Originally published in the CanMEDS Physician Health Guide, Royal College of Physicians and Surgeons of Canada, 2009.
Every physician in Canada is likely to be affected by a medico-legal issue at some point over the course of his or her career. Approximately two percent of physicians are named in a legal action each year. Far more are involved in a variety of other medico-legal difficulties. Patients or other parties may complain about a physician to a regulatory authority (college), hospital or privacy commissioner or to the Human Rights Commission. Physicians may be referred for college disciplinary hearings or have their practice reviewed. Hospital disputes and conflicts can involve doctors. On occasion, criminal accusations are lodged against a physician.
During a busy day, John, a family physician, is served with a statement of claim. The legal claim is made by the family of a 59-year-old woman, a patient John had seen and discharged, who dies of a myocardial infarct later the same day. John scans the document quickly but has to get back to work. He has difficulty completing the shift and experiences feelings of insecurity bordering on panic. Although he believes his family will be supportive, he is ashamed to tell them about the legal action and the mistakes he presumes to have made in the case.
Medico-legal difficulties are stressful for physicians for several reasons. In some cases, the problem arises from a clinical outcome that is unexpected and even disastrous to the patient. It is normal for a doctor to feel distressed when a patient dies unexpectedly or suffers a serious complication. Physicians experience empathy and sorrow for the patient and family when a tragic clinical outcome occurs. Sometimes sorrow becomes mixed with guilt. Doctors may beat up on themselves and wonder, in hindsight, whether they should have done something differently to avert the poor outcome. They may be tormented by doubts and second thoughts, even if their management of the case, viewed prospectively, had appeared reasonable at the time.
Physicians invest inordinate amounts of time and energy in their work, and their self-image is often centered on their status as a physician. Legal allegations and patient complaints frequently depict doctors as callous, negligent, or incompetent; physicians may feel this is direct assault on their essence as a person. In the face of an adverse event, complaint or legal action, physicians often harbour visions of disastrous personal consequences, such as the loss of reputation, desertion by patients, suspension of hospital privileges or revocation of their medical licence. They may also dread the possibility of media coverage of the clinical event, their trial, or college hearing.
Physicians' reactions to medico-legal difficulties
- loss of self-esteem
- social isolation from friends and family
- lack of knowledge of legal/regulatory process
- perceived or real lack of hospital/collegial support
- potential for media exposure
Physicians are also susceptible to feelings of isolation during difficult moments in their career. Heavy workloads can make it hard to maintain a social network of friends and colleagues with whom they can commiserate and share experiences. They may also feel shame and embarrassment about presumed medical errors. Many strive for perfection; viewing an adverse event as a failure, they may be inclined to keep the matter from their colleagues.
Although it is impossible to erase a physician's sadness and regret associated with a poor patient outcome, feelings of guilt, inadequacy or fear can be greatly attenuated by keeping the matter in perspective. Physicians may be consoled by the following facts and observations.
A poor patient outcome, even if unexpected, does not signify that a medical error has occurred. A delayed or missed diagnosis or a surgical complication does not equate with negligence. In law, a doctor is not expected to be perfect. Canadian courts have determined that the clinical standard of care by which a claim is judged is not one of perfection, but rather one that might reasonably be expected from a normal, prudent health care provider of similar training and experience in similar circumstances.
Sometimes, however, physicians involved in a medico-legal issue have made a mistake, such as diagnostic, management or technical error, or failure to notice or act on a laboratory or imaging result.
Although physicians strive for excellence, it is helpful to accept the fact of every clinician's fallibility. Doctors are human, and no one is perfect. In spite of a deep commitment to patient care and the best intentions, poor outcomes may, unfortunately, be related to health care delivery itself.
Doctors often work in suboptimal conditions; they may be overloaded with work and may suffer from fatigue or sleep deprivation. A physician may loath to use fatigue as an excuse for a poor outcome, but the reality is that fatigue and other system and organizational issues often contribute to the occurrence of adverse events.
All colleagues and most patients are aware that any physician event the most competent and knowledgeable among them, may encounter a medico-legal difficulty at one time or another. It is unusual for a patient to leave a physician's practice because of another patient's complaint or legal action. Colleagues, patients, other health professionals, family and friends are appreciative of a physician who is caring, conscientious and committed to his or her work. Their appreciation and support of the physician are rarely affected by a medico-legal difficulty.
Physicians' worries about the effect of a lawsuit or patient complaint on their career are often exaggerated. However, even when a medico-legal problem is reported in the media, in most cases it is quickly forgotten by all but the parties involved.
There is, of course, no magic remedy for the regret and sadness experienced by physicians about poor patient outcomes; these are burdens that all physicians carry, and are never forgotten.
Managing the stress
Physicians should not be ashamed to seek help when facing a medico-legal difficulty. CMPA members who receive a statement of claim or college complaint should call the Association right away. Medical officers at the CMPA are sensitive to the stresses engendered by an adverse event and medico-legal difficulties, and are pleased to listen to and support members suffering from uncertainty and worry. Medical officers and/or CMPA legal counsel will explain the legal process to the member. Knowing what to expect allows the doctor to prepare and feel more in control, which usually diminishes anxiety. The stages of a legal action in Canada and strategies for coping with the stress involved are also described here, under "Legal proceedings".
Nor should physicians feel inhibited from consulting their own family physician, who will usually understand and empathize with the feelings of a physician/patient grappling with a medico-legal problem. Friends, colleagues and family are also usually understanding and supportive. However, the specifics of the case should be discussed only with the CMPA medical officer or with the CMPA lawyer if the matter has been referred to counsel, so as to maintain legal privilege.
Provincial and university- or community-based physician health programs are available to provide support and assistance to physicians going through difficult moments.
Most physicians do cope reasonably well with adverse events and medico-legal issues. Many come to realize that a medico-legal difficulty is not the cataclysmic event they may have imagined. A medico-legal difficulty may induce a physician to appraise his/her practice and lifestyle and to implement constructive changes. Doctors should endeavour to achieve a satisfying work-life balance, and if a phase of practice becomes particularly stressful they may wish to modify their practice to allow for more time to invest in and take care of themselves. They should not self-medicate or use substances or alcohol to alleviate stress. It can also be helpful to engage the services of a coach, counselor or therapist to help them approach and process the complexity of issues being faced.
Positive practice changes can enhance patient safety, but physicians should also avoid the urge to practice overly defensive medicine with excessive and clinically unwarranted investigations. Above all, physicians should strive to do their best, to be thorough and conscientious, and to realize that perfection is unattainable.
John's spouse is also a family physician and is unwavering in her support during the legal process. Kind words from colleagues and patients help to restore John's confidence in himself and the system. He institutes some changes in his approach to certain patient complaints and regains a sense of work satisfaction.
Delbanco T and SK Bell. 2007. Guilty, afraid, and alone – Struggling with medical error. New England Journal of Medicine. 357 (17): 1682-3.