Debriefing in Medicine: Healing after an Adverse Event

A few weeks ago I was on weekend call. One of my patients was quite sick and deteriorated suddenly. I still remember wheeling her into the ICU. She unfortunately passed away after multiple cardiac resuscitations. This was the first time one of the patients I was responsible for as a physician, had died.

For days afterwards I was still ruminating and obsessing about every small detail that took place that day. Did I screw up? Was there something I could have done earlier to prevent this outcome? The questions never stopped. It took some time before I realized that in fact I did do everything within my power to care for her. I did my best, and nothing else and no one else would have been able to prevent her death at that point in time. She was too sick.

This realization only sunk in after I spoke with many of my colleagues and friends about it. In fact, I couldn’t shut up. I just needed to talk about my version of the events over and over and over again. And wait for their response. I wanted to know if they thought I should have done anything differently. I wanted to know how they processed events like this and how they recovered. I wanted to know if I still deserved to be here. I wanted to know if I would ever heal from the trauma of the event itself.

I genuinely cherished the overwhelming support that I received. I was not alone. This, in the saddest way, was liberating. I learned that my experience was a rite of passage, particularly for an oncologist. It happens to nearly all physicians. The questions I was asking myself were ones they continue to ask themselves when an adverse event takes place.

A mentor recounted to me how one of her patients had recently died in her sleep 2 days after completing her cancer treatment. She’s learned to embrace that we are only human and there’s only so much we can do. She believed that perhaps it was better that her patient had passed away in her sleep, for it put an end to her suffering. Her experience had taught her that with our mandate to preserve life, we must also come to terms with the inevitability of death.

Over time I came to understand that I had perceived my patient’s death as a failure or a sign of incompetence on my part. Which is quite absurd now that I think about it. I work hard to do everything in my power to care for my patients the best way I know how. Death, however, is an inescapable end to life.

I now realize that debriefing with friends and colleagues was the most therapeutic milestone throughout my healing process.

With this in mind, I believe it is crucial for every healthcare team to hold debriefing sessions following adverse events. Ignoring them without addressing the experiences and emotions of those involved will inevitably only hinder the efficiency and productivity of the team. The stress that ensues often leads to fatigue, burnout, and at times, the development of unhealthy coping mechanisms.

The most widely recognized debriefing model is the Mitchell Model which describes 7 phases to go through during a debriefing session after an adverse event takes place. This is meant to occur in a blame free, nonjudgmental environment where all members of the team participate. “[When] senior staff members discuss their own personal involvement and experience in past clinical incidents, this provides a powerful source of support for other colleagues.” (1) The debrief allows for fine-tuning of the risk management process among healthcare professionals and teams with the ultimate purpose of reducing adverse events and optimizing their management.

• Phase 1: Introduction – Every individual introduces themselves and describes their role in the incident.
• Phase 2: Fact – Core facts are corrected and completed to fill in missing details.
• Phase 3: Thought – Participants answer the question “When did you first realize this was a critical incident?” 
• Phase 4: Reaction – Participants answer the question “How did you react to the incident?” This is when peers recognize that others had the same reaction, thereby providing them with the opportunity to support one another. The realization that their feelings and reactions are in fact normal is the first step towards healing.
• Phase 5: Symptom – Discussion of symptoms and experiences during, immediately after, and 3-5 days following the incident. It took me a few days to be able to process my emotions and understand how I was feeling and why. I was eternally grateful for my friends and colleagues who were able to give me the space to talk about the incident days after the event, when I realized I was indeed still hurting.
• Phase 6: Teaching –  Reminders of critical incident stress, stress reactions, and techniques to decrease stress are discussed during this phase. I discovered, unsurprisingly, that a good daily dose of exercise helped me manage my stress levels, diffuse my frustrations, and improve the quality of my sleep. Exercise became a priority in my life.
• Phase 7: Re-entry – Any other relevant comments or discussions take place during this phase to ensure that the meeting ends after everyone has reached a resolution of their heightened emotional state.

With debriefing frameworks such as this one, we can ensure that we, as well as our colleagues, remain of sound body and mind, particularly after distressing medical incidents. Only if we take care of ourselves, can we continue to care for the most vulnerable of patients, every day. We owe this not only to our patients, but also to ourselves and to our families and loved ones.

I pray that we continue to nurture, in ourselves, and in others, the resilience to weather the storms to come, and the strength to be ever so compassionate to ourselves and to others, every step of the way.

References:

1. Vaithilingam, Nirmala, et al. “Helping the Helpers: Debriefing Following an Adverse Incident.” The Obstetrician & Gynaecologist, vol. 10, no. 4, 2008, pp. 251–256., doi:10.1576/toag.10.4.251.27442.