When Peak Performers Stumble

Surgical Complications in Spine Surgery and Compassion for the Second Victim

Healthcare professionals, particularly those in high-stakes environments like spine surgery, are at the forefront of complex patient care and are thus susceptible to profound emotional and psychological impacts when adverse events occur. The term “second victim” was first introduced by Wu in 2000 to describe healthcare providers who experience emotional trauma following a patient-related adverse event.1 The first victim is the patient who is struggling with the untoward effects of the complication, while the third victim is the health system where the event occurred.

Second victim syndrome (SVS) refers to the emotional and psychological trauma experienced by healthcare providers who are directly responsible for an adverse patient event. The prevalence of SVS among surgeons is notably high due to the highstress and high-pressure environment and the inherent risks and complexities of surgical procedures. Studies indicate approximately 30% to 50% of surgeons experience symptoms associated with SVS at some point in their careers.2 Spine surgeons are acutely prone to losing confidence and second-guessing their skills, and symptoms can range from acute stress reactions to long-term psychological conditions such as anxiety, depression, burnout, excessive caution, communication breakdown, and posttraumatic stress disorder (PTSD). However, in promptly approaching the second victim in a nonjudgmental manner, one can ensure compassion and peer support to prevent the development of depression, burnout, and emotional exhaustion.

Factors Contributing to SVS in Spine Surgery

High-Pressure Environment

Spine surgery is a high-pressure specialty where the margin for error is minimal. Surgeons are often expected to perform complex procedures with precision, and any deviation from the expected outcome can lead to patient complications. Additionally the culture of “preop/postop” conferences is often highly judgmental and punitive with little support provided to untoward outcomes.

Adverse Events

Adverse events, such as surgical complications, patient deaths, or near misses, are significant triggers for SVS. Surgeons often feel personally responsible for these outcomes, leading to intense feelings of guilt and self-doubt. Such events can lead to loss of confidence in surgical ability and are typically coupled concurrently with impaired clinical judgement, improper decision-making, and communication failures.

Professional Expectations

The culture of perfectionism and high expectations in the spine surgery profession can exacerbate feelings of failure when adverse events occur. Surgeons may fear reputational damage, litigation, and loss of professional standing. This can be exacerbated within a toxic culture where colleague surgeons assume intent and look at any adverse event with a monochromatic lens.

Lack of Support

The stigma associated with admitting emotional distress or seeking help can prevent spine surgeons from accessing necessary support. Additionally, institutional support systems may be inadequate or non-existent, leaving spine surgeons to cope with SVS on their own. It is extremely important for divisional and departmental leaders to codify a compassion-centric pathway of nonjudgmental peer support and a nonpunitive action plan to help struggling surgeons.

Effects of Second Victim Syndrome

The impact of SVS on surgeons can be profound and multifaceted, impacting psychological health, professional performance, and personal relationships.3

• Psychological Impact: Spine surgeons experiencing SVS may suffer from anxiety, depression, and PTSD. These conditions can affect their mental health and overall well-being. In addition, empathy exhaustion and depersonalization may occur with a lower sensation of personal accomplishment.

• Professional Performance: SVS can lead to decreased job satisfaction, burnout, and reduced clinical performance. Spine surgeons may become overly cautious, leading to delays in decision-making and procedural hesitations, which may cause a domino effect of further adverse events.

• Personal Relationships: The emotional toll of SVS can spill over into surgeons' personal lives, affecting relationships with family, colleagues, and friends. The stress and anxiety associated with SVS can lead to social withdrawal and strained personal interactions.

Strategies for Mitigation and Support

Addressing SVS requires a multifaceted approach involving individual, peer, and institutional support.4 It is incumbent on divisional, departmental, and hospital leadership to identify surgeons at risk immediately after the adverse event occurs, set up a peer support system within 12 to 24 hours, and approach the actual adverse events with a lens of compassion and curiosity. When the surgeon is ready and capable, a nonjudgmental root cause analysis with full operational transparency is a must.

Individual Strategies

Spine surgeons should be encouraged to seek professional help, such as counseling or therapy, to address the emotional impact of adverse events. It is essential to practice mindfulness, use stress management techniques, and maintain a healthy work-life balance.

Peer Support

Creating a culture of openness and support within spine surgical teams is crucial and perhaps the most important part of the process. Peer support programs, such as mentorship and nonjudgmental debriefing sessions, can provide surgeons with a safe space to share their experiences and receive emotional support as well as technical advice. Such programs do not occur in toxic environments with a “gotcha culture,” and leaders must be educated and trained to prevent such occurrences.

Institutional Support

Healthcare institutions should develop comprehensive support systems for spine surgeons, including access to mental health

services, regular training on coping strategies, and policies that promote a nonpunitive response to adverse events. Establishing a second victim support program can ensure that affected spine surgeons receive timely and appropriate assistance. Identification of any toxic individuals who try to weaponize complications/adverse events against the second victim should be dealt with accordingly.

Conclusion

SVS is a significant issue in the field of spine surgery, with the potential to impact the mental health, professional performance, and personal lives of spine surgeons. This issue affects both experienced and inexperienced surgeons equally. Recognizing the prevalence and effects of SVS is the first step toward addressing this critical issue. By implementing effective support systems, deconstructing toxic environments, and fostering a culture of openness and support, the surgical profession can better support its practitioners and mitigate the impact of adverse events regarding their well-being.

References

1. Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ. 2000;320(7237):726-727.

2. Seys D, Scott S, Wu A, et al. Supporting involved health care professionals (second victims) following an adverse health event: a literature review. Int J Nurs Stud. 2013;50(5):678-687.

3. Waterman AD, Garbutt J, Hazel E, et al. The emotional impact of medical errors on practicing physicians in the United States and Canada. Jt Comm J Qual Patient Saf. 2007;33(8):467-476.

4. Scott SD, Hirschinger LE, Cox KR, McCoig M, Brandt J, Hall LW. The natural history of recovery for the healthcare provider “second victim” after adverse patient events. Qual Saf Health Care. 2009;18(5):325-330.

Contributor:

Safdar N. Khan, MD

From the Department of Orthopaedic Surgery at UC Davis School of Medicine in Sacramento, California.