By Christopher Guadagnino, Ph.D.
Considerable attention has been paid to methods of eliminating medical errors and enhancing patient safety, which has led to innovative and effective interventions. The flip-side of the issue, however, seems to have been scarcely acknowledged: being involved in a medical error can cause significant emotional distress in a physician, potentially to the detriment of patient care. Being named in a medical malpractice lawsuit can produce devastating emotional disruption of a physician’s professional and personal life.
The problem is more prevalent than one would expect, while adequate support services for physicians are often unavailable, and physicians do not use available services for a variety of personal and professional reasons – according to a study published recently in the Joint Commission Journal on Quality and Patient Safety, which calls fresh attention to this issue with its disturbing findings.
The study, “The Emotional Impact of Medical Errors on Practicing Physicians in the United States and Canada,” surveyed over 3,100 physicians in internal medicine, pediatrics, family medicine and surgery and found that: the vast majority of them (92 percent) were involved in medical errors ranging from near-misses to serious events; half of those physicians experienced job-related stress as a result; a sizable percent experienced anxiety about future errors, loss of confidence, sleeping difficulties and reduced job satisfaction; the majority of those involved in serious events (80 percent) expressed interest in counseling; and very few physicians (10 percent) believed that health care organizations adequately supported them in coping with error-related stress.
Even when support services are available, physicians felt that taking time away from work for counseling was difficult (43 percent), did not believe that counseling would be helpful (35 percent), were concerned that what was said in a counseling session would not be kept confidential if they were sued (35 percent), and were concerned that their counseling history would be placed in their permanent record (34 percent). In addition, 23 percent of physicians were concerned that receiving counseling could affect their malpractice insurance costs, and 18 percent were concerned that they would be judged negatively by their colleagues for receiving counseling.
In the eight years since the Institute of Medicine published To Err is Human: Building a Safer Health System – which spawned the rapidly evolving patient safety movement – innovative approaches to address the personal impacts of medical errors on physicians are only just beginning to emerge, with the goal of removing barriers that experts say impede the use of traditional emotional support resources such as hospital employee assistance programs and counseling services, and litigation stress support services offered by medical liability insurers.
Emerging emotional support models include increasingly sophisticated root cause analysis activities after serious adverse medical events, which include opportunities for candid dialogue among members of a care team; prospective risk management dialogue at the hospital department level; and one-on-one discussions with physician peers who are specially trained to render emotional support in as confidential and risk-free a forum as possible.
Prevalent Problem Inadequately Addressed
Almost every physician has dealt with emotional distress after a medical error and is willing to admit it, while one-third of physicians reported that even near misses that don’t affect the patient had caused anxiety about future errors, professional confidence, job satisfaction and ability to sleep, according to the Joint Commission study’s lead author Amy Waterman, Ph.D., assistant professor of medicine at Washington University School of Medicine in St. Louis, MO.
Disclosing errors to patients does not alleviate physician stress, and may actually be a source of distress, according to Waterman’s findings. Although some proponents of error disclosure believe that disclosure can provide psychological relief for physicians, Waterman says her study found that physicians who were satisfied with their disclosure of a serious error to a patient were no less distressed than physicians who did not disclose – suggesting that emotional support services would be beneficial in either case.
Waterman found that even errors with minimal or no impact on patients have lasting impacts on physicians: physicians felt one and a half times more distressed when they had disclosed a minor error or near miss to their patient than physicians who did not disclose, perhaps because they feel as though they are acknowledging their own shortcomings and face possible loss of patient trust, or a malpractice lawsuit, even if the incident was attributable to system rather than individual error.
“Patients who respond angrily to disclosure add coal to the fire of the physician’s distress,” says Waterman: compared with physicians who had never disclosed an error, physicians who were dissatisfied with how their past serious error disclosure went – albeit a relatively infrequent occurrence – were four times more likely to report stress after serious errors.
Being sued for medical malpractice after an adverse medical event ups the ante dramatically, producing emotional disruption that is sometimes life-changing, writes Sara C. Charles, M.D., professor of clinical psychiatry, University of Illinois – Chicago, who has been researching the impact of medical liability litigation on physicians since the early 1980s. More than 95 percent of physicians react to being sued by experiencing periods of emotional distress during all or portions of the lengthy litigation process, while the suit may generate such an overwhelming degree of stress for physicians that they develop psychological trauma affecting every aspect of their personal and professional lives, according to Charles.
Charles writes that obsessive-compulsive personality features that most physicians demonstrate – including a preoccupation with orderliness, perfectionism, mental and interpersonal control – along with an excessive devotion to work and productivity, make them particularly vulnerable to repeated mental reviews of their role in an adverse event, as well as to a slew of emotionally disruptive feelings when they are sued for medical malpractice, e.g., suppressed anger, depression, anxiety, insomnia and an increased paranoia directed at their patients – as well as a loss of confidence and pride. Physicians often regard a malpractice complaint as an assault on their integrity, while it is especially painful to highly trained and motivated physicians to be accused of having failed to perform competently, according to Charles. Physicians may react to a suit by interacting with patients in a more defensive manner, ordering more tests and consultations, eliminating or avoiding high-risk procedures, and contemplating early retirement, she adds.
While it is good legal advice for counsel to tell a physician not to talk about the details of the case to anyone, it is poor psychological advice, and Charles writes that the single greatest help in any traumatic life event is the availability of other persons who can be understanding and offer support. Suppressing the need to talk about feelings increases a physician’s vulnerability to emotional isolation and the lingering emotional trauma of a lawsuit, writes Charles, and she encourages physicians to talk directly about their personal feelings with a trusted confidant – a spouse, family member, friend or other physician – while restricting discussion of specific details of the case to conversations with legal counsel and claims professionals.
Venues of Emotional Support
Resources designed to help physicians manage stress related to medical errors and litigation exist, although they appear to be rarely used, while new types are being developed that involve specially-trained physician peer counselors to remove utilization barriers.
Traditional venues include litigation stress services offered by medical liability insurers, hospital Employee Assistance Programs (EAPs) which offer counseling and other support services, hospital risk management and root cause analysis teams, and hospital staff psychiatrists. Critics of these venues maintain that few physicians will ever avail themselves of the services because of doubts about their value and confidentiality, and because of personal barriers such as shame, denial and reluctance to appear weak. Some hospitals have begun to integrate emotional support services with their root cause analysis investigation protocols, while some experts believe they should be kept separate.
When the Pennsylvania Medical Society owned PMSLIC, a major private malpractice insurance carrier for physicians, the Society’s Educational and Scientific Trust offered information and support services to physician suffering from litigation stress through its Physicians’ Health Programs. Since the sale of PMSLIC, the program has not been active, and there are no programs actively running via the Medical Society, according to spokesperson Chuck Moran.
PMSLIC offers a litigation support package consisting of a booklet and a DVD/CD that is designed to help insureds understand the litigation process, the initial meeting with counsel, preparation for deposition, and going to trial, says Anna Lavertue, PMSLIC’s director of communications and quality. PMSLIC’s packet has recently added materials from the Physician Litigation Stress Resource Center – www.physicianlitigationstress.org – a nonprofit website founded by physicians, insurance and legal personnel who have extensive experience with physicians coping with the emotional dimension of medical malpractice. The site directs practitioners to articles, books and websites addressing the process of litigation; suggests strategies for coping with the stress of litigation; and lists resources that provide support throughout the ordeal of litigation.
PMSLIC’s claim representatives serve as liaisons between physicians and the court system, and offer a level of emotional support, notes Lavertue. PMSLIC contracts with an outside firm offering confidential counseling services for insureds, although Lavertue believes that a small percent of physicians use that service.
Medical Protective, a major private carrier for physicians in Pa. and NJ, offers a litigation stress management booklet and Web video resource called “Maintaining Your Balance,” which covers emotional issues doctors face when coping with medical errors whether or not a lawsuit has been filed, such as demands put on spouses and colleagues, says Theresa Essick, RN, the company’s vice president of clinical risk management.
Physicians who call Medical Protective about an event that is likely to result in the filing of a lawsuit are urged to report the matter to the company’s claims department, Essick notes. For incidents not reaching that criterion, she adds, Medical Protective provides consultation services of risk management experts who help doctors discuss the incident. These consults help the doctor decide: “How should I handle this?” and “How should I talk with the patient?” while consultants provide additional guidelines and resources such as checklists the doctors can use when deciding how to handle similar situations in the future. Essick points out that doctors sometimes focus more on taking care of their patients than they do of themselves, and Medical Protective encourages doctors to prevent fatigue by getting enough rest and controlling their hours. The company recommends that doctors use quality tools such as root cause analysis, the results of which provide numerous opportunities for personal as well as system improvement.
Essick says physicians rarely use the consultant support services to deal with error-related emotional distress, perhaps because they perceive it as admitting personal weakness. While physicians may hesitate before having a frank discussion of a possible medical error with their medical malpractice insurer, Essick says that these conversations are confidential interactions between the physician and the risk management consultant.
Hospitals also offer support venues for physicians seeking to manage stress after a serious medical error, including individual counselors and root cause analysis protocols.
Joel Schwartz, M.D., chief of psychiatry at Abington Hospital in Montgomery Co., Pa., says he has had a number of physicians over the years come to him, some referred by the chief of the medical staff or by department chairs, to discuss ways in which medical errors, near misses and malpractice lawsuits were affecting them. Physicians have reported feeling guilty, responsible, irritable, anxious, depressed, or having difficulty sleeping or eating, he notes. Schwartz believes that these feelings affect many more physicians than he sees and, although he says he has established a reputation of being receptive and available to discuss stress-related problems and questions, he estimates he has met with less than one percent of Abington’s medical staff over such issues.
Schwartz says it takes a lot of courage for a physician to seek counseling, and to overcome embarrassment or fear of stigma that they may be deemed defective or unable to cope. Notices put in the hospital’s medical staff bulletin inviting stressed physicians to form a peer discussion group produced no response, he notes. “Outside of having a service available, and making service providers kind, respectful and competent, I don’t know any other way” to overcome obstacles to utilization, adds Schwartz.
“For a long time, we focused on the patient. Now, we have come to see that medical errors do have impact on physicians, and resources are only now beginning to be developed” that are optimally tailored for physicians, according to Diane Pinakiewicz, MBA, president of the National Patient Safety Foundation. Many hospitals have begun to recognize that it is inevitable that something will go wrong, that there is a teachable art and science to effective medical error disclosure, that physicians should be trained in it prospectively rather than waiting for an event to occur, and that some sort of post-disclosure emotional support mechanism for physicians should be available, says Pinakiewicz. “We’ve only begin to add that last feature to serious event risk management protocols,” she notes.
Some hospitals are beginning to link medical error disclosure policies with educational and emotional support services. Risk management teams at Geisinger Health System provide just-in-time coaching for physicians after serious events on how apologize, communicate their concern, explain the steps that will be taken to prevent the error’s occurrence in the future, and avoid liability issues, explains Bruce Hamory, M.D., Geisinger’s chief medical officer. If an incident proceeds to litigation, Geisinger strongly encourages its physicians to seek its psychological support services, which includes physician peer counseling. Because physician-to-physician conversations are potentially discoverable in lawsuit proceedings, psychological peer support avoids focusing on the facts of a medical incident, while allowing physicians to discuss their emotions and reactions to it, Hamory adds.
Only 18 percent of physicians in Waterman’s survey had received education or training on disclosing errors to patients, while 86 percent were somewhat or very interested in receiving it. To lessen the chance of disclosure going poorly, Waterman suggests that patient safety specialists and risk managers be present when disclosure occurs to respond to patient questions, debrief with the physician afterwards, and provide professional reaffirmation and support for the physicians.
Since only 10 percent of physicians in Waterman’s survey agreed that health care organizations adequately supported them in coping with error-related stress, and more than 80 percent expressed interest in counseling after serious errors, Waterman suggests that hospitals and other health care organizations consider broadening their array of formal and informal sources of error-related emotional support to physicians during and after work hours, including opening hospital EAPs to private practice physicians on the medical staff.
Waterman’s health system – BJC HealthCare, which includes 13 hospitals in the greater St. Louis, southern Illinois and mid-Missouri regions – has implemented a “Support our Staff” program, administered through its EAP, which supports health professionals involved in medical errors in several ways, including counselors leading a group debriefing to normalize staff’s reactions to a medical error incident, sharing feelings and assessing the error’s emotional and physical impact on staff, according to Waterman. A health professional could also call EAP directly after being involved in an error, while those needing additional support are offered no-cost telephone or in-person counseling sessions with the therapist involved in the debriefing, and the counselor recommends that the health professional return after the root cause analysis to process what happened. Waterman maintains that discussion with a counselor beforehand about what will happen during a root cause analysis – the purpose for the probing questions, and how not to take it personally – can help staff cope and communicate more clearly during the process. Professionals using these services have reported that they felt less alone after an error and more prepared for the root cause analysis, she notes.
“We need to normalize the idea that stress is normal,” says Waterman, and she believes that physicians could be encouraged to seek counseling after errors by assuring them that therapeutic conversations are generally protected from discovery in the event of a lawsuit.
Some hospitals have begun to incorporate more extensive emotional support opportunities for caregivers into their root cause analysis investigations of medical errors – a practice that some say mistakenly tries to integrate processes with disparate goals.
During root cause analysis of serious events, Harrisburg, Pa.’s Pinnacle Health System tries to create a non-punitive setting for the involved physician to speak freely about the incident, encourages a department chair or section chief in the same or related specialty to offer one-on-one collegial counseling, and offers professional counselors for physicians to talk through their emotions about it, according to Dana Kellis, M.D., Pinnacle’s chief medical officer.
Peer counseling groups built and promoted credibly by front-line practicing physicians themselves represents perhaps the newest model of emotional support for physicians, and is being championed by the Medically Induced Trauma Support Services (MITSS), Inc. a non-profit organization founded in June of 2002 by Linda Kenney, who as a patient in 1999 almost died from a medical error. The organization’s mission is “to support healing and restore hope to patients, families and clinicians who have been affected by an adverse medical event.” MITSS regards medically induced trauma as an unexpected outcome that occurs during medical and/or surgical care that affects the emotional well being of patients, family members and clinicians. Kenney spoke on the subject at the Hospital & Healthsystem Association of Pennsylvania’s Patient Safety Symposium this year.
“If you feel invulnerable to making mistakes, you’ve not been supported by your professional enculturation. It is hard to develop a program that is going to rely on a culture change to be effective,” given the difficulty that physicians have after a medical error to cross the barrier of public shame and come forward and say, “this is hurting me,” according to Jo Shapiro, M.D., chief of otolaryngology at Brigham and Women’s Hospital in Boston, who spoke about that issue at the National Patient Safety Foundation’s annual Congress last year.
Shapiro and some of her colleagues received peer counselor training in handling emotional stress brought on by adverse medical events, and launched a peer support team pilot project for Brigham and Women’s anesthesiologists and surgeons two years ago, she says. The team is composed of faculty physicians, residents, risk managers, chaplains, social workers and psychiatrists specially trained in peer support around adverse medical events. Brigham and Women’s hopes to roll out peer support teams for its emergency department, ob/gyn department and neonatal intensive care unit, and Shapiro is studying the program’s impact on physicians’ and residents’ perceived barriers to seeking emotional support after a medical error.
A key barrier to pursuing support services after a serious medical event, particularly among residents, is perceived lack of time, and Shapiro’s support team is examining ways of overcoming it. One approach, she says, might be proactively calling physicians and residents after a serious error to ask if they are okay, rather than waiting for physicians to seek out the peer support team. Peers would call peers, and everyone would receive a call to make the outreach less personally threatening, notes Shapiro. “We think, for physicians, it has to be a private, one-on-one discussion, preferably among physicians in the same specialty,” says Shapiro. Outreach for the program will grow as physicians in more departments are trained for the support team, allowing better matching of the event to the right peer resource, she adds.
“We absolutely separate this from root cause analysis – the purpose of which is not to help the physician, but to identify system changes to prevent an error’s recurrence,” says Shapiro. “Our approach is that it doesn’t matter who did what. We’re only here to help,” she says, adding that the head of risk management is satisfied that liability risk is not a factor if the peer support team focuses on emotional impacts – and not on root cause issues – in their discussions with physicians.