Indian Journal of Surgery (February 2022) 84(1):40–46

https://doi.org/10.1007/s12262-021-02793-3

ORIGINAL ARTICLE

“Second Victim” Syndrome Among the Surgeons from South Asia

Gaurav Jain 1 & Dhananjaya Sharma 2 & Pawan Agarwal 2 & Vikesh Agrawal 3 & Sanjay Kumar Yadav 4 &
Tashi Tenzin 5 & Moudud Hossain Alamgir 6 & Kishor Manandhar 7 & Moe Myint 8 & Abdul Majeed Chaudhary 9 &
Aziz Ahmad Jami 10 & Supakorn Rojananin 11 & Mohammad Mahbub ur Rahim 12

Received: 4 January 2021 / Accepted: 23 February 2021 / Published online: 1 March 2021
# Association of Surgeons of India 2021

Abstract
Awareness of second victim syndrome and available support systems in South Asia is quite limited. We conducted this survey to
assess its prevalence and impact among the surgeons from South Asia. A multiple choice pattern web-based cross-sectional
Google forms questionnaire was developed which focused on demographics of respondent, prevalence, impact (physical,
personal and professional), available coping mechanisms, gap in support systems, and future suggestions for dealing with
“second victim” syndrome. Answers were sought from surgeons of all surgical specialties from South Asia. A total of 658
surgeons responded to the survey, 91.03% (n = 599) reported having experienced the “second victim” syndrome. Majority
(54.3%) of respondents was from India; surgeons from 8 other countries also responded to the survey. Prevalence of “second
victim” syndrome was found similar among the two genders, different experience groups, and different specialties (p > 0.05). A
varied set of physical, psychological, and professional impacts were noted; however, any structured institute-based support
system was lacking and victims sought help from colleagues. Development of a structured “crisis plans” providing emotional,
psychological, and legal support, minimizing the trauma, and guiding the second victim through the recovery process is the need
of the hour.

Keywords Adverse events . Surgeons . South Asia . Healthcare provider . Patient safety . Second victim . Support program

Introduction
Whenever a patient safety incident, e.g., major complication
or adverse event, occurs, the first and most important per-
son(s) affected is/are the patient and his/her family. Such an
event can also adversely affect the treating clinician, who is
the “second victim,” as it can cause severe personal, profes-
sional, and physical impact on him/ her [1]. Although this
sensitive subject of “wounded healers” has received plenty
of attention in the Western countries with the development

* Dhananjaya Sharma Kishor Manandhar

dhanshar@gmail.com kishorsayami@gmail.com

Gaurav Jain Moe Myint

drjain16@googlemail.com moemyint65@gmail.com

Pawan Agarwal Abdul Majeed Chaudhary

drpawanagarwal@yahoo.com prof_abdulmajeed@hotmail.com
Vikesh Agrawal Aziz Ahmad Jami
drvikeshagrawal@gmail.com azizjami@gmail.com
Sanjay Kumar Yadav
Supakorn Rojananin
sky1508@gmail.com
sisrj82@hotmail.com
Tashi Tenzin
drbumtap98@gmail.com Mohammad Mahbub ur Rahim
dr.mahbubrahim@gmail.com
Moudud Hossain Alamgir
pavelbogra@gmail.com Extended author information available on the last page of the article

13
Indian J Surg (February 2022) 84(1):40–46
of support programs for the affected clinicians, its awareness
and available support systems in South Asia are scarce [2].
This prompted us to conduct this survey to assess its preva-
lence and impact among the surgeons from South Asia.
Methods
A web-based cross-sectional Google forms questionnaire was
sent by WhatsApp and Email to the surgeons from South
Asia, known to authors, in their personal capacity.
Participants were asked to further disseminate the question-
naire to their contacts. The questionnaire was kept open for
responses from 4 October to 4 November 2020.
The term “surgeon” here included all surgical specialties—
general, orthopedics, gynecology, ENT, urology, plastic, neu-
rosurgery, etc. A “second victim” was defined as “a healthcare
provider involved in an unanticipated adverse patient event
who become victimized in the sense that the provider is trau-
matized by the event.”
A multiple choice pattern questionnaire, which included 16
qualitative questions, was designed (Table 1). The questions
featured the ability to select more than one answer, as and
when needed. The questionnaire focused on the demographics
of respondent, prevalence, impact (physical, personal and pro-
fessional), available coping mechanisms, gap in support sys-
tems, and future suggestions for dealing with “second victim”
syndrome. All domains were discussed through multiple iter-
ations using a systematic closed and open approach focused
on assessing the domains. Content/face validity was assessed
through interviews with experts and physicians having first-
hand experience of second victim syndrome in order to check
that meaningful aspect was included.
The study responses and data were collected and managed
using the Google forms electronic tool.
Results
A total of 658 surgeons responded to the survey, 91.03% (n =
599) reported having experienced a major adverse event/
unanticipated surgical complication or a death in their patient
which led them to feel like the “second victim.”
Demographics of Responding Surgeons
Majority (490; 73.9%) of respondents were male; however,
prevalence of being second victim was similar among the two
genders (p > 0.05). Majority (360; 54.3%) of respondents
were from India. Others were surgeons from Bangladesh
(11.2%), Myanmar (8.6%), Nepal (8.1%), Pakistan (3.8%),
the Philippines (3.8%), Bhutan (3.6%), Afghanistan (3.6%),
and Thailand (1.5%) (Fig. 1). An additional 9 respondents
41
who had earlier worked in Southeast Asia, but have now
moved to other countries, also responded.
Respondents belonged to different experience groups: < 2
years out of training (13.7%); 2–6 years of training (29.1%);
6–10 years of training (23.5%); and after 10 years of training
(33.6%). These were spread across academic institution
(42.8%); private practice self (27.3%); practice corporate hos-
pital (15.8%); not-for-profit/charitable hospital (8.4%); and
district government hospitals (5.6%). Prevalence of “second
victim” syndrome was found similar among these groups (p >
0.05).
The majority of respondents were general surgeons
(43.6%), followed by gynecologists (10%), orthopedic sur-
geons (7.6%), plastic surgeons (7.1%), pediatric surgeons
(6.7%), urologist (6.5%), GI surgeons (3%), surgical oncolo-
gists (2.9%), ENT (2.4%), cardiac surgeons (2.3%), neurosur-
geons (2.3%), breast/endocrine surgeons (0.8%), and others
(4.7%). Prevalence of “second victim” syndrome was found
similar among these groups (p > 0.05).
Impact of “Second Victim” Syndrome
Extreme sadness was the commonest (50%) first reaction after
an adverse event; other reactions included guilt (35%), fear
(28%), embarrassment/humiliation (22%), depression (21%),
and other feelings like being horrified, anger, and denial.
The personal impact of adverse event on the surgeon
ranged from feeling of personally responsible for patient’s
bad outcome (38%), frustration (37%), adverse effect on fam-
ily life (29%), remorse and repetitive intrusive memories
(24%), self-doubts (23.7%), and shame (14%). 9.5% thought
about leaving the profession and 1.5% even thought about
suicide.
The physical toll on the surgeons was equally significant;
anxiety (48%), sleep disturbance (39%), difficulty in concen-
trating (33%), flashbacks (25%), irritation (24%), and head-
ache (12%) were reported. Fourteen (2.1%) respondents ad-
mitted to increased alcohol or drug abuse. However; 81
(12.1%) denied having any impact.
Surgeons’ main worry was patient’s and his/her family’s
well-being (59%), next step after the mishap (28%), possible
litigation (26%), event recurrence (24%), social defamation in
news media/social media (21%), reputation among peers
(19%), threat to professional reputation (19%), worry about
job security (16%), etc..
Twenty-one percent of surgeons reported no negative
impact on their profession. Over 41%, however, became
more risk averse and started avoiding similar procedures
for some time. Other reported negative professional im-
pacts were feeling less confident with patients (22%),
burn out (16%), loss of trust in colleagues/hospital/system
(16.1%), avoiding future contacts with the affected patient
(14%), and negative effect on professional reputation
13
42 Indian J Surg (February 2022) 84(1):40–46

Table 1 Questionnaire

S Question Options
No

1 Have you experienced a major adverse event/unanticipated surgical Yes/no

complication/death in your patient which led you to feel like the second
victim?
2 Gender of surgeon Male/female/prefer not to say
3 The number of years you have been in practice (after residency/fellowship) <2 years/2–6 years/6–10 years/> 10 years
at the time of adverse event
4 Geographical location India/Nepal/Pakistan/Bangladesh/Bhutan/Sri
Lanka/Afghanistan/Myanmar/Thailand/Vietnam/Philippines/Others
5 Your practice setting during complication Academic institution/private practice self/private practice corporate
hospital/not-for-profit/charitable hospital/small/district government hospital
6 Your specialty General surgery/urology/orthopedics/pediatric surgery/plastic surgery/surgical
oncology/CVTS/GI surgery/neurosurgery/breast/endocrine
surgery/Ob-Gyn/ENT
Other
7 What was your first reaction? No negative emotions/denial (this can’t happen!)/depression/extreme
sadness/guilt/anger/fear/embarrassment/humiliation/horrified
8 Was there any personal impact? Affected family life, due to personal sadness/thought about committing suicide?
Feeling of shame/inadequate (self-doubt)/frustration/feeling of remorse.
Repetitive, intrusive memories/felt personally responsible for patient’s bad
outcome/considered leaving medical profession/nil
9 Was there any physical impact? Sleep disturbances/difficulty concentrating/flashbacks/drug or alcohol
abuse/headache/irritation/anxiety/nil
10 What were you most worried about? Patient: Is the patient/family okay?
Himself: Will I be fired?/Will I be sued?/punishment
Peers: What will my colleagues think?/Will I ever be trusted again?
Next steps: Litigation (fear of being sued)/fear of event recurrence/fear of threats
to personal and professional identities/social defamation (news media, social
media like WhatsApp/Facebook)
11 Was there any negative professional impact? Risk aversion (avoid doing similar surgeries for some time)/went on a long leave
(difficulty to go back to work)/burnout/loss of trust in
colleagues/hospital/system/loss of business/financial loss
(lawsuit/compensation)/decreased referrals/switching job/early
retirement/lost job/temporary suspension/professional reputation
affected/resulted in loss of medical license/feeling less confident with
patient/avoid future contact with affected patient or family/do not want to
disclose/nil
12 Was there any positive professional impact? Higher awareness of responsibilities/extra attentiveness procedural techniques
and decision-making/discussing with colleagues and seeking more
advice/increasing education/training for self/listening to patient more
closely/it helped you discover your limitations/are you now more attentive to
surgical checklists?/do not want to disclose/nil
13 What was the most effective coping mechanism? Seeking social support (talking to peers/someone about feelings)/criticizing or
lecturing yourself/distancing from affected patient and family/trying to forget
the whole thing emotional self-control/keeping others from knowing how bad
things are/trying to make themselves feel better by eating, drinking, using
drugs, or medications/offer patients full disclosure and honest explanations
and fair compensation when standards of care were not met
14 What type of support system will work best, in your opinion? Institutional-based nonjudgmental and confidential, peer-to-peer support/should
involve crisis interventions (including legal support, etc.)/counseling
services/time break after serious complications/open opportunities for
discussion of complications/more training/formal mentoring system
15 Why do surgeons make mistakes? Lack of skill/knowledge/lack of attention/error of judgment/poor
communication/pressure/haste
16 What are your future suggestions? Laws should be favorable to surgeons who disclose their errors/media should
refrain itself from negative publicity/better and detailed informed
consent/surgeon-patient relationship should be maintained after adverse
event/more awareness of legal implications will be helpful/availability of
counseling services/more training/should organizations take more
responsibilities?

(10%). Fifty-one (7.7%) surgeons reported financial loss job, 4 lost their license to practice, and eleven reported
due to lawsuit/compensation. Three surgeons lost their switching jobs or taking early retirement.

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Indian J Surg (February 2022) 84(1):40–46
10, 1% 9, 1%
24, 4%
24, 4%
25, 4%
25, 4%
54, 8%
57, 9%
72, 11%
Fig. 1 Country-wise responses
The commonest (56.3%) reported positive impact on the
profession was surgeons paying extra attention to the proce-
dural techniques and decision-making. This was followed by
increased awareness of responsibilities (51%), increased dis-
cussion with colleagues and seeking more advice (48%), in-
creasing education/training for self and paying more attention
to surgical checklists (27%), discovering own limitations
(26%), and willingness to listen to patients more closely
(25%).
Comments About Available Support Systems
Fifty-six percent of surgeons acknowledged that the support
given by peers and colleagues was most helpful. Thirty-three
percent believe that offering full disclosure, honest explana-
tions, and fair compensation to patients was the most effective
coping method. Other ideas resorted to included trying to for-
get the whole thing by emotional self-control (16%), criticiz-
ing self (16%), keeping others from knowing how bad things
were (9%), and distancing from affected patient and family
(6%). Twenty-three (3.5%) admitted resorting to alcohol,
drugs, or medications.
When asked about the ideal support system, most (59%)
surgeons favored an institutional-based nonjudgmental and
confidential peer-to-peer support. The other suggestions were
open opportunities for discussion of complications (46%),
43
India
Bangladesh
Myanmar
Nepal
Philippines
Pakistan
Afghanistan
358, 54%
Bhutan
Thailand
Others
counseling services (36%), crisis interventions including legal
support (34%), more training (25%), time break after serious
complications (18%), and formal mentoring system (16%).
Surgeons’ opinion for future recommendations and preven-
tive measures included detailed informed consent process
(56%); maintenance of physician-patient relationship after ad-
verse event (53%), distancing the media from negative pub-
licity of surgeons (53%), more surgeon-favorable laws for
those who disclose their errors (48%), availability of counsel-
ing services (40%), more training (31%), accountability of
institutions (30%), and increased awareness of legal implica-
tions (28%).
Reason for Mistake Leading to the “Second Victim”
Syndrome
Error in judgment was the commonest (62%) stated reason.
Other reasons included haste/time pressure (44%), poor com-
munication (39%), lack of skills/knowledge (30%), and lack
of attention (28%).
Discussion
The term “second victim” gained immediate acceptance as it
resonates with all healthcare professionals (HCPs) who, as a
13
44
rule, care deeply about their patients and take immense pride
in their skills; thus becoming prone to be afflicted with the
“second victim” syndrome in the face of an adverse event with
their patient. Inadvertent medical errors are and will likely
always be a part of the medical system due to the universal
nature of human and system fallibility [3, 4]. Mitigation of
these is, rightly, the focus of all quality- and safety-related
endeavors in healthcare. Increasing awareness about the “sec-
ond victim” syndrome among HCPs who may be suffering in
silence has made research about this sensitive issue very im-
portant [5].
High prevalence of second victim syndrome, in up to two-
thirds of HCPs, has been noted in many studies [6, 7].
Surgeons experience more profound reactions as the second
victims because of the nature of their work, in which the link
between technical ability and patient outcome is more sub-
stantial [7–10]. In our survey, a very high number (~ 91%)
of surgeons reported second victim phenomenon. Reasons for
this may be infrastructural constraints, low level of health
awareness among general population, and unrealistic expecta-
tions of patients fanned by a biased media and mob mentality
after an adverse event. However, high prevalence is not un-
known in studies from western countries [11]. Prevalence
among genders, level of experience of surgeons, different
places of work, and different surgical specialties was found
similar in our survey. Some studies have found more pro-
nounced effects in trainees, some women and some in men
[12, 13]. The difference in the prevalence of second victim
based on their practice setup and different surgical specialties
has not been studied.
Second victims’ immediate reaction, personal impact of the
adverse event, the physical toll on the surgeons, and main worries
are well known and the same has been seen in our survey [14].
Second victim syndrome is both a contributor and consequence
of burnout in HCPs [15]. This cycle of events and its associated
emotional toll lead to negative consequences, which may include
depression and departing medicine by attrition or even suicide
[16]. A second victim surgeon is more than 3 times as likely to
consider suicide as those who had not [16]. Some may lose their
jobs and many seriously consider early retirement and leaving
their chosen profession altogether [10]. Degree of impact de-
pends upon severity of the outcome, the patient’s or their family’s
reactions, unexpected and preventable nature of complications,
complications occurring in elective surgery, pediatric or young
adult patients, failure to rescue cases, patients known to staff
members, staff member death, community high-profile event
victim or if same bad outcome occurs in a short period of time
in multiple patients, and reactions from colleagues and institution
[12, 17].
One undesirable professional by-product of second victim
syndrome is damage to institutional core values, morale, and
reputation, leading to a more conservative decision-making
which has been termed as the “third victim” [18, 19]. The
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Indian J Surg (February 2022) 84(1):40–46
commonest professional impact for the affected surgeon is the
tendency to become more conservative and risk averse [8, 11].
Such risk aversion can affect the quality and safety of subsequent
patient care to some extent; such a patient has been labeled as the
“fourth victim” [19]. Second victim syndrome has many similar-
ities to “post-traumatic stress disorder” and its recovery pattern
has been studied and documented [8, 17].
An adverse event like the “second victim” syndrome can
also provide a positive impact including a learning opportuni-
ty. Similar to other studies, our survey revealed surgeons be-
ing extra attentive about the procedural techniques and
decision-making; increased awareness of responsibilities, fol-
lowing guidelines and surgical checklists more accurately and
closely, increased discussion with colleagues; and seeking
more advice and increasing education/training for self [6].
After an adverse event, the commonest coping mechanism
by most surgeons is to seek support from colleagues, peers,
and family members, even when a structured institutional
emotional support system is available [10, 12]. As seen in
our survey, the emotional response of second victims is varied
and unorganized. Other insightful and wise strategies for cop-
ing with an error include complete disclosure and apology,
learning to deal with imperfection, preventing recurrences,
and helping others by teaching about the error [20–22].
The need to provide institutional support to second victims
is self-evident. Many institutions, universities, and academic
bodies have successfully developed structured “crisis plans”
providing emotional and psychological support, minimizing
the trauma, and guiding the second victim through the recov-
ery process [23]. Barriers to seeking support include difficulty
with access, concerns about lack of confidentiality, negative
impact on career, potential damage to professional reputation,
fear of litigation, culture of stigma and blame, discomfort and
a lack of training how to disclose, and inadequate systems for
communications, analysis, discussion, and learning from mis-
takes [11, 17, 20, 24, 25].
The most striking observation, as a gap, from our survey
was that there is currently no formal, institutional, or peer
support program available for surgeons as second victims in
South Asia. Apart from an occasional publication, the major-
ity of the literature on this issue has been published in western
countries [2, 26]. The increasing tendency to resort to physical
violence and legal means for adverse events compounds the
trauma to the second victims. An awareness campaign to suc-
cessfully develop support programs is the need of the hour in
South Asian setting. Respondents to our survey have brought
out the desired qualities of an ideal support system:
institutional-based nonjudgmental and confidential peer-to-
peer support, open opportunities for discussion of complica-
tions, counseling services for HCPs, immediately available
“real-time” crisis interventions (including emotional first aid
and legal support), more training, and a formal mentoring
system [17, 24]. A culture of shame and blame, in which
Indian J Surg (February 2022) 84(1):40–46
errors are seen as personal failures, should ideally be replaced
by a culture in which errors are seen as opportunities to im-
prove the system [19]. A lesson can be learned from Aviation
industry which focuses on “what went wrong” rather than
“who went wrong” [27]. Additionally, our survey found ma-
jority of respondents wishing for better and detailed informed
consent process (for better understanding of surgical risk by
patient); maintenance of surgeon-patient relationship after ad-
verse event; refraining the media from negative publicity and
public trial of HCPs; and more favorable laws for clinicians
who disclose their errors [19, 28].
It can be argued that the term “second victim” is seen as
being inappropriate in some fields, with suggestions that the
term should be abandoned [29]. However, the term is already
in wide use and easily reflects the adverse impact of surgical
complications on the operating surgeon. This was the first
such study among South Asian surgeons and similar re-
sponses form 659 surgeons working in different surgical spe-
cialties, across different experience groups, working in differ-
ent types of hospitals in 9 different countries across South
Asia strengthen the observations seen in our study. As this
was an open online survey, inherent limitations of our study
include inability to calculate the actual percentage of re-
sponses, possibility of a non-response, and recall bias with
non-responding surgeons being those who never experienced
“second victim” syndrome. These findings may be further
validated by larger studies.
Conclusion
Prevalence of “second victim” syndrome is very high (> 91%)
among surgeons of South Asian countries and it has a signif-
icant negative impact on their professional and personal life.
Surgeons struggle and use a variety of coping mechanisms;
however, any formal support system to deal with this is non-
existent. Development of a structured “crisis plan” providing
emotional, psychological, and legal support, minimizing the
trauma, and guiding the second victim through the recovery
process is the need of the hour.
Declarations
Conflict of Interest Nil.
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Affiliations
Gaurav Jain 1 & Dhananjaya Sharma 2 & Pawan Agarwal 2 & Vikesh Agrawal 3 & Sanjay Kumar Yadav 4 &
Tashi Tenzin 5 & Moudud Hossain Alamgir 6 & Kishor Manandhar 7 & Moe Myint 8 & Abdul Majeed Chaudhary 9
Aziz Ahmad Jami 10 & Supakorn Rojananin 11 & Mohammad Mahbub ur Rahim 12
1 6
Department of Surgery, University of Wisconsin School of Medicine
and Public Health Milwaukee, Madison, WI, USA
2
Department of Surgery, NSCB Government Medical College,
Jabalpur, MP 482003, India
3
Pediatric Surgery, Department of Surgery, NSCB Government
Medical College, Jabalpur, MP 482003, India
4
Breast and Endocrine Surgery, Department of Surgery, NSCB
Government Medical College, Jabalpur, MP 482003, India
5
Faculty of Postgraduate Medicine, Khesar Gyalpo University of
Medical Sciences, Thimphu, Bhutan
13
Indian J Surg (February 2022) 84(1):40–46
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Publisher’s Note Springer Nature remains neutral with regard to jurisdic-
tional claims in published maps and institutional affiliations.
&
Department of Surgery, TMSS Medical College, Bogra, Bangladesh
7
National Academy of Health Sciences, Kathmandu, Nepal
8
Department of Surgery, University of Medicine, Magway, Myanmar
9
Lahore Medical and Dental College, Lahore, Pakistan
10
Afghan Surgeon Society – West, Herat, Afghanistan
11
Mae Fah Luang University, Chiang Rai, Thailand
12
RO Diagen Cooperative Hospital, General Santos, Philippines