Several surgeons have recently reminded me that the impacts of adverse patient outcomes on physicians and nurses’ lives are deep and lasting. In previous posts, we’ve explored that terrain from several angles. We’ve touched on the process of recovering from adverse patient outcomes through the lens of my personal experience, who becomes a “second victim” and why, and how to support a colleague after an adverse patient outcome. Today, let’s go a step further. Let’s explore the three paths available to those recovering from adverse patient outcomes.
Research on Second Victim Recovery
There is a body of scientific literature which details the experience of the “second victim.” Granted, not everyone likes that term -- the word “victim” sets off alarm bells for some -- but since it’s the term the scientific community recognizes, I hope you’ll just roll with me on it for now.
If the term “second victim” is new to you, let me clarify. Sidney Dekker, pilot and international expert in safety science, identifies a second victim as a practitioner who is traumatized themselves when someone they aim to heal or protect is harmed, especially when that practitioner wonders whether they had a hand in the harm or might somehow have prevented it. Be that practitioner a pilot, a nurse, a physician, or an aerospace engineer, the effects on them can be devastating at times. These effects often follow a predictable pattern, not unlike bereavement. With “Inside the Whirlwind,” “3 Reasons Why We Grieve Patients’ Unexpected Losses,” and “Fear Itself,” we began to scratch the surface of the turmoil that sometimes erupts. What we haven’t really explored, though, is what happens after the aftermath. In other words, what patterns emerge in physicians and others further along the path to recovering from adverse patient outcomes.
In an article from 2009, researchers identified six stages of recovery for the physician or other individual who has been injured by this type of life experience. Like Elizabeth Kubler-Ross’s stages of grief, these stages may overlap or come up repeatedly. Their universality reveals our common humanity, although the particular emotional hue and intensity may vary from one person and circumstance to the next. Interestingly, though, in the sixth stage, which researchers labelled “Moving On,” travelers diverge along three distinct paths. They drop out, they survive, or they thrive.
In my experience, these three paths are not entirely fixed. Healers may bounce from one to another, or create a unique hybrid of two or more over the years. Nevertheless, I think it’s helpful for us to see the three alternatives and understand a little better what our choices are.
One path people follow when attempting to recover from a patient’s adverse outcome is that of “dropping out.” Don’t let that term fool you. It’s not meant critically. Sometimes dropping out turns out to be tragic, but other times it’s highly functional.
What does “dropping out” look like? A whole array of possible responses, which may be more or less available to us depending upon our profession and specialty. It may mean:
A nurse moving from an intensive care unit to the post-anesthesia care unit, thereby getting a fresh start
A physician leaving emergency medicine for the lower acuity of urgent care
Narrowing one’s scope of practice, like an OB/GYN who stops delivering babies
Leaving clinical medicine all together to pursue work in administration
Getting aggressive about early retirement
Quitting medicine completely for some other line of work
In the most heart-rending instances, however, dropping out may mean:
Depression without treatment
Addiction without recovery
Some roads obviously provide a better life outcome for the individual than others. And in many of these instances, the patient population suffers a hidden, but no less unfortunate loss of accumulated clinical experience. I invite us not to judge any of them, however, as each represents the tip of an iceberg of loss for that individual. I want to make it our goal to try to understand the individual’s efforts to navigate that loss and the pain accompanying it, and to reduce barriers to getting support through the process wherever we can.
The second road injured healers may take has been dubbed “surviving.” What does that look like? Sticking it out right where you are, possibly even limping along, never fully healing. It may require thicker skin. One may or may not pull back from patients. Burnout, resentment, or cynicism may surface and never remit.
I suspect this road may be disproportionately crowded with physicians. Given that we enter practice relatively specialized, physicians may experience less flexibility than nurses, respiratory therapists, or advanced practice providers to apply for a post in a different area of the hospital or another specialty. While a nurse might readily move from ICU to PACU, a physician likely will not, at least not without additional post-graduate training.
Further, physicians often enter practice with significant debt, and that debt may keep them locked in place occupationally. That may not be all bad in some instances. When my own patient’s terrible outcome occurred, I was crushed and absolutely considered leaving medicine behind. I concluded, however, that medicine needed to pay off medical school’s debts. That choice to stay in place is not one I regret. With time, I found my way beyond those initial impulses to fuller healing. I fear that deep healing never would have come had I simply moved on.
Again, there is no judgment here. After all, those who are surviving are, in fact, surviving and serving others. Nonetheless, it intrigues me to consider how we might support one another in moving beyond barely hanging on. Can surviving become the threshold to something more?
The path of thriving belongs to those who find a way -- semi-miraculously at times -- to wring something beautiful out of a whole lot of ugly. At some point down the road, even decades later, these folks say things like:
“It was a terrible experience, but if it had to happen, I’m glad it happened to me.”
“I’m a better person today. It made me who I am.”
“It was really awful, but I’m grateful. Perhaps it was meant to be. Look at what has come of it.”
Thriving might mean a nurse, devastated by a medication error, who invests enormous energy in ensuring that type of error never occurs again. Maybe a surgeon takes it on herself to ensure that her trainees fully understand the ethical management of certain complications. Or a nephrologist takes on more intensive education of dialysis personnel than a hospital has ever known. In every case, the individual honors the painful event -- theirs and the patient’s -- by making it a vehicle for life and healing. They transform straw into gold.
Let’s be clear. Thriving is not feigned optimism or pretending to be happy. It is growth on a very high order. I really mean it when I say I do not judge the path that anyone takes after this sort of an event. These events can be devastating to compassionate, skilled people. However, if I could open just one door for any of us, it would be that door to thriving. Hence, the name Thrive.
How do they do it? That is absolutely worth exploring, and we will in future posts. For now, I invite you to just look around and start to notice thriving where you might see it. Then, if you haven’t already, subscribe to the blog to explore how we can do that for ourselves and one another, too.