The surgeon as second victim: a review of the phenomenon in surgery with implications for neurosurgical practice

Across surgical disciplines, second victim reactions emerge as a common and predictable occupational hazard rather than a rare exception, particularly in high-risk specialties such as neurosurgery. These reactions often overlap with professional grief after a patient death or catastrophic complications. Trainees and early-career surgeons, individuals with perfectionistic traits or preexisting burnout, and surgeons working in punitive or unsupportive institutional cultures appear particularly vulnerable. Triggers include unexpected intraoperative deaths, perceived preventable complications, adverse outcomes in young or pediatric patients, and events entangled with medicolegal conflict. Coping strategies range from adaptive approaches, such as structured reflection, learning-focused case review, and seeking peer support, to maladaptive patterns, including emotional withdrawal, avoidance of high-risk cases, defensive medicine, and thoughts of leaving surgical practice. Surgery-specific peer-support programs and debriefing models have been developed and are generally well received, although rigorous outcome data remain limited. Emerging literature in neurosurgery and neurointervention suggests that the second victim phenomenon is especially salient where small technical decisions may determine irreversible neurological harm. Neurosurgeons report a substantial emotional burden, features consistent with posttraumatic stress after catastrophic complications, and high levels of moral distress and moral injury around end-of-life decisions and perceived unbeneficial treatment. The purpose of this narrative review is to examine the second victim phenomenon in surgery and its relevance for neurosurgical practice, with an emphasis on recognizing that such experiences are intrinsic to the work and that integrating education, structured debriefing, peer-support processes, and a supportive institutional culture are critical to sustaining humane, high-quality care across a career.