• Doctors sick from own errors

    Who heals the healer?

    Falling victim to a medical mistake is terrible for a patient, but it can also be devastating for physicians. That could be just as bad for you and your fellow patients in turn.
    in short

    When Jo Shapiro, an experienced surgeon from Boston, made a mistake during an operation, she was devastated. Help from family and friends helped her cope.

    However, she wondered how colleagues with less experience and less support dealt with problems like these.

    She started the Center for Professionalism and Peer Support in her hospital in Boston. There, she trains medical professionals in dealing with ‘adverse events’.

    These days, she also trains nurses and physicians in the UMCG in Groningen.

    Physicians often respond very emotionally to medical mistakes or complications. The consequences may be severe: burnout, depression and a high risk of suicide.

    Helping medical professionals with their feelings is also beneficial to patients. A depressed or burned-out surgeon communicates badly and is prone to make even more mistakes.

    A conversation with a trained colleague is the best solution, Shapiro found. Those volunteers help the doctor to tap into their own coping skills.

    Shapiro trained over 70 doctors and nurses in the UMCG. That number will grow in the following years.

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    She knows what it’s like to make a mistake, to harm a person – your patient – while you were actually trying to help. Even now, fifteen years later, Jo Shapiro feels emotions creeping up when she talks about it.

    ‘There was this older man I had to operate on’, says Shapiro, who recently delivered her inaugural speech as a professor of professionalism and peer support at the University of Groningen. ‘He had this outpouch in the throat that caused him to have trouble swallowing. Food and liquids stay in this pouch and sometimes they come back up and people breathe in food particles into the lungs, which can lead to severe pneumonia. It has a real effect on your quality of life and the only effective solution is surgical.’

    Terrible and devastated

    So Shapiro, an experienced surgeon from Boston, did what she had done so many times before. She went in through the mouth and cut the muscle between the ‘pouch’ and the rest of the throat. And that’s where it went wrong. She made a tiny perforation in the throat that caused saliva to seep into the neck and led to severe infections, which left the patient very ill for quite a long time.

    ‘I felt terrible about it, even though the patient knew it was a risk. I felt really, really bad – devastated, actually. Because I was supposed to help this man and make him better. Instead, I had made him much worse.’

    Luckily, Shapiro had her husband – who is also a doctor – along with loving family and understanding friends. All of them gave her lots of support, far more than most people receive. So, she thought: how do others deal with this? ‘I was very experienced and had helped many patients before. That helped a bit, too. But what if you’re young or at the beginning of your career?’

    It stayed with her. So as she advanced in her career and got involved in training professionals, she decided a programme should be put in place that helped physicians after a mistake or ‘adverse event’ as the unhoped-for occurrences are often called. Now, she trains volunteers at the UMCG to reach out to colleagues in distress: 70 doctors and nurses have already been instructed.

    Only human

    For Shapiro’s strong reaction is no exception. ‘After something happens, we feel devastated. For we are healers and instead, we have harmed somebody!’, Shapiro says, making clear that she, too, is part of the group of doctors that she wants to support. ‘We feel ashamed, because we are not supposed to make a mistake and if we do, we not only let our patient down, but we let ourselves down and our colleagues.’

    Jo Shapiro

    Jo Shapiro is a surgeon, co-founder and director of the Center for Professionalism and Peer Support of the Brigham and Women’s hospital in Boston. She launched centre in 2008. Since that time, the Center has become a model for institutions that are seeking methods to enhance teamwork and respect and seek to help mitigate the epidemic of burnout that is plaguing the medical profession. She was awarded the chair Professionalism and Peer Support in October of 2014 by the Groninger Universiteitsfonds of the University of Groningen. Since then, she has trained over 70 medical staff member of the UMCG.
    It’s very much acculturated, she feels. Doctors and nurses are trained to believe that if they are smart enough and dedicated enough, they can deliver perfect care. But of course, they can’t: they’re only human. Also, a mistake is seldom the result of one man or woman. ‘We are part of a very complex system’, Shapiro says. ‘It can’t be all up to you – it isn’t!’

    Though she doesn’t like to give examples of other people than herself – protecting privacy is deeply embedded in her system – she has spoken to enough doctors, trained enough nurses and done more than enough research to know that this strong emotional response is no exception. Physicians are more likely to suffer from burnout or depression. The suicide risks are staggering. A male physician has a 40 per cent higher chance of committing suicide than ‘normal’ men. A female physician is 130 per cent more likely than the average. They may quit their job or permanently lose faith in their abilities. ‘Those are very real figures!’

    And even though these numbers are from American research, Shapiro encountered very little difference in Europe. ‘That’s odd, isn’t it? You would expect it would be worse in America because of the legal system and the very real danger of being sued. But I have no indication that it is.’

    Poor communication

    Maybe that’s because medical professionals are all in the same boat. They are all trained to help people, but when they make a mistake – because they are still human – it may endanger human beings.

    However, the strong emotional reactions of the physicians should be dealt with, not only for the sake of the doctors who often feel they don’t even deserve support, but also because of the patients. ‘Nobody wants to be helped by a burned-out or depressed physician. They communicate poorly and are more prone to make even more mistakes.’

    The best way to help doctors deal with their emotions is by talking to peers, Shapiro found. It’s the colleagues that best understand the dilemmas you’re facing, not the psychologists. The UMCG recognized that, too: it’s the first hospital in the Netherlands to facilitate this.

    Nowadays, Shapiro comes to Groningen at regular intervals to train volunteers that have been nominated by their colleagues, in order to reach out to physicians in trouble.

    Just there to listen

    Training is essential, Shapiro found. A simple ‘I know how you feel’ talk isn’t going to cut it. Also, the volunteers have to learn that this conversation is totally different from the ones they are used to. ‘Usually, when you and I would have a conversation, you would tell me your problems and I will tell you what should be done’, Shapiro illustrates. ‘We both expect this, because I am the doctor and we doctors have a love of fixing.’

    Still, you have to be aware of the fact that you can’t fix this one. ‘They are there just to listen.’

    Without training, the talk can easily go awry. ‘The volunteer does not know how you feel’, says Shapiro. ‘He or she can only imagine.’

    Also, they have to take care not to belittle the problem. They should avoid saying things like: ‘Don’t worry, it will be alright’. Or: ‘It’s not so bad. The patient got better eventually, didn’t he?’

    Those remarks may even make it worse, because the doctor might think his feelings are uncalled for. Yet the emotional distress for the doctor may be just as strong when somebody dies as it is when his patient has some minor discomfort. The problem is more in feelings of shame or losing faith in your abilities.

    The results are encouraging

    The most important thing is that volunteers have to help the doctor-in-distress to tap into his or her own coping skills, for example by asking things like: ‘What has helped you when things were bad in your life?’ He or she may say: ‘exercise’, or ‘spending more time with friends’. It really doesn’t matter what the answer is, as long as the doctor is encouraged to take care of himself – even if it is just for the sake of his patients.

    ‘They have a tendency of not doing that, maybe because they feel they don’t deserve it. However, not taking care of yourself, may put patients at risk even more’, says Shapiro.

    The programme is taking hold at the UMCG more and more. The results are encouraging. Shapiro got an overwhelming amount of positive feedback, she says. In the coming months, she will start an official survey to actually find out how the medical staff in the UMCG responds to the programme.

    But there is more. ‘We found that – and this is typical for the Dutch system – incidents are registered as ‘calamity’, or ‘incident’ or ‘complication’. Until now, only staff that has to deal with ‘calamities’ is offered peer support, while research shows that the nature of the event has nothing to do with the way the doctor feels about it. So we should integrate those other things into the training, too.’