Last week the following interview was published in the Irish Medical Times. You can also read it on the IMT website.
Paul Mulholland speaks with Dr Kris Vanhaecht ahead of his talk at the RCPI’s St Luke’s Symposium next month about the traumatic impact adverse clinical events can have on doctors
It was during the routine examination of doctors as part of a Masters in Health Administration five years ago that Dr Kris Vanhaecht first began to seriously consider the psychological effect that patient safety incidents had on medical professionals. Dr Vanhaecht, who is Associate Professor in Quality Management at Leuven University in Belgium, was teaching a course on quality and safety for the Masters.
For the course, doctors were required to write about patient safety issues and then present their work in an oral examination. During one particular presentation, Dr Vanhaecht was struck by how a doctor described an incident he was personally involved in where a patient died as a result of medical error.
The doctor, who was visibly upset about what happened to the patient and the manner in which hospital management dealt with the incident, said that this was the first time he described the case in detail.
Also, the next doctor who came into his office, a GP, described an occasion early in his medical career when he arrived at a house after having received a call from a man that his wife was ill, only to be told that the woman had died.
The GP said he still dreamed and had flashbacks about the incident and, as a result, suffered from sleeplessness. When recounting the story, the GP began to cry. That night, Dr Vanhaecht found it difficult to sleep himself.
The next day he contacted a colleague in the US, with whom he had previously conducted research. “I said ‘this is what happened to me yesterday’,” Dr Vanhaecht told Irish Medical Times. “It cannot be that I am the first that is experiencing this sort of thing. That is how I became involved in the area of second victims. To be honest before I had that experience I never heard of the topic second victims.”
The phrase “second victim” (the first victim being the affected patient/and or their family) was first coined by Professor of Health Policy and Management at Johns Hopkins School of Public Health, Prof Albert Wu, in a paper in the British Medical Journal to describe the traumatic impact an adverse patient safety event can have on a doctor.
Prof Wu was responding to the groundbreaking report To Err is Human from the Institute of Medicine in the US, which estimated that errors caused 44,000 to 98,000 deaths annually in the country, with a total cost of between $17 billion (€15bn) and $29 billion (€26bn) each year. In the ensuing discussion, Prof Wu said that the impact such incidents had on doctors should not be ignored.
It was not until 2009 that the phrase was further defined as relating to a healthcare provider involved in an unanticipated adverse patient event, who became victimised in the sense of being traumatised by that event.
The subject has become more refined with the introduction of the concept of “third victims”, which describes the effect these incidents can have on hospital managers and the reputation of the hospital itself, especially when consideration is given to the negative media coverage such incidents provoke. If the symptoms of second victims are similar to post-traumatic stress disorder, the third can be classified as a type of institutional trauma.
Dr Vanhaecht will be in Dublin to discuss the subject at the RCPI’s St Luke’s Symposium in October. His main argument is that patient care can be improved if proper supports are provided to doctors and hospital staff in the wake of cases of medical error.
This has proved controversial among some patient advocates, who believe that such thinking diverts focus from the patient to the medical staff who committed the error in the first place. Discussion is also taking place about whether the phrase “second victim” is even the best way to describe the issue. But Dr Vanhaecht believes strongly that helping doctors and other staff who are struggling to cope in the wake of patient safety incidents is for the benefit of everyone.
“After these incidents, some of the symptoms that second victims have are fear and anxiety,” he says.
“They are not convinced that they have the knowledge and skills any more to perform their work in the best possible way. To perform an operation, for instance, you have to be convinced about your skills. Yet they begin to hesitate. We know that if doctors are struggling with their knowledge and skills then the chance or the probability that there will be new incidents will be higher. It is a vicious circle.”
Providing proper support to these medical professionals can therefore help raise the level of quality and safety in hospitals and other healthcare facilities. The first step for this to be achieved, according to Dr Vanhaecht, is for the taboo around discussing adverse events to be broken.
“We know that medical doctors often have trouble going to somebody else and saying ‘I made a mistake, something happened to my patient. I’m not feeling well about it. I have flashbacks, I have sleeplessness. I am second guessing my skills.’”
Yet the only way to tackle the problem is by acknowledging it. Being able to discuss errors honestly is the first way to ensure they don’t happen again in the future. The issue is closely related to the concept of open disclosure. Dr Vanhaecht says it is vital that doctors and other healthcare professionals need to feel more comfortable about discussing their mistakes. For this to occur there needs to be a culture change within hospitals.
“You cannot ask a medical doctor for an open disclosure for a patient if you let him stand alone afterwards,” he says.
“As a manager you should support these medical doctors. I think that in a lot of cases you as a manager sometimes need to go together with your medical doctor and your nurse to the patient. You must be able to say sorry; you don’t have to say we made a mistake, but that you see there is something wrong.”
To help medical professionals cope with the incidents, peer support systems should be established, according to Dr Vanhaecht. These systems should involve support by peers trained in the second victim phenomenon and include the close monitoring of clinicians by front-line managers, with referrals to patient safety or risk management experts when necessary. A third tier comprises expedited referral to professional counselling services following the unanticipated clinical event.
“More than 50 per cent of clinicians, if they can talk about it, don’t need additional support because they can then discuss it with colleagues and give it a correct place in their mind and in their work,” Dr Vanhaecht argues.
“A lot of clinicians involved in patient safety incidents, who receive the proper support, become better clinicians afterwards because they are more focused on these issues.”
Also doctors who were not directly involved in an adverse event often need support as well as they can become fearful that a similar incident can happen to them. As adverse events are usually the result of system failures, rather than mere individual error, those involved in the administrative and managerial structure, the third victims, who are psychological affected by one of these cases should avail of support too.
In the case of CEOs or those in high management positions, this support should be sought from outside the hospital structure, according to Dr Vanhaecht.
The strain of dealing with an adverse event can be felt throughout a whole institution and needs to be taken seriously given their prevalence. Dr Vanhaecht says that the incidence of these events is higher than originally estimated.
In the 1999 paper, it was estimated that 5 per cent of patients suffered adverse events. Recent research from the US suggests it is closer to 13 per cent. Also, the number of medical professionals who can be described as second victims is likely to be higher than the cited proportion of approximately 50 per cent.
“In literature at the moment, the number that is used is that 50 per cent of clinicians will get some level of symptoms during their career,” he says.
“If I give talks about these numbers with medical doctors and ask them for feedback about my presentation they tell me there is only one mistake: The number of 50 per cent is a total underestimation.”
It can be argued that most doctors at some point in their career are affected either psychologically or emotionally, to various degrees, by the death of a patient due to medical error, or another type of adverse event.
This makes the lack of support for medical professionals in these cases more troubling. Dr Vanhaecht says that only a small number of hospitals have the structures in place to help staff deal with adverse patient events in an open and comprehensive manner. When he first became interested in the area, Dr Vanhaecht conducted a survey of hospitals to examine if they provided this support, and, if they did, to what standard.
“About 50 per cent of hospitals told us that they had a system. When we asked them to send protocols only one-in-five of them was able to do so. We evaluated them. None of these protocols accorded to the international guidelines. I don’t want to talk about Ireland but I see in all other countries worldwide that it is only in a minority of hospitals that there is a structured peer support system, and a minority is even an overestimation.”
Cause for optimism
The findings of the survey are in line with research in other countries. In spite of the paucity of supports that are available, Dr Vanhaecht says that a cause for optimism is the very fact that the research is happening in the first place, and that interest in the area has grown in recent years. In an Irish context, this interest can be seen in the fact that Dr Vanhaecht will be speaking at the St Luke’s Symposium on the subject, although he acknowledges there is still a long way to go before the necessary systems are present at ground level to assist doctors and other staff.
“It is not a coincidence that we are talking about it in Ireland, that we are doing studies with Spanish colleagues, with Italian colleagues, with Dutch colleagues, with Belgian colleagues, and that very good work is being done in the UK Royal College of Physicians,” he concludes.
“It is a hot topic at the moment, but it will need another five to 10 years, I’m afraid, for real progress to be made.”
ᐧ For more details on the RCPI’s St Luke’s Symposium visit the RCPI website