Within months of completing my training, I received the call that every doctor dreads.
“You’ve been named in a malpractice lawsuit,” said the hospital administrator on the other end of the line.
The family of a patient I had seen briefly a year before believed that a colleague’s decision not to operate hastened her demise. Now their lawyers, combing through the medical records, believed that a single sentence in my note brought that doctor’s decision into question. As a second or maybe even third opinion, I had written that the woman was a “possible candidate” for surgery.
The truth was that when I saw her she was a possible candidate, but only tenuously so. In fact, her health deteriorated so rapidly that by the time she finished seeing all the specialists and returned to her original surgeon, the chances of her surviving any treatment, no matter how heroic, were almost nil.
Though I knew all that, in the weeks after that telephone call I couldn’t help questioning myself, going over the case in my mind as soon as I woke up, then again and again late into the night. I froze with fear every time I was asked for my opinion on a diagnosis or treatment plan and became a master at evasion, littering my assessments and write-ups with words like “maybe,” “perhaps” and “will await further work-up.” And I wondered if my colleagues knew, if the blot on my record had already soaked through the fabric of my professional reputation.
In the end, the family dropped the case; I never met with any lawyers or went to court. But memories of the all-encompassing threat of a claim came flooding back when I read a recent study of how litigation affects doctors.
Medical malpractice lawsuits have existed in the United States for more than 150 years, though today, most medical errors are never pursued in court, and a large majority of claims never result in any kind of payment to patients. And even though the direct and indirect costs of such suits account for only 2.4 percent of total health care costs, that’s still $55 billion yearly. To say nothing of the even more important social costs, an issue addressed last month in The Journal of the American College of Surgeons.
Researchers surveyed more than 7,000 surgeons and found that nearly one in four were in the midst of litigation. Surgeons involved in a recent lawsuit were more likely to suffer from depression and burnout, including feelings of emotional exhaustion and detachment, a low sense of accomplishment and even thoughts of suicide.
“Malpractice is at the top of the list of major stressors for most physicians,” said Dr. Charles M. Balch, the lead author and a professor of surgery at the University of Texas Southwestern Medical Center in Dallas. “It’s right up there with financial distress, serious work-home conflicts and life-and-death circumstances.”
Other studies estimate that, depending on the specialty, anywhere from 75 percent to 99 percent of practicing doctors will over the course of a lifetime be threatened with a lawsuit. “We are not talking about some small subset of physicians who are vulnerable because they are weak,” said Dr. Tait D. Shanafelt, a co-author and associate professor of medicine at the Mayo Clinic in Rochester, Minn. “Malpractice affects a wide swath of our colleagues and their patients.”
Doctors who have been sued may end up practicing defensive medicine, ordering unnecessary tests and medications or refusing to treat patients with more complex illnesses altogether as a safeguard against future litigation. Those same doctors can also become burned out, which can lead to even more errors, and more malpractice claims.
“Burnout may be what reinforces the connections between malpractice, defensive medicine and poor-quality care,” said Amitabh Chandra, a professor of public policy at the Harvard Kennedy School of Government and an economist who has written extensively on medical malpractice.
The study authors propose that one way to disrupt the negative cycle is to improve communication between patients and doctors, so that patients are aware of the risks that can occur despite a doctor’s best efforts. Another important step is instituting programs that continue those conversations even after an error occurs. “We need supportive work environments and more programs that allow doctors and patients to resolve issues directly,” Dr. Balch said.
But change will require looking at malpractice reform in a new way, one that gives weight not just to the economic costs but to the ways reform might affect how patients and doctors interact.
“Ultimately we are dealing with doctors who are working under enormous pressures,” Dr. Chandra said. “For them, the emotional costs are colossal.”