I was a third-year medical student in 1999 when the landmark report titled “To Err is Human” was released by the Institute of Medicine (IOM), unveiling the uncomfortable truth about the fallibility of physicians and our medical system. I remember it vividly. The publication’s scandalous revelation that nearly 100,000 preventable deaths occurred in hospitals each year shocked me. I recall feeling simultaneously offended and defensive at the implication that doctors could be wrong. Medicine, after all, was a noble profession requiring hard work, sacrifice and intellectual rigor. It was a calling to heal and serve. It seemed incongruous with my worldview that a physician might actually cause harm. I was exposed to medicine by my father, who practiced nephrology and ran the dialysis unit at an urban county hospital. He was trained in an era when physicians were predominantly male and of a skin color to match their pressed white coats, and the physician-patient relationship was best characterized by the adage “doctor knows best.” I came of age at a time when the rigors of medical education coincided with the advent of protocols, algorithms, metrics and evidence-based medicine. The IOM report rightfully fueled the patient-safety movement in conjunction with an accelerated interest in research and systematic change to avoid unnecessary death and medical errors. Twenty-three years after the report’s publication, however, our health care system still struggles to address medical error and its ramifications at an organizational and system level. Importantly, our system has further failed to adequately address the human struggle faced by individual clinicians confronting such errors. Medical errors exist at the far end of a continuum of unexpected events in clinical practice and they are devastating for all involved. Even when care is attentive and patient compliance perfect, unexpected outcomes occur in medicine. Unanticipated diagnoses, delays in diagnosis, premature death — these are all included in the realm of “unexpected events” even if nothing has gone “wrong” in medical care. These events cause physicians to suffer self-doubt, worry, shame and guilt, sometimes exacerbated by the magnitude of the event, the temperament of the clinician and the institutional climate in which these events occur. Emotional distress is common after a medical error. The threat of medical malpractice forces a provider to also deal with uncertainty and fear surrounding the legal sequelae of an unexpected event. An article in the New England Journal of Medicine from 2011 suggests that by age 65, 75 percent of clinicians and upwards of 90 percent of surgeons will have faced a malpractice claim. Despite the prevalence of statistics shared in the above-mentioned publications, doctors don’t talk much about this side of medicine. Why not? In part, the answer may lie in the fact that the culture of medicine discourages personal disclosures of this nature. Doctors are meant to project composure and remain free of emotional entanglements, which might cloud medical judgment. Perfection is expected, which leads to a zero-tolerance policy for mistakes, since, obviously, when treating humans, there has to be an emphasis on getting it right. In such a culture, an error or unexpected outcome invariably can lead the tending physician to feel shame and guilt. A sense of isolation often accompanies these feelings, exacerbated by the unwritten code that one should not discuss any potentially litigious details with peers that may be judged to reflect a lack of clinical competence or that may surface as evidence in later legal proceedings. Reflecting on my two decades in clinical practice, it remains uncommon to explore the ramifications on the individual physician’s well-being after an unexpected event. This lacuna has prompted my interest in promoting discussion about risk and uncertainty in medicine. Given the prevalence of unexpected events, medical error and malpractice, why are we not talking more about how doctors feel? Of the staggering number of physicians who report burnout or of those who die by suicide, how many have experienced an adverse outcome that may have affected their well-being, contributing to these troubling outcomes? Burnout is common, with research suggesting patient-care suffers in its shadow. Similarly, depression scores have been associated with an increased risk of medical error. Is the same true for the physician preoccupied with a past mistake or adverse event? How many of us have a graveyard of patient experiences consisting of moments that did not go well and in which we felt some culpability — even if we assumed an unrealistic share of the perceived responsibility? How many of us have learned of a differing diagnosis on a patient made outside our exam room and then scoured our records to make sure we did not miss something? Our negativity bias, carefully honed through years of training to anticipate the uncommon yet worst outcome, serves us well professionally while detrimentally turning inward, amplifying the voice of the physician’s inner critic. There are antidotes on the individual and institutional level to attenuate the toxic distress that occurs downstream of an unexpected event. First, publications in the medical literature on second-victim syndrome have added language to describe the experience of clinicians, or second victims, involved in an unexpected event and its sequelae. Second, there is research to support the practice of mindfulness and self-Compassion (MSC) and its benefits on well-being and productivity. Psychologist Kristin Neff, PhD, the first to define self-compassion operationally, explains that the primary goal of MSC is treating yourself as you might treat a dear friend. MSC provides the opportunity for greater self-awareness of thought patterns that are highly critical and a pathway to metabolize them. Third, on an institutional level, programs such as Dr. Jo Shapiro’s Peer Support program based at Massachusetts General Hospital (MGH) aims to change the culture of medicine and provide immediate support to those requesting it after an adverse event. Trained peer physician counselors are available to offer a supportive framework for a clinician in distress. Finally, physician coaching is another avenue to cultivate awareness and manage self-destructive thoughts. Though an unregulated industry, coaching programs for physicians have been associated with decreased burnout and emotional exhaustion and an increase in resiliency scores and quality of life. For the physician practicing today, these tools are worth cultivating. After all, for most physicians, confronting the inevitable unexpected event requires resilience, reflection and insight in order to recover and best serve our patients — and ourselves. Source
