Competent Peer Support After Medical Error

See Also

Pathophysiology

Adverse patient outcomes (including those due to medical error)
1. May result in second-victim effect, self-conscious emotions, shame and protective behaviors
Second Victim Effect
1. Health care worker experiences distress related to adverse patient outcomes
2. Associated with Major Depression, anxiety decreased empathy and maladaptive coping
3. Wu (2000) BMJ 320(7237):726-7 +PMID: 10720336 [PubMed]
4. Seys (2013) Eval Health Prof 36(2):135-62 +PMID: 22976126 [PubMed]
Self-Conscious Emotions
1. How a person feels about themselves based on self evaluation
2. Impacted by Second Victim Effect and adverse patient outcomes
Shame
1. Self-inflicted sense of decrease worth as a globally flawed person resulting in significant distress
2. Broadens sense of overall worthlessness beyond a specific action, behavior or circumstance
Self protective behaviors when experiencing shame
1. Withdrawal or hiding
2. Attack of self
3. Avoidance
4. Defensiveness
5. Attack of others

Management
Shame Competence and Peer Support

Shame Competence (constructive engagement by peers)
1. Maintain an ongoing awareness of shame
  1. Shame is an unspoken taboo that is best recognized and addressed
2. Recognize shame and the events that may trigger it (e.g. adverse patient outcomes)
  1. Peers may better understand shame by placing themselves "in their partners shoes"
3. Recognize shame related behaviors (see above)
  1. Includes withdrawal, avoidance, defensiveness and attack of others
  2. Harsh reactions to these behaviors may further worsen shame
4. Proactive peer support
  1. Peer support is based on kindness, curiosity and genuine empathy
  2. Provide unhurried support in a private, safe environment
Peer Support Strategies
1. Validate emotional distress
  1. Listen and avoid "fixing" the distress
2. Invite sharing of self-evaluation
  1. How does this event make you feel?
  2. Be aware of self-conscious emotion and shame
3. Name emotions
  1. It sounds as if you are "down or hard on yourself","beating yourself up"
4. Normalize the shame emotion
  1. Shame (or "beating yourself up") is a normal reaction to adverse patient events
  2. Hindsight is an unfair judge of clinical decision making, when resource limited and cognitive load is high
  3. Recognize that adverse events are inevitable
    1. Common occupational hazard, esp. in high risk specialties (e.g. Emergency Medicine)
    2. NOT equivalent to being a bad clinician
5. Share your own experiences
  1. "I've felt this way before, Can I share with you how I dealt with my feelings"
6. Examine assumptions
  1. Validate the person as good (e.g. "you are a good clinician and person")
  2. Recognize that we are human and both fallible AND able to learn and grow from our mistakes
Other general measures for the affected clinician (but avoid giving this as unsolicited advice)
1. Protect the non-work hours
  1. Adequate sleep, nutrition and Exercise
  2. Schedule time doing enjoyable, non-stressful activities
  3. Spend quality time with family and friends
2. Avoid self-medication
  1. Alcohol or substance use
  2. Overuse of sleep-aid medications
3. Mindfulness
  1. Learn to break the cycles of rumination or catastrophizing
4. Seek support as needed (may discuss feelings about case, but NOT case details)
  1. Mental health counseling (including Trauma Informed Care)
  2. Local peer support
  3. Professional societies

Prevention
Morbidity and Mortality (M&M Conferences) and Peer Review

M&M Conferences may exacerbate shame when focused on blame
1. Instead, transition blame from self to specific actions and factors that lead to adverse outcomes
M&M Conferences may also provide an avenue for peer growth and healing
1. Focus on specific actions and system factors that lead to adverse patient outcomes
  1. What could you have specifically done to avert this complication in the future?
  2. What events or factors outside provider control impacted the outcome?
2. Avoid harsh or blaming language
3. Recognize provider emotional distress that results from adverse patient outcomes
  1. Shift focus off self and onto specific preventive actions in the future
  2. Encourage self-kindness (e.g. how would you medically manage others with emotional distress)
  3. Encourage professional help seeking
  4. Seek follow-up to provide longitudinal conversation, partnership and periodic check-Ins

References