Dealing with the Stress of Adverse Events and Medico-Legal Issues

"…very little attention has been devoted to healthcare workers involved in adverse events to help them cope with their responses."

The authors noted that despite the developments in adverse event investigations "very little attention has been devoted to healthcare workers involved in adverse events to help them cope with their responses".¹

Over the past decade, there has been an exponential increase in the number of processes available to investigate and manage adverse patient events. An adverse patient incident in a hospital setting may result in a root cause analysis, an open disclosure process, a hospital investigation, a complaint to AHPRA and/or a Health Complaints Entity, a coronial investigation and, on occasion, a medical negligence claim. All of these processes take time and it may be several years before they reach an end.

Appropriately, the focus of these processes is on the management of the patient and their family, and also ensuring that any lessons learned result in improved patient outcomes. But what about the medical practitioners who are involved in these adverse events and medico-legal processes? What are their reactions and needs? How can they best cope? How can we assist our colleagues who are involved in these events?

Doctors' reactions to adverse events

The initial reactions of doctors to adverse patient events include numbness, detachment, distress, confusion, anxiety, grief and depression, withdrawal or agitation, and re-experiencing the event. Added symptoms which are related to medical errors include shame, guilt, anger, self-doubt and loss of confidence.¹ Difficulty concentrating is also common, and the medical practitioner may be significantly impaired in performing their usual role. These symptoms may last from days to several weeks.

A few medical practitioners go on to suffer long-term consequences, such as flashbacks, avoidance of situations associated with the trauma and increased arousal, including sleep disturbance and irritability. Some doctors consider leaving the profession.

Six stages of “recovery” have been identified after an adverse patient event:

1. Chaos and accident response. 2. Intrusive reflections. 3. Restoring personal integrity. 4. Enduring the inquisition. 5. Obtaining emotional first aid. 6. Moving on: dropping out, surviving or thriving.²

Doctors' reactions to medico-legal issues

A claim or complaint against a medical practitioner also causes emotional and physical stress, regardless of the outcome. Research has shown that the threat of a medical negligence claim is one of the most severe sources of stress in medical practitioners’ working lives.³ A survey of medical practitioners who were the subject of a medical negligence claim found the following reactions:

• 96% of medical practitioners acknowledged an emotional reaction for at least a limited period of time.
• 39% experienced depression, including symptoms such as depressed mood, insomnia, loss of appetite and loss of energy.
• 20% experienced anger, accompanied by feelings such as frustration, inability to concentrate, irritability and insomnia.
• 16% described the onset or exacerbation of a previously diagnosed physical illness.
• 2% of medical practitioners engaged in excessive alcohol consumption.
• 2% experienced feelings of suicidal ideation.⁴

Symptoms may last for only a short period, recur with each step in the process, or persist throughout the entire claim or complaint.

A recent Australian survey examined the differences in psychological morbidity between general practitioners who have experienced a medico-legal matter and those who have not.⁵ Those practitioners with a current medico-legal matter reported increased levels of disability in work, social or family life, and higher prevalence of psychiatric morbidity, compared to those with no current matter. Those respondents with a history of past medico-legal matters reported increased levels of disability and depression subscores. Male respondents with a current or past medico-legal matter had significantly higher levels of alcohol use than male respondents with no experience of medico-legal matters.

Managing adverse events and medico-legal issues

The ability to cope with stress is highly individual and medical practitioners need to reflect on their own means of coping. There are a number of strategies that medical practitioners can use to deal with the stressful nature of an adverse event, claim or complaint. Effective coping responses include both problem solving and emotionally focused coping. Practitioners need to learn to switch between the two, when appropriate. Problems can arise if the medical practitioner tries to apply the wrong response in a given situation, for example, trying to solve an unsolvable problem.

One of the first steps in coping is to obtain sufficient information about the process in which the medical practitioner is now a participant. MDA National’s Claims and Advisory Services team can provide detailed information about the particular medico-legal process that a Member is involved in. Additionally, medical practitioners need to understand what can be expected psychologically and, throughout the process, they need to observe their emotional and physical reactions. If any symptoms develop, such as depression, physical illness or substance abuse the practitioner should consult their general practitioner. Self-medication should be avoided, even if faced with the common symptom of insomnia.

For many medical practitioners, a feeling of being “out of control” pervades the onset of a claim or complaint process. Medical practitioners often feel like they are on a roller coaster ride, with alternating feelings of confidence and loss of self-esteem, of assurance and self-doubt. Regaining a sense of mastery and control is important. Medical practitioners often have difficulty identifying their strengths but are well practised in identifying their weaknesses. By identifying strengths, medical practitioners are then in a position to develop them and look at shaping their life and work to feed those strengths. Engaging in activities that make the practitioner feel in better control of their personal and professional lives will assist in restoring a sense of balance (see Table 1).

Assisting colleagues after an adverse event

Peers are the most popular source of support after an adverse patient event.⁷ Strategies for assisting a colleague in this situation include:

• Encourage a description of what occurred.
• Begin by accepting this assessment.
• Do not minimise the importance of the event.
• Acknowledge the emotional impact of the event: “This must be very difficult for you. How are you doing?”⁸
• Assist the colleague in identifying other supports, including contacting their medical defence organisation.

Table 1 – Strategies for coping with claims and complaints⁶

The role of MDA National

When dealing with a medico-legal issue, MDA National’s aim is to obtain the best possible outcome for our Member. Unless the Member is well and able to cope with the process, then the best result for that Member is difficult to achieve. Therefore, providing support to our Members is an integral part of MDA National’s role. Our Claims and Advisory Services team has extensive experience in supporting Members throughout the course of a claim, complaint or other medico-legal process.

Every Member will have their own individual needs, depending on their personality and the nature of the matter they are dealing with. Some Members find it relatively easy to implement strategies to cope with the stressful nature of the process, while others may be reluctant or unable to obtain the support they need.

To ensure our Members are provided with an appropriate level of support when dealing with a medico-legal issue, MDA National has an additional program to provide support to Members:

Doctors for Doctors Program

- The aim of this program is to provide understanding and support to a Member, and enable the Member to share their experience with another doctor during the course of an incident notification, claim, complaint, investigation or other process.

- The Claims Manager will discuss the program with the Member and provide a prompt referral if the Member would like to use this service at any stage during the case.

- The program complements the role of the Claims Manager and offers the Member additional support from a colleague.

A Doctor's Perspective

During my training in Intensive Care Medicine I was part of a team that treated a middle-aged man for cardiogenic shock. In the process of treating this man, the team was required to emergently reintubate him for respiratory failure. A series of unfortunate events followed that resulted in an unrecognised oesophageal intubation. The man sustained a severe hypoxic brain injury from which he died about a week later.

This was a catastrophic day for the man, his family and all the staff involved in his care. Despite the post-event management and open disclosure being well executed, my colleagues and I suffered in our own ways as we worked out how to function under the burden of such a confronting situation.

My responses to my first time in this situation were feelings of terror, shame, incompetence, self-loathing, despair and anger. In the subsequent weeks and months I suffered flashbacks to these events. I felt like an abject failure and an incompetent doctor. I chose to share my experience and I spoke confidentially to colleagues, friends, family and professionals. It took a long time to process the chaos of that day.

The turning point for my recovery from this difficult time was when I actively chose to take this on as a learning experience. I chose to address the communication and technical factors in my practice that had contributed to this event. I also committed to honour this man by teaching people about my experience. I do not want others to experience this, if possible. I discovered many others,including my clinical role models, had been through similar experiences. I gradually made my peace with that terrible situation.

During the subsequent coronial hearing I was well briefed by a compassionate legal team. I presented my evidence and had an opportunity to offer suggestions about how to prevent this happening again. I spoke with the bereaved family and my colleagues. The legal team organised another debriefing of the intensive care team after the hearing. We shared the experience again and we healed further.

This event has been a powerful driver of the development of my practice and teaching. It has also made me realise that I am part of a large, caring community, which despite all the difficulties, strives for the best possible care for people, even after the worst possible circumstances. The process was hard emotional work and I could not have thrived alone.

Dr Cameron Knott is an Intensivist and a MDA National Member.

¹Wu A, Steckelberg RC. Medical error, incident investigation and the second victim: doing better but feeling worse? BMJ Qual Saf 2012; 21:267-270 
²Scott SD, Hirshinger LE, Cox KR et al. The natural history of recovery for the healthcare provider “second victim” after adverse events. Qual Saf Health Care 2009; 18:325-330. 
³Schattner PL, Coman GJ. The stress of metropolitan general practice. Med J Aust 1998; 169:133-137. 
⁴Charles SC, Wilbert JR, Kennedy EC. Physicians’ self reports of reactions to malpractice litigation. Am J Psychiatry 1984; 141:563-565. 
⁵Nash L, Daly M, Johnson M et al. Psychological morbidity in Australian doctors who have and have not experienced a medico-legal matter: cross sectional survey. Aust N Z J Psychiatry 2007; 41:917–925. 
⁶Charles SC. Coping with a malpractice suit. West J Med 2001; 174:55-58. 
⁷Hu Y, Fix M, Hevelone ND, et al. Physicians’ Needs in Coping With Emotional Stressors. Arch Surg 2012; 147: 212-217. 
⁸Wu A. Medical error: the second victim: The doctor who makes the mistake needs help too. BMJ 2000; 320: 726-7.