences?  Do we have the emotional bandwidth to support our colleagues while addressing our own needs?  Will we have the foresight to plan for the emotional recovery from these experiences instead of suffering in the aftermath? Will we avoid seeking help due to mandatory reporting of mental health treatment for state licensure in two-thirds of states?

It’s not if we experience second victim syndrome, it’s when.  Most of us already have stories that haunt us, and there are new stories being written every day.

See this article published at KevinMD.

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