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Blog: Loss of Patients

When a physician is devastated by the loss of a patient

Physician devastated by a patient's deathCase study #1: A primary care physician sees a longtime patient for her annual physical, and all lab results are normal. Two weeks later, she sees him for what she thinks is the flu, presenting with symptoms of neck stiffness, nausea, vomiting, light sensitivity, and confusion. It turns out to be bacterial meningitis.

The physician and staff take emergency measures to treat her, and there’s a dramatic scene as emergency personnel rush through the clinic’s lobby, but the patient dies despite aggressive treatment. The patient’s husband, mother, and two young children, who have been waiting in the lobby, are distraught. The physician, nurse, and receptionist are stunned. They’ve known this patient for more than a decade, and they can’t believe they couldn’t save her. For days afterward, the physician has trouble focusing, and he sees that the nurse has become very matter-of-fact and unsmiling to his patients. His receptionist says she hasn’t been able to sleep, and she’s been making mistakes with appointments and failing to give him some messages. Other clinicians walk by quietly, not knowing what to say.

Case study #2: An obstetrician delivers a baby, but the baby becomes ill and is rushed to the NICU, where for weeks he teeters on the brink of death. When the physician goes back to the delivery room a few days later for another delivery, she realizes that a different mother has the same appearance and gestures of the mother whose child is in the NICU. Even at home, the physician feels frozen whenever her digital clock, which reminds her of the digital clock in the hospital, shows the same time the tragedy happened. She feels a sense of déjà vu, over and over, and she feels disconnected from every new patient, every new baby she’s about to deliver, and her work. It’s like PTSD, she thinks, and then she feels ashamed for thinking this way.

Case study #3: An orthopedic surgeon who is known as “the guru” in his city for hip replacements performs surgery on a healthy middle-aged patient. Though the team performs the procedure correctly, and the anesthesiologist monitors the patient appropriately, the patient suffers a debilitating stroke. Afterward, the surgeon suddenly feels like he’s lost his nerve, something that’s never happened to him before. He used to feel energized and even excited to go into surgery to offer his expertise to his patients. Now, though he’s been recognized for years for his superb surgical skills, he finds he’s frightened to go it alone.

How can this dysfunction happen in medical practices?

Feeling distraught, ashamed, and fearful are normal feelings for physicians after sudden, tragic patient outcomes. Unfortunately, physicians have been taught for decades that the best way to deal with the loss of a patient is to buck up, stay strong, and move on as quickly as possible. For some physicians, this may be possible. For many others, it’s not. We’ve been taught to suffer alone, and the struggle can be exhausting and life-altering.

Up to 79 percent of residents and attending physicians have experienced a significant catastrophic event or traumatic personal event within the previous year.1 All too frequently this impacts the way they practice and leads to anxiety, depression, sleeplessness, and a reduction in job satisfaction and clinical confidence.2 Other specialists have a significant event every three to five years. It’s telling that 10 to 15 percent of physicians consider leaving the practice of medicine because of this type of event.3

Physicians are impacted by adverse events because we have a strong desire to help our patients. With superb clinical skills and a strong commitment to offer the best care possible, we believe we should be able to avert medical disasters, so we roll up our sleeves, we engage, we draw from our years of experience, and we do everything we can to save our patient. That’s why an unexpected event lessens our confidence and composure—and generates sadness and grief that we can’t push aside.

To make matters worse, catastrophic events don’t happen to just one provider; they happen to a team. When a patient suffers, the whole team suffers and many of us don’t know what to do with this grief. Every team member is impacted differently and experiences the pain at different times. It also impacts others in a facility who are not directly involved in the incident, creating “third victims.” The event starts as a personal issue, becomes a cultural issue, and grows into an organizational issue.

How can physicians help themselves?

It’s essential to embrace the idea that you’re human. If someone else were suffering, you’d be kind to that person and treat him gently. So, too, you should be kind to yourself!

For case study #1, as an example, the primary care physician should remember the basics of taking care of himself: eating right, exercising, and engaging in activities that bring him a sense of peace. The physician should not isolate himself, even if it’s what he’s most inclined to do. He should make an effort to socialize with trusted friends, walk with a colleague, and listen to music he finds moving. He should accept invitations. He should connect with his team members, empathizing with those who were also affected by the loss. He might also want to seek assistance with his primary care provider or a therapist.

For case study #2, in addition to caring for herself, the obstetrician can recognize the triggers that evoke strong feelings and work to change them. She can buy a new clock for her home—an analog clock that looks nothing like the clock in the delivery room. She can consciously appreciate the unique qualities of her new patients, focusing on their individuality and recognizing the benefit she provides to their lives.

For case study #3, in addition to caring for himself, the surgeon can create a step-by-step plan to ease himself back into his practice. He can start, for example, by shadowing a fellow surgeon to help rebuild his clinical confidence. After that, he can request collegial support and assistance as needed. In this way, the physician’s skills and confidence return with the help of his surgical community. The physician can make a strong comeback, confident once again in his skill and uninterrupted by fear, doubt, and uncertainty.

What can a provider do to help a colleague who is experiencing symptoms associated with a bad patient outcome?

Emotional support is essential. Little gestures translate into huge benefits for the provider who is suffering. Here are a few concrete ways to help:

  1. Close the door and share your story. Saying, “I went through a situation like
    this . . .” can help dispel fear, isolation, and self-condemnation. In communicating this, you’re saying, “We’re all in this together. You’re not alone.” Talk to someone who is trusted and empathetic without going into the details, making sure not to divulge patient information. In a hospital or clinic it is possible to establish a confidential provider support program through a QI or CQIP program, and this offers a wonderful resource to providers. (For more information, you can contact us about our Leading Well Provider Support Services.)
  2. Let your colleague express emotion. Listening is a powerful tool. Most physicians just want to go from Point A (a terrible place) to Point B (the way things were), and they need help getting there. They want a logical, step-by-step approach. Do what you can to help your colleague get to Point B. Empathetic listening promotes healing.
  3. Ask, “How can I help you?” Remember that the medical team exists for both the patient and caregiver.
  4. Reaffirm your colleague’s keen level of skill. Say, “I respect you and I think you’re a good doctor.” This sends the message that your colleague is respected, trusted, and still a part of the team.
  5. Step in for your colleague. Say, “Let me take your next patient” or “Let me take your call tonight.” You or another colleague can say, “I’ll call you tomorrow and see who should take your call tomorrow night.” This can help your colleague process the event and prevent possible future errors. For a physician who resists, say, “It’s shown that error rates go up when physicians are distracted by a bad outcome. That’s why I’d like to take your call tonight. Please go home and take care of yourself.”
  6. Do something small to help. Bring food. Write a nice note. Bring a small bouquet of flowers. Smile, or give your colleague a pat on the back. Invite your colleague out for coffee, wine, or beer. Offer to go for a walk. Share a CD—say, “I think you’d like this.” Give a gift card. One physician who had lost a patient remembered a time that a fellow physician who was normally very quiet surprised her with a gift card to a coffee shop. She was so touched that she kept the plastic card long after the money ran out, just so she could remember that kind gesture during such a difficult time.
  7. If your colleague can tell you what’s making day-to-day life difficult, you can offer your help to problem-solve. You can be the one who says, “Buy yourself a new analog clock and give the digital one to Goodwill.” Remember that you don’t have to fix the problem. A warm hand of support does wonders.
  8. Check in from time to time. As physicians we’re taught to be respectful of boundaries, but we shouldn’t let that get in the way of stepping in. Without lingering, say, “How’s it going?” and offer to help. Even for quiet, self-sufficient physicians, it’s always OK to offer a gesture of kindness.
  9. If you see your colleague in a meeting, sit next to him or her. If in doubt, do.
  10. If the suffering is especially acute or continues, help your colleague find a good therapist, a yoga class, a mindfulness or meditation class, or other appropriate resources.

Conclusion

Most physicians bounce back quickly. Some don’t. This differs by the individual and can depend on the physician’s personality, where he grew up, how his family taught him to deal with grief, and more. Some people simply don’t want to talk about it.

A strong team is made up of providers who care for each other when one is momentarily shaken. They know that bad things can happen to good doctors. They build each other up. They realize that we walk together on this path. Help your group become a strong team.

When the crisis passes, progressive leaders say, “I want to thank everyone for the support they’ve shown me during this crisis.” Saying this gives others permission to accept support when they experience a crisis. In time this attitude can get built into the organization, making providers feel connected to each other. They start pulling together more effectively. They find themselves naturally giving support and understanding to each other during times of adversity, thereby shifting to a just culture. And as a team, they find they’re providing better care to patients.

1.Yue-Yung Hu, Megan Fix, Nathanael Hevelone, Stuart Lipsitz, Caprice Greenberg, Joel Weissman, and Jo Shapiro, “Physicians’ Needs in Coping with Emotional Stressors: The Case for Peer Support,” Archives of Surgery, 147 (2012): 212-217, doi:10.1001/archsurg.2011.312.
2. Amy Waterman, Jane Garbutt, Erik Hazel, William Claiborne Dunagan, Wendy Levinson, Victoria Fraser, and Thomas Gallagher, “The Emotional Impact of Medical Errors on Practicing Physicians in the United States and Canada,” Joint Commission Journal on Quality and Patient Safety 33 (2007): 467-476.
3. Susan Scott, Laura Hirschinger, Karen Cox, Myra McCoig, Julie Brandt, and Leslie Hall, “The Natural History of Recovery for the Healthcare Provider ‘Second Victim’ after Adverse Patient Events,” BMJ Quality and Safety 18 (2009): 325-330.


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