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When physicians are traumatized

Amy Paturel , MS, MPH, special to AAMCNews
August 13, 2019

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Nearly 80% of doctors have experienced a distressing patient event in the last year, and many go on to suffer from depression, anxiety, and PTSD. Now, a growing number of medical schools and teaching hospitals are giving doctors resources to handle difficult scenarios.

On a fall afternoon in 2017, first-year medical student Miranda Haslam was chatting with colleagues in the Temple University Hospital Emergency Department’s trauma bay when police burst through the doors carrying a young man riddled with gunshot wounds.

“I stood against the wall, trying to stay out of the way, when I caught a glimpse of his face and realized he was little more than a boy. A boy with six gunshot wounds in his chest and abdomen,” says Haslam.

In a carefully choreographed sequence, the emergency room resident intubated the boy, nurses started IV lines and cut away his clothing, and trauma surgeons sliced through his chest. Blood gushed onto the doctors’ trauma gowns and pooled on the floor as surgeons discovered a bullet had torn through his left atrium, a literal shot through the heart.

He was already gone.

Haslam noticed how different the body seemed compared to her cadaver from gross anatomy. “I thought about how this boy, young and healthy just moments before, ended up with a bullet hole in his heart,” she says. The boy was one of three gunshot victims Haslam saw on her first day shadowing residents in the trauma bay.

Haslam’s only responsibility that day was to watch and learn. She didn’t have to treat the patient, clean the body, or notify the boy’s parents. Still, the scene stayed with her.

“It’s not a matter of if clinicians are going to experience trauma while providing care, but when and how often.”

Albert Wu, MD, MPH
Johns Hopkins School of Public Health

In a 2000 British Medical Journal editorial, Albert Wu, MD, MPH, professor of health policy and management at Johns Hopkins School of Public Health, coined the term “second victim” to describe health care providers who are traumatized on the job. While the term is controversial (the use of the word “victim” can be offensive to both patients and physicians), there’s no dispute that when an unanticipated event happens, there are two populations with distinct needs: The patient and family members, and the clinicians caring for them.

“It’s not a matter of if clinicians are going to experience trauma while providing care, but when and how often,” Wu says. According to a 2011 study published in the Archives of Surgery, nearly 80% of residents and physicians faced either an adverse event or a traumatic personal event in the preceding year.

Traditionally, doctors learned to process dramatic experiences on their own time, preferably away from the hospital. But that expectation of stoicism is slowly beginning to shift. Academic deans have established learning communities, launched physician well-being initiatives, and incorporated resilience training into the medical school curriculum. And some pioneering institutions are providing peer support to affected health care workers following a distressing clinical event.

“Instead of suffering in silence, medical students, residents, and faculty are learning how to talk about the trauma they experience,” says Joseph Sakran, MD, assistant professor of surgery at Johns Hopkins University School of Medicine.

A population at risk

In a profession that abides by the “first do no harm” credo, practicing medicine is physically and emotionally challenging work. And that work can sometimes take a steep toll.

A 2019 meta-analysis published in the Journal of Patient Safety reported that more than two-thirds of providers involved in an adverse clinical event suffered from troubling memories, anxiety, anger, remorse, and distress. A 2013 meta-analysis further found that up to 43% of physicians suffer from depression, anxiety, post-traumatic stress disorder (PTSD), or even suicide in the days and weeks that follow an unexpected patient event.

While medical errors garner the most attention, everyday medical experiences — a stillborn baby, a gunshot wound, or a patient who suddenly takes a turn for the worse — also haunt physicians. More than half of traumatized physicians are devastated by an event they didn’t cause.

“Over time, and without support, these clinicians are at risk for ongoing emotional trauma that affects not only themselves and their families, but also their future patients,” says Susan Scott, PhD, RN, director of professional nursing practice and coordinator of patient safety at University of Missouri Health Care (UMHC).

Even when support programs are in place, doctors may perceive seeking assistance as a sign of weakness. So they isolate themselves, or they slog through their days and hope their distress dissipates. A 2010 survey found that 68% of those involved in a patient safety event did not receive any institutional support.

Toward a healthier culture

To support clinicians, some medical institutions are hiring chief wellness officers. Others are developing voluntary, confidential peer support groups to address the “second victim phenomena.” And medical school and health system leaders are striving to create a culture where the emotional aftershocks of adverse patient events can be acknowledged and managed.

“Part of our preventive approach to the psychological stress of medicine is establishing learning communities,” says Douglas Reifler, MD, associate dean of student affairs and medical humanities professor at Temple University Lewis Katz School of Medicine. “With learning communities, there’s a structure within the curriculum for peer support.”

Beginning in the first year of medical school, with gross anatomy, students have a safe space where they can reflect on dramatic experiences. First-year students write about the life history of their cadaver while second-year students explore what it means to wear a white coat.

“Over time, and without support, these clinicians are at risk for ongoing emotional trauma that affects not only themselves and their families, but also their future patients.”

Susan Scott, PhD, RN
University of Missouri Health Care

Temple hired Pulitzer Prize-winning writer Michael Vitez to encourage health care providers to give a voice to their feelings and learn how tell a story. Haslam first shared her trauma bay experience at Temple’s Story Slams, an open forum where students, residents, and faculty can reflect on traumatic events. “We view it as a clinical skill to be able to understand a story and communicate it in terms that are understandable to patients,” Reifler says.

Like the Temple curriculum, Johns Hopkins encourages students to share their thoughts and experiences with one another. In fact, Wu teaches a patient safety course that includes a 1.5-hour small group session on handling adverse events. “These are second-year students who are about to go out in the ward and are justifiably afraid that they’re not going to know what to do when things go wrong — and things will go wrong,” Wu says.

Through role play, simulations, and discussions, students learn how to manage challenging situations, how to disclose, and how to move on. By the time students enter their first year of residency, they’re more adept at starting difficult conversations. They also have a better handle on when and how to support their fellow clinicians.

Caring for the caregiver

Even though the culture of medicine is slowly beginning to shift, many doctors are still reticent to ask for help. That’s one reason medical schools and teaching hospitals are developing supportive resources for all clinicians.

After seeing so many health care providers suffering, Jo Shapiro, MD, associate professor of otolaryngology at Harvard Medical School, pitched the idea of a peer support program to the president of Brigham and Women’s Hospital (BWH). The result: BWH’s Center for Professionalism and Peer Support (CPPS). Since the program launched in 2008, more than 25 national and international programs have been modeled off it. The guiding principle: attend to the well-being of caregivers, educators, and researchers so that they, in turn, can give their best to patients.

Part of the success of CPPS, says Shapiro, is that peer support colleagues reach out to anyone involved in potentially emotionally stressful situations. That helps normalize the process and destigmatize any negative emotions. “People don’t have to seek support. Somebody presents it to them on a platter and they can choose to partake or not,” says Shapiro.

At UMHC, Scott launched forYOU, a three-tiered model to provide escalating support to wounded clinicians:

  • The first tier: emotional support from trained peers.
  • The second tier: One-on-one support and group debriefings when the whole team experiences an unexpected patient outcome.
  • The third tier: Referral to professional mental health services.

Johns Hopkins also offers peer support through a program called Resilience in Stressful Events (RISE). With RISE, trained peer volunteers are available 24/7 to support clinicians and they respond within one-half hour of a stressful patient-related event. Students, residents, and faculty also learn to look for signs that are suggestive of a “second victim” response and to proactively deliver psychological first aid, or PFA, to that colleague using a structured conversation.

“We view psychological first aid as CPR for the mental health crises in medicine,” Wu says. “Every health care worker should have the tools required to address their colleagues’ needs for emotional support immediately following a difficult clinical event.”

“It may take a little while to shift the culture. In my limited clinical experience, the teams that do best have leaders who prioritize wellness, community, and conversation.”

Miranda Haslam
Temple University Lewis Katz School of Medicine

Several other institutions are also incorporating peer support training into the curriculum and offering grand rounds on the subject of “wounded clinicians.” University of Chicago Pritzker School of Medicine has even developed a shareable resilience training curricula for residents that any institution can download from the AAMC’s MedEdPORTAL®. “We looked to the literature and created a framework and a teaching session for our senior residents,” says Amber Pincavage, MD, associate professor of medicine at the University of Chicago Medical Center.

Support programs and inspired curricula are especially important for academic health institutions where medical students and trainees are forming their professional identities. “Peer support is one way forward, away from a culture of invulnerability, isolation, and shame and toward a culture of shared humanity,” says Shapiro.

Haslam is walking in that direction, joining a new generation of physicians who aren’t afraid to share their stories and actively support each other as they navigate the landmines of medicine. She even serves as an “Our Wellness Liaison” at Temple, where she facilitates conversations about mental health and well-being and serves as an advocate for her classmates and peers.

“It may take a little while to shift the culture,” Haslam says. “In my limited clinical experience, the teams that do best have leaders who prioritize wellness, community, and conversation.”

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