NEW ORLEANS -- "Don't talk to anyone about it; just keep going."
Have you heard those words after you -- or someone else -- made a medical error or saw an unanticipated adverse event at your hospital or outpatient practice? Such sentiments are not uncommon, but they are also not helpful, several experts said here at the annual meeting of the American College of Physicians.
Doctors and other clinicians are often "second victims" when a medical error or other unexpected trauma kills or injures a patient. The circumstances can make it especially agonizing for the physician, said Albert Wu, MD, MPH, professor of health policy and management at Johns Hopkins University, in Baltimore. "Sometimes the patient is a little more relatable to you," he said. "You make a personal connection to them and feel that much more of an injury when something goes wrong."
A Variety of Outcomes
Pediatric cases can be especially tough, he continued. "When we make errors and there are things we did wrong, we feel personally responsible. Then there are those cases where we failed to rescue the individual," such as when the staff tries unsuccessfully to resuscitate someone using CPR.
Or "perhaps it's [the doctor's] first experience with death, or unexpected demise; the person is doing well and suddenly they pass away," said Wu. "[The physician is thinking], 'Will I be fired? Will I be sued? What will my colleagues think?'" It's also a blow to the most important thing any physician possesses: their reputation, he added: "'Am I slipping? Can I still do this?'"
After a medical misadventure occurs, there are three possible outcomes for the physician involved, according to Susan Scott, PhD, RN, manager of patient safety and risk management at the University of Missouri Health Care System, in Columbia.
"The most positive outcome is thriving -- making something positive out of the event," she said. "Another one is surviving -- their performance plummets and they're never quite the same after that. But the one that worries me the most is called the 'dropping out' phase; the individual has a career transition as a direct result of the event," such as going from academic medicine to being a bench researcher with very little patient contact.
What to Say?
One problem is that after such an incident happens, colleagues don't know what to say to a physician involved. "I heard a lot of clinicians say, 'I know he's going through a tough time, but I don't know what to say, so I'm not going to say anything,'" said Scott. "The biggest support they can provide is when they have a similar story they can share."
To help people at her institution get through such incidents, Scott founded the in 2009. The program offers staff members three levels of support:
- Local/departmental support from a department chair, supervisor, or manager who offers one-on-one reassurance and/or a collegial critique of the case
- Trained peer support from peer counselors and patient safety officers or risk managers who provide one-on-one crisis intervention as well as support through any investigation or potential litigation
- An expedited referral network to connect staff members needing professional help to psychologists, social workers, employee assistance programs, or other professional services
'It's important to have someone available around the clock, not just from 9 to 5 Monday through Friday," she added. "A lot seems to happen around 7:45 on Friday night. Monday morning at 9 is a long time to wait."
"The ForYOU Team is our personal intervention," said Scott. "When something bad happens, we [let people know] we're here or our staff; we're watching their backs. We can see the culture changing; it's exciting to see."
Support for the Whole Staff
Wu and his colleagues started a similar program at Johns Hopkins in 2011, called . When someone contacts the program for help, a responder "tries to call back in a really timely way; the average time is within 10 minutes," said Wu. "And it's for all employees," including food service workers, elevator operators, and environmental service workers.
RISE is designed to be confidential; "we don't take notes, we don't write down the name of the patient," he said. That way, if RISE team members are questioned by someone outside the organization later, they can say they don't know all the details.
Requests for help from RISE have increased lately, from one a month initially to about eight calls a week currently, said Wu. "Gradually people began to understand this was something that was just for them."
Nurses call more often than doctors, but RISE also facilitates a lot of group calls too. "The doctors will sit in back and suddenly have a lot to say. We do a lot of psychological first aid," he said.
The point is to show up and be supportive, Wu continued. "If you stop in and be supportive and are there, we can do a lot of good, probably without saying anything." RISE now has about 40 trained volunteers -- including physicians, social workers, chaplains, an EMT, and an equipment tech.
If you do want to say something to a colleague who has just experienced a medical misadventure, Wu gave a few suggestions in terms of emotional and informational support:
- "Are you OK?"
- "You've had a tough break."
- "Thank you for sharing with me."
- "These things happen to all of us."
- "You did everything you could."
- "Let me tell you about something that happened to me."
Another thing a colleague can say is, "Do you feel safe?" Wu added. "About a month ago, we had our first call of someone saying, 'I'm feeling suicidal.' We walked them to the psychiatric ER because that was an emergency."
Once, after Wu had made an error and was feeling very bad about it, "a nurse said, 'When you're done with your training, you can take care of me any time.' That's what I needed to hear," he said.
Are organizations like RISE a cost-effective resource? Wu's group did an analysis using human resources data, and found in the affirmative. The group's main expense is $30,000 per year for a nurse manager to run the program; a staff member having to take time off due to being involved in a medical misadventure can cost the hospital $211 per day, or $100,000 if he or she quits and needs to be replaced. "But if they get supported, the institution saves $22,576 ... They might have had to spend in days off or replacing that person," Wu said.
"Care for the patient requires care for the provider too," he added. "We encourage our organization to make provisions for ways to support people who are doing the hardest work." He also recommended (MITSS), which provides support for clinicians, patients, and families affected by an adverse event.