When Doctors Make Mistakes

We teach children to admit their mistakes. Why does that become so difficult when the child grows up to become a doctor?

A parent tells a young child, “You made a mistake. Mistakes happen. Fess up to it and tell your friend you are sorry.”

It is one of our earliest lessons about character. When you hurt someone, don’t hide from it. Tell the truth. Accept responsibility. Say you are sorry.

Some of those children grow up to become physicians.

Then the lesson becomes much more complicated.

Mistakes occur in every medical specialty and at every level of experience. Most cause little or no harm. Some are caught before they ever reach a patient. But others result in serious injury or death, leaving a physician with the devastating realization that something he or she did—or failed to do—contributed to a patient’s suffering.

Medicine has systems for examining what happened: incident reports, quality reviews, root-cause analyses, and morbidity and mortality conferences. All are necessary.

But there is another question we have traditionally been less comfortable asking:

What happens to the doctor who made the mistake?

The Second Victim

The patient who has been harmed is unquestionably the first victim. Nothing about a physician’s distress should diminish that fact.

But physicians can also suffer after serious adverse events, particularly when they believe they were responsible. This response has been called the Second Victim Phenomenon, or SVP.

The term itself is controversial because calling the physician a “victim” can seem to equate the doctor’s suffering with the patient’s. They are not equivalent. But whatever terminology we use, the phenomenon is real.

Physicians may experience guilt, shame, anxiety, sleeplessness, depression, loss of confidence, and persistent replaying of the event:

What did I miss?

Why didn’t I recognize it?

What should I have done differently?

These reactions are common and can persist for months or even years. Studies of anesthesiologists and neurosurgeons describe self-doubt, guilt, sleep disturbance, impaired concentration, and loss of professional confidence after serious adverse events. 

Some physicians recover and learn from the experience. Others struggle to move beyond it.

And that should concern all of us.

Why should society care?

Concern about SVP can sound like another physician-wellness initiative. It is much more than that.

A physician who cannot recover from a serious error may become a less effective physician.

Some doctors lose confidence in their judgment. Others become excessively cautious, ordering tests or consultations not because they believe they are necessary but because they are terrified of ever missing something again. Defensive medicine can expose patients to unnecessary testing and procedures while adding costs to an already expensive healthcare system.

Psychological distress can also affect concentration, decision-making, communication, and professional performance. The relationship between burnout and objectively measured medical errors is complex, and we should not claim that one inevitably causes the other. But there is enough evidence for concern about a destructive cycle in which adverse events cause distress and unresolved distress can, in turn, impair the clinician caring for the next patient. 

Some physicians respond by reducing their clinical work or leaving medicine. In one recent study of neurosurgeons after serious adverse events, nearly a third had considered changing employment or profession or had made serious efforts to do so. 

Society has an interest in preventing that loss. An experienced physician represents not only years of expensive training but decades of accumulated clinical judgment that cannot easily be replaced.

There is another consequence that may be even more important.

Embarrassed and frightened physicians may not tell anyone what happened.

Physicians experiencing distress after an adverse event may hesitate to discuss it even with colleagues. Embarrassment, guilt, fear of appearing weak, concern about reprimand or licensure, and fear of litigation can discourage them from seeking help. Those same forces can discourage formal reporting to hospitals and healthcare systems.

Research on power distance—the influence of hierarchy within organizations—helps explain why. When large differences in authority are accepted as normal, those lower in the hierarchy may be reluctant to speak up. Fear of negative evaluation can further inhibit medical-error reporting. 

That turns a physician’s private embarrassment into a patient-safety problem.

An error that remains hidden cannot readily teach colleagues, expose a defective system, or prevent the next patient from being harmed.

Medicine makes admitting mistakes difficult

Medical education emphasizes competence, as it should. But an unintended message can emerge:

Good doctors don’t make mistakes.

That is an impossible standard.

Physicians are also trained, sometimes indirectly, to endure adversity without showing vulnerability. Don’t complain. Finish the shift. Take the next call. See the next patient.

The morbidity and mortality conference can reinforce that culture.

At its best, an M&M conference is an exercise in collective learning: What happened? What did we miss? What should we do differently next time?

At its worst, it becomes an exercise in hindsight:

Why didn’t you order the test?

Why didn’t you call the consultant?

How could you have missed that?

The physician presenting the case may already have asked those questions a thousand times.

We should never eliminate rigorous review. Accountability is essential. But accountability and humiliation are not the same thing. If physicians believe acknowledging an error will result primarily in embarrassment or punishment, we should not be surprised when some remain silent.

Prepare doctors before the mistake happens

We spend years teaching physicians how to prevent errors but surprisingly little time teaching them what to do after one occurs.

Residents report that education about errors often concentrates on reporting requirements, complaints, and legal responsibilities rather than how to disclose an error to a patient, manage their own emotional response, or support a colleague afterward. They have specifically asked for more practical preparation. 

That education should begin before the first serious error occurs.

Physicians should learn how to disclose an error, where to obtain confidential support, and how to help a colleague struggling after an adverse event. Senior physicians should know how to approach a distressed colleague rather than waiting for that person to ask for help.

But this responsibility cannot rest entirely on individual physicians.

Hospitals have responsibilities, too

An important development has been the emergence of Communication and Resolution Programs (CRPs)—structured institutional approaches to responding when healthcare has harmed a patient.

A CRP is intended to replace institutional silence with a more constructive process: communicate promptly with patients and families, investigate what happened, explain the findings, apologize when appropriate, work toward resolution, and learn how to prevent recurrence.

CRPs are increasingly recognized as the standard approach to harmful medical events in the United States and Canada. The Centers for Medicare & Medicaid Services now requires U.S. healthcare organizations to attest whether they have an evidence-based CRP and whether they track its effectiveness using standardized metrics. Yet research examining patients’ actual experiences with these programs suggests substantial room for improvement in how they are implemented. 

There is an important connection between CRPs and the Second Victim Phenomenon.

A hospital cannot reasonably expect a frightened, ashamed physician to navigate disclosure alone. A well-designed response should accomplish two things simultaneously: provide honest communication and resolution for the patient while supporting the clinician sufficiently to participate openly in that process.

This does not mean protecting incompetence or excusing negligence.

It means recognizing that accountability works best in a culture where people can tell the truth.

And finally, the patient

This brings us to the most important reason for helping physicians deal constructively with their mistakes.

We want them to be honest with their patients.

Patients who have been harmed want to know what happened. They want an explanation. They want to know what will be done to prevent it from happening again.

And most want something very human: an apology. Research on patient responses to medical errors shows how strongly patients value prompt disclosure, explanation, and acknowledgment. 

A physician overwhelmed by shame, frightened about professional consequences, or unable to accept personal fallibility may retreat instead into silence, defensiveness, or carefully constructed language that never quite acknowledges what happened.

That can injure the patient again.

So society should care about Second Victim Phenomenon not simply because we want physicians to feel better.

We should care because we want them to remain good doctors—to continue thinking clearly, avoid unnecessary defensive medicine, remain in the workforce, report mistakes so others can learn from them, and have the courage to be honest with the patients they have harmed.

Which brings us back to the parent and child.

Before medical school, hospital committees, M&M conferences, malpractice attorneys, CRPs, or Second Victim Phenomenon, the lesson was much simpler:

You made a mistake.

Don’t hide it.

Tell the truth.

Learn from it.

And when you have hurt someone, say:

“I am sorry.”