New culture for coping: Turning to peer support after medical errors

The legal impact from a medical error can be devastating; so can the emotional toll. Doctors at a Boston hospital are helping one another.

By Kevin B. O’Reilly — Posted Sept. 11, 2006

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Jo Shapiro, MD, immediately recognized that she perforated her patient's throat during surgery. The patient survived but developed a chest and neck infection and later sued unsuccessfully. Once the initial shock passed, Dr. Shapiro, chief of otolaryngology at Brigham and Women's Hospital in Boston, came to realize that she was a second victim of the adverse event.

Sadness, fear, anger, panic, humiliation, guilt and shame were just a few of the emotions that set in. Fortunately, she was married to a physician in whom she could confide and lean on for support. She wondered, though, about how well a physician without built-in peer support could handle the aftermath of an adverse event or medical error.

It's very hard, according to Frederick A. Van Pelt, MD. The BWH anesthesiologist said he felt isolated after a patient of his, Linda Kenney, required open-heart surgery when sedative from the nerve block he administered for a total ankle replacement somehow entered her bloodstream, sending her into cardiac arrest.

To change the go-it-alone culture, Drs. Van Pelt and Shapiro in July helped form the BWH Peer Support Team to aid physicians grappling with the psychological, emotional and social difficulties they face when things go wrong.

Dr. Shapiro, who is one of more than 20 BWH health professionals on the Peer Support Team, said the goal is to help doctors realize that once the patient's condition has been stabilized or resolved it's OK for physicians to think about their own reactions.

"In our [medical] culture, it's not seen as normal to be emotionally affected by your work," Dr. Shapiro said. A peer can help bridge the gap between what has traditionally been expected and the emotional upheaval doctors often feel after an adverse event or medical error.

"There's this culture in medicine that we're superhuman," said Dr. Van Pelt, chair of the Peer Support Team task force. "Bad things happen. Suck it up and move on. It's a strategy that hasn't worked very well."

How BWH's peer support works

Peer support conversations are not shielded from legal discovery, but they aren't documented in any way and are entirely separate from the hospital's quality improvement process. Janet Barnes, BWH's executive director for clinical compliance and risk management and a former medical liability defense lawyer, said she's comfortable the Peer Support Team won't hurt physicians or the hospital legally.

The Peer Support Team is being piloted with operating room professionals but may soon be expanded to other areas of the hospital. Though it was formally launched in July, the group staged its first peer support intervention a year ago, according to Barbara L. DiTullio, an OR assistant nurse manager and a member of the Peer Support Team task force.

"With each session, the interest and momentum for the support sessions has increased," DiTullio said in an e-mail, noting that health professionals, who are not required to attend, have reported that the sessions were "extremely helpful in resolving their emotional distress."

One recent session was organized within hours of a case in which a patient had passed the critical portion of a complex procedure, but unexpectedly became asystolic and could not be resuscitated. Even OR veterans "were devastated" by the event, DiTullio said, and surgeons, anesthesiologists, nurses, surgical technologists and medical staff involved in the case attended the support session to discuss their reactions. According to Dr. Van Pelt, though, one-on-one peer consultations are likely to outnumber group sessions by 10-to-1.

Gaining momentum

Dr. Van Pelt and Barnes already have made presentations about the Peer Support Team to the Oak Brook, Ill.-based University HealthSystem Consortium and HCA Inc., with appearances before Oregon and Minnesota patient safety groups scheduled for this fall. The BWH effort comes on the heels of increased attention to aiding physicians after errors.

In 2002, Dr. Van Pelt reached out to Kenney after her recovery and helped her form Medically Induced Trauma Support Services, a nonprofit she runs that offers physician peer referrals and group sessions for patients, families, doctors and other health professionals. In 2003, the Oakland, Calif.-based integrated HMO Kaiser Permanente instituted a structured support system to help its health professionals handle adverse events, though it does not feature one-on-one peer support.

And earlier this year, Harvard's 16 teaching hospitals -- including BWH -- adopted a consensus statement, "When Things Go Wrong," that says hospitals should provide support to help health professionals grapple with the emotional aftermath.

Peer support is crucial, say proponents, because physicians trust that another physician will relate to their experiences and because it comes without the stigma still attached to mental health counseling. Though hospital employee assistance programs have long offered an avenue for professional counseling, doctors have been reluctant to seek such help because of cultural and regulatory barriers.

It's now beginning to change, but for years medical boards have asked physicians whether they sought mental health counseling and required documentation about any course of treatment, said Luis T. Sanchez, MD, president of the Federation of State Physician Health Programs.

The Peer Support Team is "a great idea," Dr. Sanchez said. "Anything that opens up discussion about feelings is good, because talking about those kinds of things is traditionally not where doctors go."

Dr. Van Pelt is quick, however, to clarify that the Peer Support Team is not intended to replace professional counseling.

"We're not out to create junior therapists, but to offer some emotional first aid," he said. "It's starting to catch on."

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When things go wrong

Physicians may be traumatized by serious adverse events or medical errors, and their responses may be similar to those that occur during any distressing experience, experts say, including:

Cognitive: Confusion, disorientation, worry, self-blame, intrusive thoughts and images.

Emotional: Shock, sorrow, grief, sadness, fear, anger, numbness, irritability, guilt and shame.

Social: Extreme withdrawal, interpersonal conflict.

Physiological: Fatigue, headache, muscle tension, stomachache, increased heart rate, exaggerated startle response, difficulty sleeping.

Source: Psychological First Aid Manual handout, "When Terrible Things Happen," produced by the U.S. Dept. of Veterans Affairs National Center for Post-Traumatic Stress Disorder

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