After the mistake: the doctor as “second victim”

“The patient is fine. Everyone keeps telling me it could happen to anyone. I just can’t stop replaying that night.”

A doctor might say this three weeks after a complication that, in the end, turned out well. A doctor for whom it did not turn out well might say it too. For both of them the picture is surprisingly similar: sleep is broken, every on-call shift feels like walking on thin ice, they are quiet at home and more meticulous at work than ever before — and at the same time less sure of themselves. They hardly ever talk about it. Not because there is no one to talk to, but because they feel they have no right to. It was the patient who suffered. Who are they to be hurting?

It was precisely this question that the American physician Albert Wu answered in 2000. In a short editorial in the BMJ he wrote that a serious error in healthcare often has two victims: the patient and their loved ones on one side, and the doctor who was involved on the other. He called the second one the second victim. The term caught on, although it is not without its problems, which I come to near the end.

In this piece I do not write about legal proceedings, liability or how institutions formally handle errors — those are questions for other professionals. I write about what remains once all the procedures are over: a person who went into medicine to help, and then harmed someone, or at least feels that they did.

What “second victim” means

Wu used the term for a healthcare professional who is emotionally wounded by an event in which a patient was harmed or put at risk. It was later extended to nurses, midwives, pharmacists and others, because something very similar happens to them. Two things matter here.

First: it does not have to be an error in the narrow sense. The same reaction can be triggered by a complication that could not have been prevented, the unexpected death of a young patient, or a “near miss” that someone caught in time. The body does not draw a precise line between “it was my fault” and “it happened while I was there”.

Second: the reaction is not a sign that the doctor is weak or unsuited to the profession. In a 2013 systematic review, Deborah Seys, Albert Wu and colleagues gathered studies on how often healthcare professionals find themselves in the role of second victim after an adverse event. Estimates ranged from roughly 10 to 43 per cent. The range is wide because the studies measured things differently, but even the lower figure tells us this is a common experience, not an exception.

For doctors, something else is added. A profession in which you are expected to be flawless often attracts people who have been strict with themselves since childhood. I have written more about this in Perfectionism in professions where mistakes are not allowed. Someone who has lived their whole life by the rule “a mistake is unacceptable” does not just lose confidence after their first serious error. The very foundation on which they built their sense of worth begins to shake.

How it shows: in the body, in the mind, in behaviour

The reactions are very similar to those we know from other distressing events. Some fade within days, others last for months. Among the most common are:

• Intrusive memories. The scene keeps coming back, most often at night or when a similar case appears. Thoughts run in circles of “what if I had …” — in the knowledge base we call this rumination.
• Physical reactions. Insomnia, a pounding heart when the ward phone rings, a knot in the stomach before a procedure that used to be routine.
• Emotions. Guilt, shame, fear of the next mistake, sadness for the patient, anger — at yourself, at the system, at a colleague, sometimes even at the patient, which then becomes a further source of shame.
• Behaviour. Excessive checking, extra tests “just in case”, avoiding certain procedures or patients, withdrawing from colleagues, more alcohol or sleeping pills.
• Doubting the profession. “Maybe I’m not cut out for this.” For some, this turns into seriously considering leaving medicine.

In a large survey of doctors in the United States and Canada, published by Amy Waterman and colleagues in 2007, most of those who had been involved in an error reported greater anxiety about future errors, and many also reported poorer sleep, loss of confidence and lower job satisfaction. It is telling, too, that only a small share of respondents felt their institution adequately supported them in coping with this kind of stress.

Six stages on the road to recovery

In 2009 Susan Scott and colleagues carried out in-depth interviews with healthcare professionals who had been through an adverse event and described how recovery unfolds. From their accounts they identified six stages. These are not strict rules: some overlap, the order can shift, and one stage can last a very long time.

The last stage is the most telling. Some people leave the profession or move to work without direct patient contact. Others “survive”: they carry on working, but carry the event with them as a quiet burden that speaks up with every similar case. And others grow from the experience — they become more attentive, kinder to colleagues, and often the first to offer support when the next error happens to someone else. According to the researchers, the difference between these outcomes lay not so much in how “strong” a person was, but above all in whether, at the fifth stage, they had someone they could tell.

Guilt or shame: “I made a mistake” or “I am a mistake”

When I talk with someone about a mistake, what interests me most is how they put it. “I misread the result” is a different sentence from “I’m obviously incompetent”. The first is about an action, the second about the whole person.

The psychologist June Tangney spent decades researching the difference between guilt and shame. Guilt is about an action: I did something bad. It is unpleasant, but it turns a person outwards — towards the patient, towards repair, towards learning. Shame is about the self: I am bad. It turns a person inwards, into hiding, withdrawal, numbness or defensive anger. I wrote more about the difference in Guilt and shame are not the same — and the difference matters, and you will find short explanations in the knowledge base under guilt and shame.

For a doctor, this distinction is very practical. Guilt that a person can bear is valuable: it helps them talk about the event, take part in the review and change something. Shame, though, silences people. Someone who is ashamed will not talk about the mistake, will not ask for help, and will find it harder to contribute to making sure something similar doesn’t happen again. So shame is not only a private pain — it is also an obstacle to patient safety.

Why silence is so tempting — and so dangerous

In medicine, errors are often handled along the lines of “name, shame, blame”. Even where the official culture is different, an unofficial one remains: mistakes are whispered about, not discussed. A young doctor quickly learns that it is wiser to keep quiet. An older colleague might say “that’s how it is, move on” — and in doing so, without meaning to, signal that feeling things is not part of the job.

In a study published in 2006, Colin West and colleagues followed internal medicine residents over several years. They found that an error the residents themselves perceived was associated with later burnout, depressive symptoms and lower quality of life. Even more telling: distress was also associated with a greater likelihood of later errors. A vicious circle forms — an error brings distress, and distress raises the risk of the next error. Silence does not break the circle; it feeds it.

Here the second victim story touches a wider theme: how hard it is for doctors to seek help for themselves. Fear of what others will say, and the belief that the one who heals must remain untouched, are powerful. I write about where and how a professional can find help without fearing for their reputation in Who heals the doctors: how professionals seek help.

A conversation that comes too late

This is how a conversation in the doctors’ room might sound a few weeks after the event (composite, not a real person):

“You’ve been quieter lately. Is something up?”
“Nothing. I’m tired.”
“Did it start after that case in intensive care?”
“… I don’t know. Maybe. It was all reviewed. They said it wasn’t my fault.”
“I didn’t ask whose fault it was. I asked how you are.”
“I’m not sleeping. Every time the phone rings, I think something’s gone wrong again.”
“The same thing happened to me ten years ago. I didn’t tell anyone for six months.”

This short exchange holds almost everything that research on peer support emphasises. The colleague first asks how the person is, and only then — if at all — what happened. They don’t pass judgement on fault. And they share something about themselves that says: you’re not the only one, this isn’t proof that you’re a bad doctor.

What helps: peer support

Out of the recognition that the fifth stage is crucial, peer support programmes have been set up in some hospitals abroad. At the University of Missouri, Susan Scott and colleagues developed the forYOU programme, and Johns Hopkins Hospital has a programme called RISE. What they share is that trained colleagues — not managers, and not those investigating the event — reach out to the person soon after it happens and offer a conversation. Not therapy and not an assessment, but the human contact of someone who knows what it is like.

What a good colleague does in such a conversation:

• Comes to you rather than waiting. Someone who is ashamed will not ask.
• Asks about the person, not the case. “How are you sleeping?” is often a better question than “What happened?”
• Doesn’t reassure too quickly. “It wasn’t your fault” can sound like closing the conversation. It is better first to hear what the person feels.
• Normalises the reaction, not the event. Not “it’s nothing”, but “your reaction is understandable and common”.
• Knows when to refer on. If distress doesn’t ease or keeps deepening, a colleague is no substitute for professional help.

If there is no such programme where you work, it doesn’t mean there can be no support. Often it starts with a single colleague you dare to ask: “Has anything like this ever happened to you?”

Exercise: a letter to a colleague it happened to

This exercise draws on research into self-compassion, which I wrote about in Self-compassion instead of self-criticism: what Kristin Neff’s research shows. Most doctors can be far more forgiving towards colleagues than towards themselves. The exercise turns that ability inwards. Give yourself twenty minutes, paper and a pen.

1. Write down the facts in five sentences. What happened, without adjectives about yourself. Not “I was careless”, but “I missed a value in the result”.
2. Imagine a colleague you respect who was given exactly the same situation — the same day, the same tiredness, the same patient, the same complication.
3. Write them a short letter. What would you say to them? What would you wish for them? What would you certainly not write?
4. Read the letter aloud as if it were addressed to you. Notice where you resist and which sentence is hard to accept. That one is often the most important.
5. Separate two questions. In one column, write what you can learn or change from the event. In the other, what was outside your control — organisation, workload, the nature of the illness. This is not about excuses, but about accuracy.

If the exercise opens up more pain than you can manage on your own, that is not a failure. It is a sign that you need someone with you.

Where this view falls short

The term “second victim” has its critics — and rightly so. In 2019, in the BMJ, Melissa Clarkson and colleagues, among them patient advocates who had themselves experienced harm in healthcare, proposed that the term be abandoned. They pointed out that the word “victim” can blur accountability, and that to patients and their loved ones who truly suffered harm it can sound like an inappropriate comparison. I agree that a doctor’s suffering and a patient’s suffering should not be weighed against each other. A doctor’s distress is real, but it is not the same, and it is no substitute for honest acknowledgement and repair towards the patient.

So self-compassion is not making excuses. Someone who has made a mistake also has responsibilities — to the patient, to the family, to making sure it doesn’t happen again. And that is exactly why it matters that shame does not paralyse them: only a person who is not flooded by shame can truly take responsibility.

The second thing this piece cannot do: if errors stem from overload, too few staff or an organisation that doesn’t allow safe work, an individual’s recovery will not fix the system. The answer there lies elsewhere — in changes at the level of the institution.

And third: if your reactions don’t ease after several weeks, if signs of depression appear, if the scene floods you with the kind of force typical of trauma, or if thoughts come that it would be better if you weren’t here, turn to a doctor or psychiatrist — even if you are a doctor yourself. In Slovenia you can call the crisis line Klic v duševni stiski on 01 520 99 00 (every day from 7 pm to 7 am) or the Samaritan helpline on 116 123 (24 hours a day), and in an emergency 112.

What opens up in therapy

In relational family therapy, in which I am training under supervision, we don’t stop at what happened in the hospital when someone has been through an event like this. We are also interested in why it hit in exactly the way it did. How were mistakes received in your family? Was there anyone who was allowed to get things wrong without losing love? Were you a child who had to be good to keep the peace? Christian Gostečnik describes how, in difficult moments, we as adults respond according to patterns we internalised in our first relationships. A mistake at work therefore often wakes an old, very old voice.

Therapy is not a place where anyone judges whether you acted rightly. It is a place where you can say what you don’t dare say at work, without being assessed for it. A place where “I am a mistake” slowly turns back into “I made a mistake” — and where you can think about what you want to do with this experience from here. You may also find it helpful to read Healthy guilt and toxic guilt: how to tell them apart.

What to remember

• A second victim is a healthcare professional who is emotionally wounded by an event in which a patient was harmed. It is a common reaction, not a sign of weakness.
• According to Scott and colleagues, recovery has six stages; whether it ends in leaving, “surviving” or thriving depends heavily on support.
• Guilt (“I made a mistake”) opens the way to repair; shame (“I am a mistake”) closes it.
• Silence doesn’t help: distress after an error is linked to a higher risk of further errors. Talking to a colleague who knows what it is like is often the first step.
• Self-compassion is not making excuses — it is what makes it possible to truly take responsibility. If the distress doesn’t pass, seek professional help.