December 2004 Bulletin

The Liability Stress Syndrome

Litigation takes an emotional toll

By Frank B. Kelly, MD and Mark C. Gebhardt, MD

Most practicing orthopaedic surgeons will, at sometime, be named in a medical liability lawsuit. The financial burdens, including time away from practice while preparing for and defending against such a suit, are formidable. But the biggest cost is the emotional injury experienced by the accused physician, who may have done the best possible for the patient under difficult circumstances.

Although any legal dispute is stressful, an alleged medical liability suit can be especially traumatic for a physician. From our years in medical school (and often even well before then), physicians want to help others. We do not imagine that our medical careers might be jeopardized if the results of a treatment are less than perfect.

Certainly malpractice does occur, and it is incumbent on us to deal fairly with a patient who has been wronged or a colleague who is not practicing up to standards. But, more and more, the public is expecting perfection. The line between an unfortunate outcome and perceived malpractice is blurring. Many patients believe that a less-than-perfect result justifies a lawsuit; “someone (besides the patient) needs to be held accountable.”

That “someone” is usually the treating physician. A liability suit is filed and the physician is soon consumed by the emotional agony of the litigation process: “the liability stress syndrome.”

Emotional ramifications

Although many malpractice claims are found meritless, some of these lawsuits may not be dismissed for several years. For the physician, the emotional injury has already been inflicted; the associated stress may well have permanent ramifications.

Careful attention to professionalism, communication skills and continued medical education are expected from a Board-certified orthopaedic surgeon. They lead to safe, effective and appropriate care. These measures also decrease the risk of a medical liability lawsuit. Establishing proper rapport with a patient and the family, being forthright and honest if mistakes do occur, closely following those patients who do have complications—all of these approaches can lessen one’s exposure to litigation. Unfortunately, even if these recommendations are followed, a patient may still file a claim.

It is obviously devastating for the patient when things go wrong despite the physician’s best efforts. Physicians should be supportive when care in which we have been involved goes awry, irrespective of whether we have any fault or causation in the event. We owe it to our patients to remain involved, to be supportive and understanding and to take whatever steps are necessary to treat the complication.

Someone who has not been the subject of a lawsuit may find it difficult to appreciate the emotional effects of such a suit on a caring, concerned physician and that physician’s family. We’ve spent our lives doing the best we can to treat our patients properly; now someone is telling us that we don’t really care whether our patients get well or not. Most physicians who have been sued will list the suit as the single most stressful experience of their lives.

Symptoms of stress

As litigation proceeds, the symptoms of “liability stress syndrome” may appear. Profound feelings of bitterness, anger, distrust and depression are common. Insomnia can be a major symptom; the suit is never far from the physician’s thoughts.

A lawsuit can drain away the joy of being a physician. Some doctors will withdraw from the practice of medicine altogether. Others will turn to alcohol or consider suicide. These feelings may be intensified when the physician is not actually at fault, the patient wasn’t actually harmed or the suit is a frivolous one.

According to Sara Charles, MD, one of the leading researchers into the liability stress syndrome, the emotional turmoil of a suit does not have to debilitate the physician. Physicians can and should take steps to maintain their own well-being. Although each physician who has been sued may have a personal way of dealing with the stress, the following approaches, many of which are recommended by the St. Paul Fire and Marine Insurance Company, have been proven effective. Practicing them may help prevent the ultimate “costs” of a liability suit: burnout and dropout.

Become familiar with the legal process

The legal system is foreign to most physicians. As a result, we are even more intimidated when we are victims of medical liability litigation. Your attorney should become one of your closest friends. Discuss the case frequently. Make sure you and your attorney are compatible; if not, request a change. Your team of attorneys must be “experts” in the issue and more prepared with appropriate literature, expert witnesses and knowledge than the opposing team.

Gaining an understanding of the legal system, developing a rapport with your legal counsel and analyzing the strengths and weaknesses of the case with your attorney will increase your confidence and possibly reduce some of the associated stress.

Stay focused and keep a healthy perspective

Make every effort not to take the lawsuit personally. Legitimate suits are filed and patients who have been harmed should receive support and restitution. But some plaintiffs and their attorneys may be out for a “windfall” from any source. Physicians are a common target because we are perceived as having “deep pockets.”

Do not add feelings of guilt, shame or weakness to your stress. Remember: the majority of orthopaedic surgeons have been sued at least once. You are not alone!

Try to stay focused on your practice. Don’t let the lawsuit, which is in the past, damage your future. If a mistake occurred, you might recall that some of history’s greatest performers “failed” on a fairly regular basis. See what you can learn and apply to reduce any possible recurrence.

Involve your family and colleagues

Most orthopaedic surgeons are reluctant to discuss stressful situations with their families and closest colleagues. However, failure to involve one’s spouse in discussions about a medical liability suit could damage your relationships in ways that endure long after the suit is settled. Let your spouse know you need and appreciate his/her support.

Children often fear the worse and need reassurance. Your mood will be affected by the suit; your family, especially your children, need to know that your altered behavior is not the result of their actions.

You may find it helpful to discuss the litigation process (but not the specifics of the case) with some of your physician colleagues. Those who have been involved in liability litigation are usually willing to listen and may have suggestions about coping with the emotional issues.

Even though you may not want to, force yourself to spend time with family and friends. You need their support; being active can help take your mind off the suit.

Exercise regularly

One of the best methods of coping with liability stress syndrome is regular exercise. Regular exercise greatly increases your ability to respond to stress.

Exercise enables you to “do something” with the emotion that accompanies the suit. Other benefits include increased energy and concentration during the day and less insomnia at night. Take time off work if there is a trial.

The emotional turmoil and stress that accompany a medical liability suit can be devastating. But remember that you are not alone. Most of your orthopaedic colleagues have endured this same crisis. Liability stress syndrome can be managed by working with your attorney to become more familiar with the legal system, by maintaining perspective and staying focused on the future, by reaching out to family and friends for emotional support, and by exercising regularly.

Frank B. Kelly, MD, and Mark C. Gebhardt, MD, are members of the AAOS Physician Stress Project Team.

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