Medical Liability: Coping With Litigation Stress

WHEC Practice Bulletin and Clinical Management Guidelines for healthcare providers. Educational grant provided by Women's Health and Education Center (WHEC).

It will come as no surprise to the readers that being a physician can be hard work physically and emotionally -- starting with long years as a medical student, continuing into training as a junior physician, and then working as a specialist. For a substantial proportion of practitioners, their work and working conditions can affect them negatively, and lead to stress, fatigue, burnout, anxiety or depression, and substance abuse. Various groups have been talking recently about ill-health among physicians. About 90% of all American College of Obstetricians and Gynecologists (ACOG) Fellows who responded to the 2006 ACOG survey on Professional Liability indicated they had at least one claim filed against them during their professional careers. Being sued for medical liability can be one of the most stressful life events a physician experiences. Nearly half of the physicians in ACOG survey said that medical practice is very or extremely stressful. Almost a fifth of resident physicians rated their mental health as fair or poor, which is more than twice the rate in the general population. There are reports of burnout in 25%-60% of physicians, with up to three-quarters of them reporting burnout in some studies (1). 8-12% of physicians in practice might develop a substance abuse problem at some stage in their career (1). Embedded in most liability litigation is a "bad outcome" which, with or without actual medical error, profoundly affects physicians. When medical error is involved, many physicians experience increased somatic and psychologic distress. Sometimes new regulations that are designed to improve working conditions backfire and do the opposite. This "silent desperation" among some physicians can be a disastrous situation. We urge the professional societies and governments to pay more attention to stress and burnout among physicians, especially to remove the stigma that burnout brings. When physicians are not well, the performance of healthcare systems can be suboptimum. Physician wellness might not only benefit the individual physician, it could also be vital to the delivery of high-quality health care. The work stresses faced by physicians, the barriers to attending to wellness, and the consequences of unwell physicians to the individual and to healthcare systems are enormous. The health systems should routinely measure physician wellness, and discuss the challenges associated with implementation. Healthy physicians mean healthier patients, safer care, and a more sustainable workforce.

The purpose of this document is to promote mental wellbeing of healthcare providers by the provision of productive and healthy workplaces. We recommend the adoption of an approach to promote mental wellbeing, putting in place a system to monitor such wellbeing, and the provision of flexible working. The guidance recognizes that work has an important part to play in the promotion of mental wellbeing, and that having a workforce that is mentally well will lead to economic benefits for the organizations, by increasing job commitment and satisfaction and staff retention, raising productivity, and reducing absenteeism. Healthcare providers should not have to choose between saving themselves and serving their patients. There are many programs in the USA, Canada and UK that are designed to improve physician's wellness by recognition of potential health problems and by the provision of education and support (e.g. from basics such as getting enough food at work, sleeping properly, and to how to deal with adverse events, complaints, and litigation). The endpoint is better care for patients and improved system outcomes.

Background

We all entered into medicine with the idea that hard work and dedication would provide us with the necessary knowledge and skill that would enable us to provide best-practice care for our patients. Only we could do what we did, and we were happy to make the necessary sacrifices in the name of patient care. Hard work, dedication and the drive for perfection were the spirit of the day. Exhaustion was a sign of a job well done. So, what has changed? The world of medicine has become more complex. Personal, economic, government and societal pressures have forced the one-time cottage industry to suffer from the pains of running medicine as a business. With more external bureaucracy, restricting rules and regulations, limits on autonomy and control, and a growing list of third party, patient and family demands, healthcare providers are finding it more frustrating to do what they need to do, and are getting paid less for doing it. All these factors have contributed to increasing levels of dissatisfaction, frustration, anger, stress and burnout. In some cases these factors have progressed into bouts of depression, substance abuse, and/or suicidal ideation. Besides the toll it takes on personal life and career satisfaction, increasing levels of stress, burnout and fatigue are known to adversely affect performance efficiency, resulting in behaviors that negatively impact work relationships and patient care. So, what is the best way to address the problem?

If a physician is currently involved in litigation, he or she should understand the sources of stress and how to cope. If physician has been sued in the past, he or she need to recognize the effect the experience may have had on them and their family. Physicians are important citizens of healthcare systems, and evidence indicates that many physicians are unwell. Physicians who are affected by the stresses of their work may go on to experience substance abuse, relationship troubles, depression, or even death (2). Results of emerging research show that physicians' stress, fatigue, burnout, depression, or general psychological distress negatively affects healthcare systems and patient care. Thus when physicians are unwell, the performance of the healthcare system can be suboptimum. The corollary is that physician wellness might not only benefit the individual physician, but also be vital to the delivery of high-quality healthcare. Recent surveys conducted by World Medical Associations showed physicians are generally healthy when it came to tobacco use, and contrary to popular belief, drug and alcohol use is no greater in the medical profession than it was in other occupations (3). Yet more demands on physicians and their increasing lack of control are leading to a silent desperation among physicians. Women in the profession in particular appear to be at greater risk of suicide, and a significant proportion of all physicians have symptoms of depression and anxiety, according to the report by World Medical Association (3). The image and professionalism of physicians, the threat to their self regulation, patient safety and accountability without authority all have contributed to mental stress.

Many professional organizations, leaders and governments have recognized these facts and are taking actions to support physicians, through national leadership, raising awareness of the problems and reducing the stigma of burn-out and education. Wellness goes beyond merely the absence of distress and includes being challenged, thriving, and achieving success in various aspects of personal and professional life. The conclusion of UK's National Confidential Enquiry into Patient Outcome and Death (CEPOD), about the European Union's working-time directive is stated here (4). This directive came fully into force on Aug 1, 2009 and it affects physicians' working hours. Traditionally, physicians have worked very long hours. The working-time directive seeks to limit the maximum working week to 48 hours. CEPOD found that the working-time directive meant that hospital staff had little time to hand over to the next shift, and that delays in contacting a consultant led to unnecessary deaths in hospital. They looked at 1635 deaths in detail, and found that in 407 cases there was a clinically important delay to a first review by a consultant. However, in one news piece, the Department of Health was reported as saying that there was evidence that the shorter working week was decreasing hospital mortality (4). The U.K.'s National Institute for Health and Clinical Excellence (NICE) released guidance on November 5, 2009 for employers about promoting mental wellbeing.

Professional hypocrisy -- dispensing to others yet personally ignoring advice about leading a balance life -- is not a new problem for medical practitioners. This pernicious paradox leads healthcare professionals into the sad irony of caring for patients while neglecting themselves and those close to them. Moreover, in the medical training as autonomous decision-makers, physicians frequently translate into denying their own need for help. Substantial pressures, intrinsic to the care of patients, are amplified in an era of increasing regulation, heightened expectation and decreasing professional satisfaction. These distortions exist throughout all levels of medical education with painful impact on patient and practitioner alike. In a recent study of stress surveying nearly 200 Canadian women physicians, three major themes were identified: perfectionist attitudes toward professional and personal activities; the reality of multiple roles, especially caring for small children and competing demands.... That compromised time for personal activities or rest; a work environment not always flexible or hospitable to the needs of women physicians (5). Similar studies catalogue the factors which impact house staff as well as medical students and contribute to depression, dissatisfaction with patient care, cynicism and burnout (6). The so-called "hidden curriculum" with its troublesome influence on idealism and empathy is unfortunately quite visible in its formative impact. These elements coupled with compulsive traits (useful in attending to detail, potentially crippling in fueling the beliefs that healthcare professionals ought to make no errors) are the ingredients for trouble in professional life, and demand that healthcare professionals squarely face these issues.

Medical Take -- What is the Problem?

Why a medical professional liability suit is so stressful? The nature of a medical professional liability claim virtually guarantees that a physician who is being sued will undergo tremendous stress. Physicians rightfully pride themselves on their medical knowledge and skill. In a medical malpractice case, however, it is attorneys who argue medical knowledge and skill before a jury. And, when trial is involved, the attorney must develop a strategy that blends medical fact with human emotion to make a possibly complicated and medically involved case comprehensible to a jury that is most likely made up of non-medical individuals. The task is daunting one. Physicians are likely to fear the litigation process. Some defendant physicians, concerned that their attorney may know the law but fall short of understanding the medicine, try to become medical mentor to both their attorney and the jury that may hear their case. Others try a head-in-the-sand approach and sit back, allowing their attorney to do all the work. Yet others, sure that they did nothing wrong, remain aloof, detached, and distant from their case. The vast majority of physicians, however respect the process and are willing to follow the guidance of their attorney because they know that litigation represents a world whose rules they do not know, whose processes they cannot control, and whose decisions may forever mark their professional life.

The plaintiff seeks compensation; for compensation to be paid, fault must be proven. Most of the physicians feel the trust they have worked so hard to establish with the patient has been breached. At its heart, the medical liability claim accuses you of failing to do your job. Both the legal system itself and the litigation process create stress for most physicians. The litigation process is very unpredictable with many stops and starts. Many medical liability cases take an average of 3-4 years to be resolved (7). Lack of resolution for such a long time is highly stressful on its own. People who successfully apply to and complete medical school and demanding obstetrics and gynecology training tend to share a number of personality traits -- making coping with a medical liability lawsuit especially stressful, because:

  • They set high expectations for themselves and demand the best effort;
  • They are hard-working and conscientious;
  • Attention to detail is compulsive;
  • They are directive and like to be in charge;
  • Physicians are accustomed to and comfortable with being in charge, but the legal system is not under their control. It is an alien environment, very unlike medicine;
  • Medicine is collegial, the legal system is adversarial;
  • 'Proper' physicians have always taken part in emergency medical admissions, work long hours and are always available to their patients;
  • Physicians feel they have worked hard and sacrificed to gain the skills, and it is justifiable to be proud of what has been accomplished;
  • Medicine values promptness and rapid resolution of problems, delays are an unavoidable element of the legal system;
  • The lawsuit represents a challenge to your competence, integrity, and self-concept;
  • Physicians feel they have been labelled a failure, a bad doctor;
  • The lawsuit represents a challenge to the physician's competence, integrity, and self-concept.

Intolerable Paradox

The impact of medical errors on health care professionals needs to be addressed to provide support and healthy coping strategies. Also gaining more attention and emphasis in recent years is the impact that medical errors have on health care providers, deemed the "second victim". The concept of the term second victim is coined to express the resultant impact on clinicians (8). However, the history of health care professionals being impacted by an unexpected situation or error dates back to 1817. The Triple Tragedy of 1817 is an extreme example of the impact of medical errors on health care providers (9). Today, in modern medicine there is often no place for mistakes. Following the 1999 Institute of Medicine (IOM) report To Err Is Human: Building a Safer Health System, a culture of patient safety developed, with an emphasis on avoidance of system failures, including use of technology, safe practices, procedures, and policies, all of which combine to form an "organizational culture". Despite the often-heard "doctors are only human", innovations such as precise laboratory and diagnostic testing have created expectations of near perfection from clinicians by patients, and at times, hospitals (8). When errors or harm occurs, clinicians can experience shame, guilt, and a sense of failure. Moreover, they are discouraged from talking about these events, for fear of litigation, yet they want open discussion with colleagues about medical errors as part of a hospital culture, to feel supported and work through powerful personal emotions (10).

In 1984, David Hilfiker, MD published in the New England Journal of Medicine, the following, describing the perils of medical mistakes on the clinician, medicine as a profession, and society: "The drastic consequences of our mistakes, the repeated opportunities to make them, the uncertainty about our own culpability when results are poor, and the medical and societal denial that mistakes must happen all results in an intolerable paradox for the physician. We see the horror of our own mistakes, yet, we are given no permission to deal with their enormous impact....The medical profession simply has no place for its mistake" (11)(12). Clearly medical mistakes do occur, and healthcare professionals are emotionally affected. Unfortunately, the support and sympathy needed to deal with these mistakes are often lacking. At best, one can hope for a lack of public criticism or judging. Clinicians feel singled out, agonize over the event, and replay it many times in their mind; they question their level of competency. Lacking the ability or mechanism to deal with the error, they often develop dysfunctional responses as a mean to protect themselves.

Guilt and Shame

Guilt and shame typically are the primary feelings that should be recognized and addressed during, and following liability litigation. Deep shame and a reduced sense of self-worth may be felt in response to litigation because of a fear of public exposure. Anxiety is the usual reaction to these threats to one's integrity, self-confidence, and well-being. Whether consciously experienced or not, depressive reactions and a sense of diminished self-worth commonly follow guilt. When a lawsuit is completely unexpected, its effect may be traumatic, resulting in shock and numbness, alternating with a hyper-arousal state, including sleeplessness and tension. An institution's rapid intervention to emotionally support clinicians may offer sufficient help to healthcare providers involved in adverse events; however, the grinding, drawn-out repercussions of a prolonged lawsuit frequently require more extensive support, including professional mental health resources (13). Clinicians feel singled out, agonize over the event, and replay it many times in their mind -- they question their level of competency. Lacking the ability or mechanisms to deal with the error, they often develop dysfunctional responses as a mean to protect themselves.

First, consider that making an error that harms a patient can be the greatest distress for clinicians in their professional careers. Feelings of failure and fear of disciplinary actions and malpractice allegations may result in shame, grief and guilt. This can affect subsequent patient care. As young clinicians who perceive they have made medical errors in the past demonstrate less empathy and feelings. They are then at greater risk for subsequent errors. Those who are depressed are two-times more likely to make additional errors (14). Guilt is usually associated with a particular event, while shame reflects a failure of one's entire self. Guilt prompts a person to make amends, while shame prompts a desire to hide. Confession, restitution, and absolution are means to deal with feeling of guilt. However, a confession is often discouraged for fear of litigation or simply because no appropriate forums exist to confess (i.e. to discuss the events) (15). Morbidity and mortality conferences often focus on "who did what incorrectly" and "who missed what" with a resultant name, blame and shame scenario. This type of setting offers no assistance for clinicians to deal with errors and makes no acknowledgment that often the healthcare system itself contributes to the medical error for which the professional is harboring shame or guilt.

Studies over the past 4 decades have shown that physicians die by suicide more frequently than non-physicians (31). Because of this striking finding, experts with knowledge and experience in areas including medicine, health insurance, and physician licensing recently convened to address factors in the profession that can discourage physicians experiencing depression and other psychiatric conditions from seeking treatment. Many medical licensing applications include questions that ask about the physical health, mental health, and substance use of applicants. Some licensing boards undertake investigations if physicians seek treatment, which can lead to sanctions irrespective of whether there is any evidence of impaired functioning. The idea that physicians fear damaging their careers or putting their medical license in jeopardy if they seek treatment for such problems is gradually receiving increased attention by published reports, and underscores an important consequence of stigmatism with respect to physician ill health. The culture of the medical profession has been recognized as a key factor that might deter physicians from taking care of themselves.

With well-documented effects of medical error on health care professionals (attendings, nurses, and residents), what are the interventions to help deal with personal and professional impact of medical errors? How can escalation of the "second victim" be prevented or minimized? Because physicians may be reluctant to reach out, if you see a colleague who appears to be under stress, take the initiative and talk to them about what you can do to help. Informal interventions from concerned friends, family or work colleagues can often be successful if the approach is empathetic and supportive, and advice and encouragement is provided in a non-threatening, confidential manner. Being open to feedback is a good step in addressing the problems. In some cases, a more structured approach by an objective third party may be helpful. These interventions are best conducted by individuals who have the necessary skill set and training to guide the discussion toward a successful outcome. Typically, they may take on more of a coaching posture with a goal toward addressing physician-specific concerns. These sessions can and should be conducted in a confidential manner and provided in a setting that is both convenient and comfortable.

Identifiable Stages in "Second Victim" Stages

Healthcare professional involved in medical errors often times are greatly affected both emotionally and personally. Feelings of isolation, shame, guilt, anger, loss and depression are all possible responses. Research shows that nearly all physicians who are sued experience emotional distress that can go on throughout the litigation process. Most physicians experience: initial shock and denial; anger; anxiety about the professional and financial impact of the case; feelings of loss of control; frustration; difficulty concentrating; insomnia; major depressive disorder; adjustment disorder and new physical illness or recurrence or exacerbation of previous illness. To best understand and ultimately assist clinicians involved in medical errors, one must understand the phenomena of the second victim and the associated stages. As described in 2009 by a University of Missouri study, there are 6 predictable and identifiable stages in the second victim phenomena (16). These are summarized below:

Second Victim Stages

StageNameFeatures
1ChaosError realized and recognized, how and why did this happen, care for the patient
2Intrusive reflectionsRe-evaluate event with haunted re-enactments, self isolation
3Restoring personal integrityManaging gossip, questioning trust, fear
4Enduring the inquisitionRealization of seriousness, wonder about repercussions, who can I talk to
5Obtaining emotional first aidSeeking personal and professional support, where can I turn to for help
6

6a
Moving on

Dropping out
One of the following:

Changing professional role, leaving profession or new practice location
6bSurvivingCoping, continue plagued by event but performing at expected level
6cThrivingGains insight and perspective into error, learns from event, and not focused solely on the error

It is key to recognize these steps, even if our colleagues are not self-aware of them. Claims managers and defence attorneys often advise physicians not to speak to anyone regarding any aspect of a medical liability case. Nevertheless, physicians need to express their emotional responses to being sued. Literal adherence to the advice to speak to no one can result in isolation, increased stress, and dysfunctional behavior. Such behavior may jeopardize family and work relationships. The ability to function professionally and to represent oneself appropriately and effectively during pre-trial discovery and trial also may be adversely affected. Thus, physicians are encouraged to inform family members of the lawsuit, the allegations, the potential for publicity, and any expected testimony, while maintaining confidentiality about the specifics of the case. Children should be told about the lawsuit and their questions honestly answered, commensurate with their age and ability to understand the information. Open communication with family members will assist in reducing emotional isolation and self-blame (17).

Institutional Support and Peer Solidarity

Why does one physician thrive in his or her career while another experience stress? The answer lay in part in being able to manage and recover from adversity. Resilience meant rising to challenges, responding creatively, learning and growing. Clinicians often bear the burden of medical errors in isolation. Institutional mechanisms must be developed and utilized to help healthcare professionals deal with the impact of medical errors. While often counseled not to discuss the case or events, confidential venues must be established to deal with the personal impact of the error. The critical need is for acknowledgment, recognition, and intervention to assist the clinician in coping with medical error to minimize the second victim role and actively prevent any tragedies (18). Also physicians are required to disclose medical errors to patients. This requirement and the ethical issue of disclosure can also assist the clinician in dealing with the error. Therefore, it is imperative that they are trained and comfortable in the process of disclosure of medical errors and anticipated options (18). Disclosure is component of coping strategies for the second victim.

Department leaders, section chiefs, and residency program directors need to pay special attention to the format and environment on morbidity and mortality reviews. Is there an added focus on what can be done from a system (not individual standpoint) to prevent recurrences? Is there public acknowledgment as reference to the error impact on the healthcare team or individual professional? For these to occur, the leaders must implement these forward changes. The first step is a general acknowledgment within the medical profession that medical errors are inevitable. Further, clinicians need to be trained in managing these errors both for their patients and for self-perspectives (19). We can also recognize and verbalize our understanding of the impact of errors on our colleagues. Asking about the emotional impact of the mistake and how they are coping is also helpful. Sharing personal experiences with medical errors and successful coping strategies can help reduce a colleague's sense of isolation. An institution's rapid intervention to emotionally support clinicians may offer sufficient help to healthcare providers involved in adverse events; however, the grinding, drawn-out repercussions of a prolonged lawsuit frequently require more extensive support, including professional mental health resources.

Despite the anxiety and stress caused by the demands of the litigation process, the opportunity for critical learning and professional development to facilitate dealing with future adverse outcomes should not be overlooked. By maintaining honest, collaborative, caring communication with patients, physicians may prevent a breakdown in the physician-patient relationship, which frequently contributes to litigation (20). Moreover, within the context of a patient-centered risk management program, disclosure, apology, and when appropriate, offers of restitution may result in diminished litigation and associated litigation-related stress (21). In coping with medical error, it may be necessary for some physicians to develop a more realistic, less idealized, and more forgiving sense of personal identity, competence, and self-confidence. Errors in decision making cannot be avoided throughout one's career. One of the healthiest responses is recognition of the error and the development of a plan to decrease the likelihood of future similar occurrences. This activity often provides comfort and healing to the physician (22).

Also, physicians are required to disclose medical errors to patients. This requirement and the ethical issue of disclosure can also assist the clinician in dealing with the error. Therefore, it is imperative that healthcare providers are trained and comfortable in the process of disclosure of medical errors and anticipated options. Disclosure is a component of coping strategies for the second victim. The Second Victim Coping Strategies are summarized below (11):

  1. Responsibility accepted;
  2. Discussions with colleagues;
  3. Patient disclosure and apology;
  4. Analysis and evaluation of error;
  5. Practice adaptations to reduce repeat errors;
  6. Advocate for medical error cultural change in medical profession.

Approach to Stress Management

As physicians, we may recognize the more obvious physical symptoms of stress such as chest pain, palpitations, headaches, muscle pains, panic/anxiety attacks and gastro-intestinal (GI) distress. However, we may not recognize the more subtle symptoms such as irritability, mood swings, apathy, loss of focus, sleep disturbance, isolation and just an overall sense of not being happy. The following steps give an overview to consider in dealing with stress. The first step is recognition and awareness. It is hard to self-diagnose, and since physicians work under stress most of time, it rarely registers. However, there are different tactics that we can take to help ourselves, and also resources available which can provide assistance in understanding the impact stress is having on our lives -- and addressing it effectively and constructively.

  1. Become aware that stress exists;
  2. Recognize its impact on self and others;
  3. Address barriers and resistance to seeking support;
  4. Identify self-help strategies;
  5. Explore lifestyle management:
    • Relaxation,
      • Proper nutrition, exercise, sleep and habit control,
      • Time management,
      • Work-life balance,
  6. Seek coaching and mentoring;
  7. Accept supportive intervention;
  8. Work on stress management;
  9. Explore conflict management or sensitivity training programs;
  10. Seek counseling.

Recognition and Support

Once we recognize that we are under stress, the customary default position is that we can handle it ourselves. We have lived with stress all our lives and feel like we can manage it on our own. Physicians are reluctant to share their inner emotional concerns, and admitting that they are under stress is often self-perceived as being a blow to our egos. Discussing it with someone else also opens up concerns about how others might view our competence and ability to perform. The following are the signs of stress:

  1. Physical symptoms: anxiety or panic attacks; chest pain or palpitations; headaches; muscle aches; fatigue; GI distress.
  2. Psychological symptoms: irritability, agitation and/or impatience; mood change; sense of being overwhelmed; difficulty concentrating; inability to relax; impaired work quality, efficiency and productivity; depression.

The lists of external and internal barriers that may influence our behavior as physicians to seek help are listed below. Many of these attributes are as a result of attitudes and lifestyles perpetuated by the medical training process. We need to remind ourselves that we are not invincible, nor immune to the pressures of the surrounding environment.

  1. Training: technology and knowledge vs. people skills; autonomy and self-reliance; self-sacrificing.
  2. Psychology: denial; egocentricity; drive for perfection; repressed feelings and detached concern; receptivity.
  3. Environment: complexity; accountability; time pressures and over-extension; reimbursement; liability.

The question is -- who is going to tell us? It is a sensitive issue. Most physicians will not readily seek assistance and become resistant to someone who interferes. Depending on the organization you work for, many of the services for stress management may be offered through Human Resources, a Physician Wellness Committee, or a physician-focused Employee Assistance Program that can offer trained physician peer coaches. In most cases, early intervention process does the job. Identifying those at risk, and working with them early on in the process has a greater chance for success than post-event crisis intervention, which usually takes on more of a negative approach.

Programs Run by Healthcare Organizations to Improve Physician Wellness

In the USA, the Joint Commission Accreditation for hospitals mandates that the medical staff "implement a process to identify and manage matters of individual health for licensed independent practitioners which is separate from actions taken for disciplinary purposes" (23). The organization also offers educational materials for dealing with issues such as the disruptive health professional. Obstetricians and gynecologists should recognize that being a defendant in a medical professional liability lawsuit can be one of life's most stressful experiences. Negative emotions in response to a lawsuit are normal and physicians may need help from professionals or peers to cope with this stress. Residents, as young physicians in training, may be particularly vulnerable to the psychologic and emotional upheaval that often occurs when named in the medical liability claim. State or local medical societies and medical liability insurance carriers often sponsor support groups for defendant physicians and their families. Support mechanisms for residents also may be available through residency program directors, department chairs, departments of risk management or mentors (24). In the absence of such services, individual professional counseling can be of great benefit. Rapid intervention facilitates healthier coping strategies and can restore a sense of equilibrium and self-esteem during an unpredictable time.

One program that warrants attention for its effort to assist clinicians dealing with medical errors is the University of Missouri Health System (UMHS) "Second Victim -- forYOU Team" (25). Since 2007, the forYOU Team has provided "emotional first" interventions to help healthcare providers during difficult times surrounding unanticipated outcomes. This team is available to all UMHS staff and is confidential. Members of the team are not counselors but peers with supportive and good listening skills. Conversations focus not only the actual event of event details but on the second victim's emotional response. This program eliminates or greatly diminishes the potential for clinician isolation, while at the same time providing access to confidential "confessor" figure. Because forYOU Team members are peers and not counselors, second victims may more easily relate to them clinically, while avoiding a potential stigma of "seeing a counselor". The goals of the forYOU Team are to explore the natural history of second victim suffering and recovery by interviewing previously traumatized clinicians. Further, they seek to create a general awareness about the second victim concept and provide education and supportive approaches for effective healing and restoration. Additionally, to provide "emotional first aid," there is an internal rapid response team of formally trained peers who can be dispatched immediately, if needed.

In UK, the National Clinical Assessment Service aims to "help to clarify the performance concerns [of physicians], understand what is leading to them and support their resolution in order to, where possible, restore safe and valued practice" (3). The organization offers online resource materials such as access to the Practitioner Health Program that provides a free confidential service for physicians who have mental or physical health concerns or addictions. The UK's National Institute for Health and Clinical Excellence (NICE) released guidance on Nov 5, 2009 for employers about promoting mental wellbeing by the provision of productive and healthy workplaces (4). Such workplaces, obviously, include hospitals and clinics. NICE recommends the adoption of an approach to promote mental wellbeing, putting in place a system to monitor such wellbeing, and the provision of flexible working. The guidance recognizes that work has an important part to play in the promotion of mental wellbeing, and that having a workforce that is mentally well, will lead to economic benefits for the organization, by increasing job commitment and satisfaction and staff retention, raising productivity, and reducing absenteeism. This also discusses the practical perspective of physicians' wellness in terms of health-systems performance and quality, and how physicians' wellness should become a quality indicator. Wallace and colleagues posit a model of interventions to improve physicians' wellness, which includes awareness in the workplace and prevention, and treatment and recovery for unwell physicians (23). It is very expensive to train a physician, and it is perhaps ironic that NICE's cost-effectiveness approach might be the one to bring about change. Keeping physicians well and fit for work can only be a win-win situation.

The Canadian Medical Association has a dedicated center for physician health and wellbeing, and every provincial medical association within Canada has a physician wellness portfolio. In addition to providing support to distressed physicians and their families, the Alberta Medical Association Physician and Family Support Program is engaged in several wellness educational activities, such as promotion of adequate sleep and workplace nutrition, and support for dealing with adverse events, complaints, and medical legal litigation.

Physician Wellness as an Indicator of Health-System Quality

In view of the effect of suboptimum physician wellness on health systems, measurement of provider wellness as a health-system quality indicator could be highly beneficial. For effective improvement in health-system quality and performance, however, quality indicators need to be both measurable and actionable (26). We need valid and reliable methods to measure healthcare provider wellness as an indicator of health-system quality, and evidence about how best to intervene if suboptimum system performance is identified. Fortunately, physician wellness is measurable. Despite methodological challenges, existing instruments can assess physician wellness at a system level. For example, Arnetz (27) used a standardized questionnaire -- the quality of work competence survey -- to assess ten core components of organizational and staff wellbeing that included mental energy, work climate, work tempo, work-related exhaustion, skills development, organizational efficacy, and leadership. From these components, he computed an overall weighted score that represented a global, composite measure of the overall health of the organization. Arnetz (27) suggests that subjective indicators from employees can be used to gauge and improve organizational performance and wellness. He argues that improvement of physician wellness can improve the organization's wellbeing and health, and that physician wellness should receive the same priority as patient care and financial viability. That is, individual physician wellness is a valid indicator for organizational health.

Measures of physician wellness also seem to be actionable in situations of suboptimum physician wellness, and effective interventions have been implemented (28). Three interventions were introduced to a primary care group consisting of six sites and 32 physicians. The interventions were designed to enhance physicians' control over their work environment, improve efficiency in office design and quality of staff, and contribute to a sense of satisfaction and meaning derived from patient care. The results showed clinically and statistically significant decreases in emotional and work-related exhaustion -- key indicators of burnout during the study, and other improvements in physician wellbeing were noted. In a study of stressed physicians to assess the effect of a counseling intervention on burnout, RÝ and colleagues (29) showed clinically and statistically significant reductions in emotional exhaustion and sick leave at 1-year follow-up in the 185 physicians who completed the study. Although interventions could improve physician wellness, very little research has directly examined the effect of such interventions on patient care or health-system performance. Although much is known about physician distress and the negative effect on patient care, little is known about whether interventions directed at physician wellness will also improve patient care (30). However, study did suggest that stress management interventions could be beneficial to both physicians and their patients. They showed a strong relation between a stressful workplace and malpractice risk in both medical departments and hospitals. Furthermore, they recorded significant reductions in medication errors and malpractice claims after introduction of stress-management programs to 22 hospitals; by contrast, rates for the 22 hospitals in the control group (matched on bed numbers, frequency of claims, and rural vs. urban) remained unchanged. Nevertheless, further research is needed to explore how interventions designed to improve physician wellness are also beneficial to patients and the organizations that support such interventions. Studies that identify both individual and organizational wellness interventions and that assess the effects of such interventions on patient care, efficiency, and productivity, will be important to support both the promotion of wellness programs and the inclusion of physician wellness as a quality indicator. The figure below proposes a model to show the empirically established links between physician ill health described above, and the potential interventions that could improve physician and system outcomes (23).

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Fig. 1. A model of physician ill health and the links with health-care system outcomes, and potential interventions to improve physician and system outcomes. Solid lines are empirically supported; broken lines are potential links.
Fig. 1. A model of physician ill health and the links with health-care system outcomes, and potential interventions to improve physician and system outcomes. Solid lines are empirically supported; broken lines are potential links.
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The first step in incorporation of physician wellness as a quality indicator is to promote dialogue among key stakeholders (physician groups, health-system decision makers, payers, and the general public) about the components needed in such a quality-indicator system to best measure physician and organizational wellness, and the interventions needed to improve physician and organizational wellness. Assessment of physician wellness as an indicator of an organization's quality of health care is only the first step. Increased awareness of the importance of physician wellness, both individually and organizationally, is needed by physicians, their patients, and their employers. A shift in the culture of care and wellness of physicians is necessary. If these groups do not recognize the crucial importance of physician wellness, there is little reason to expect that physicians and their employers will invest in taking better care of physicians, or that the public will support and appreciate such efforts. Ultimately, individual physicians will personally benefit from taking better care of themselves. Such efforts would probably lead to increased job satisfaction and overall wellbeing, and reduced likelihood of physicians experiencing an overwhelming sense of stress and burnout. The organizations employing physicians will benefit by having more productive and efficient healthcare providers in conjunction with reduced absenteeism, job turnover, and recruitment and retention issues. And perhaps the patients themselves will benefit by receiving better quality of care.

Summary

Being sued for medical professional liability is a common experience for obstetricians and gynecologists. Even the best, most skilled physicians can be sued. A medical professional liability case presents a crisis for the obstetricians and gynecologists and his or her family. Learn to recognize the symptoms of stress, develop coping strategies, and seek the help you need. As an obstetrician and gynecologist, you must be prepared for the probability that you will be sued. The stress resulting from a medical liability case can have a negative effect on your personal and professional life, and your ability to defend yourself against the charge. When physicians are unwell, the performance of healthcare systems can be suboptimum. Physician wellness might not only benefit the individual physician, it could also be vital to the delivery of high-quality health care. There are the work stresses faced by physicians, the barriers to attending to wellness, and the consequences of unwell physicians to the individual and to healthcare systems. The health systems should routinely measure physician wellness, and discuss the challenges associated with implementation. Healthcare professional involved in medical errors often times are greatly affected both emotionally and personally. Feelings of isolation, shame, guilt, anger, loss of confidence, loss of empathy, and depression are all possible responses. It is important to take action. Physicians are a precious resource and soon to be in short supply. For our own sake, and those of our colleagues, we need to get a better understanding of physician needs, concerns and priorities and be better able and equipped to address the growing stress, frustration and burnout infiltrating our practices. We need to proactively provide physician support services in a positive, supportive, confidential and collegial manner, and provide guidance and assistance in helping physicians adjust to the pressures that are a reality of today's health care environment.

Institutions can help prevent second victims by recognizing the potential impact medical errors can have on clinicians and implementing formal programs to assist them. Emphasis must be placed on confidentiality and immediate emotional first aid response to clinicians. Further, institutions and departments must advocate a culture of support and trust -- not one of the "name, blame, shame" game. To paraphrase the Institute of Medicine, "To err is human: To survive intact is humane". Obstetricians and gynecologists should recognize that being a defendant in a medical professional liability lawsuit can be one of life's most stressful experiences. Negative emotions in response to a lawsuit are normal, and physicians may need help from family members, peers, or professionals to cope with this stress. Open communication will assist in reducing emotional isolation and self-blame. However, pertinent legal and clinical aspects of a case must be kept confidential, except for disclosure within the confines of a protected counselor-patient relationship as determined by state law. We need to make it easy and acceptable for physicians to open up and share. Early intervention through friends, family or colleagues or through more formal physician wellness programs is the preferred choice. Identifying those at risk, and working with them early on in the process has a greater chance for success than post-event crisis intervention, which usually takes on more of a negative approach.

Resources

  1. Physician Litigation Stress Resource Center
    Coping with Litigation Stress
  2. American Medical Association
    Physician Health

Funding: The Women's Health and Education Center (WHEC) with its partners in health, has developed this curriculum which will enable and encourage medical schools and healthcare providers to include patient safety in their courses. The series on Medical Liability is funded by WHEC Initiative for Global Health.

References

  1. Editorial The Lancet. Doctors get ill too. Lancet 2009; 374:1653
  2. Sargent MC, Sotile W, Sotile MO, et al. Stress and coping among orthopedic surgery residents and faculty. J Bone Joint Surg Am 2004;86:1579-1586
  3. Hanson D. Physician suffering from 'silent desperation'. World Medical Association. 2009; Available at: http://www.wma.net/en/40news/20archives/2009/2009_16/index.html Retrieved 22 August 2011
  4. UK's National Confidential Enquiry into Patient Outcome and Death (CEPOD) Nov 5 Report. 2009;Available at: http://www.ncepod.org.uk/2009dah.htm Retrieved 2 July 2011
  5. Stewart DE, Ahmad F, Cheung AM, et al. Women physicians and stress. J Women Health Gender-Based Med 2000;9:185-190
  6. Thomas N. Resident burnout. J Med Assoc 2004;292:2880-2889
  7. American College of Obstetricians and Gynecologists. Coping with the stress of Medical professional liability litigation. ACOG Committee Opinion No. 406; May 2008
  8. Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ 2000;320:726-727
  9. Jane Austen's World. A triple tragedy: how Princess Charlotte's death in 1817 changed obstetrics. Available at: http://janeaustensworld.wordpress.com/2008/11/22/a-triple-tragedy-how-princess-charlottes-death-in-1817-changed-obstetrics/ Accessed 22 July 2011
  10. Liebman CB, Hyman CS. A mediation skills model to manage disclosure of errors and adverse events to patients. Health Aff (Millwood) 2004;23:22-32
  11. Hilfiker D. Facing our mistakes. N Engl J Med 1984;310:118-122
  12. Goldberg RM, Kuhn G, Andrew LB, et al. Coping with medical mistakes and errors in judgment. Ann Emerg Med 2002;39:287-292
  13. Scott SD, Hirschinger LE, Cox KR, et al. Caring for our own: deploying a system wide second victim rapid response team. Jt Comm J Qual Patient Saf 2010;36:233-240
  14. West CP, Huschka MM, Novotny PJ, et al. Association of perceived medical errors with resident distress and empathy. JAMA 2006;296:1071-1078
  15. Ofri D. Ashamed to admit it: owning up to medical error. Health Aff (Millwood) 2010;29:1549-1551
  16. Scott SD, Hirschinger LE, Cox KR, et al. The natural history of recovery for the healthcare provider 'second victim' after adverse patient events. Qual Saf Health Care 2009;18(5):325-330
  17. Charles SC, Frisch PR. Adverse events, stress, and litigation: a physician's guide. New York (NY): Oxford University Press; 2005
  18. Weiss PM. To err is human -- to air is humane: disclosing adverse events to patients. Obstet Gynecol 2007;62:217-218
  19. Gold KJ, Kuznia AL, Hayward RA. How physicians cope with stillbirth or neonatal death: a national survey of obstetricians. Obstet Gynecol 2008;112:29-34
  20. Beckman HB, Markakis KM, Suchman AL, et al. The doctor-patient relationship and malpractice. Lessons from plaintiff depositions. Arch Intern Med 1994;154:1365-1370
  21. Kachalia A, Kaufman SR, Boothman R, et al. Liability claims and costs before and after implementation of a medical error disclosure program. Ann Intern Med 2010;153:213-221
  22. Helmchen LA, Richards MR, McDonald TB. How does routine disclosure of medical error affect patients' propensity to sue and their assessment of provider quality? Evidence from survey data. Med Care 2010;48:955-961
  23. Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. Lancet 2009;374:1714-1721
  24. ACOG Committee Opinion. Coping with the stress of medical professional liability litigation. Number 497; August 2011
  25. University of Missouri Health System. Second Victim -- forYOU Team. Available at: http://www.muhealth.org/body.cfm?id=1876 Accessed 22 August 2011
  26. Committee on Redesigning Health Insurance Performance Measures. Payment and Performance Improvement Programs, Institute of Medicine of the National Academies. Pathways to quality health care. Performance measurement: accelerating improvement. Washington DC: National Academics Press, 2006
  27. Arnetz BB. Subjective indicators as a gauge for improving organizational well being: an attempt to apply the cognitive activation theory to organizations. Psychoneuroendocrinology 2005;30:1022-1026
  28. Dunn PM, Arnetz BB, Christensent JF, et al. Meeting the imperative to improve physician well being: assessment of an innovative program. J Gen Intern Med 2007;22:1544-1552
  29. Ro KEI, Gude T, Tyssen R, et al. Counseling for burnout in Norwegian doctors: one year cohort study. BMJ 2008;337:a2004
  30. Shanafelt TD, Novotny P, Johnson ME, et al. The well being and personal wellness promotion strategies of medical oncologists in the North Central Cancer Treatment Group. Oncology 2005;86:23-32
  31. Hampton T. Experts address risk of physician suicide. JAMA 2005;294(10):1189-1191

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