Introduction
Healthcare is complex and patient care can often involve unpredictable factors1-3. Whether due to this complexity or the limits of human cognition and physical endurance, errors can be expected4,5. These errors, formally referred to as ‘medical error’ within the literature, are estimated to be the third leading cause of morbidity and mortality in North American countries6,7. The medical error literature identifies common preventable human errors such as improper medication administration, iatrogenic injury from surgical procedures, and mistaken patient identity8. Several studies have described that the highest proportion of preventable medical errors happen in the emergency department with the most common type of error being diagnostic errors that lead to disability or death 9-14. Herein lies a potential problem: if the error is classified as preventable, with whom does the responsibility lie? Is it fair to individual physicians to classify the rate of preventable errors as part of safety and quality improvement initiatives? How might the perception that their error was preventable affect their perception of their own competence? Perhaps more critically, how might this perception impact their sense of responsibility? Pertaining to these questions, there is a highly focused literature on how diagnostic errors promote a rhetoric of individual clinician vigilance, through de-biasing, cautiousness, and personal reflection15-22. On one hand, theories on how cognitive biases impact diagnostic error offer a sensitive approach: physicians make errors because of cognitive limitations and innate tendencies. On the other hand, this focus is paired with strategies to correct for these tendencies, thereby increasing the pressure on the individual clinician to ‘correct or prevent’ their own errors. Another perspective points to knowledge and experience gaps as the main factor in diagnostic error23. While this may imply a need for a more effective medical residency curriculum, there is still pressure on the individual clinician to self-assess and address gaps.
The exact rate of diagnostic errors is debated24, however, the impact of these errors on patients is only one focus of a growing literature6,25-28. Recently the impact that these errors have on the well-being of first responders and physicians has also been explored29-37. Among physicians, emotional responses to medical errors can last from days to years, and may include feelings of underperformance or failure, shame, self-doubt, fear, guilt, embarrassment, anger, depression, posttraumatic stress injury, and suicide29-36. Research demonstrates that medical errors can have long-term impacts relating to lack of confidence, concentration, memory, and impaired work performance37-40. Other studies report anxiety about future errors, difficulties sleeping41, or prematurely leaving the medical profession42-43. Due to the impacts of unanticipated adverse patient events, injuries, and errors, the physician has been referred to as the “second victim” in a seemingly vicious cycle33,44-50. The “second victim” often loses confidence in themselves, takes on a level of responsibility for the patient outcome, and begins to undervalue their clinical skills44-50. Historically, postulated reasons for this include cultures of blame, shaming from colleagues, and the degree of perfectionism that exists within clinical medicine51-52.
Despite the growing attention on the physician as “second victim,” how physicians recover from errors and how or if they learn to move forward is a space that is underexplored. Shepherd et al. (2019) identified several dimensions that influence how physicians learn from errors34. We explore one of those dimensions more closely: understanding the emotional response. In particular, we wanted to better understand the process by which physicians shared experiences of error with supervisors, colleagues, and/or trainees, and if there are common patterns among their post-error recovery and growth.