As the physician opens the door from the examining room, a man confronts her with an envelope. He hands it over and quickly departs. Anxiously the doctor opens the envelope, her hands trembling. She freezes with the shock of realization: She has received a summons accusing her of willful and intentional harm to a patient. She is being sued for medical malpractice. She wonders, “Who was this patient? When did I see him? What did I do wrong?”
Thus begins an odyssey of turmoil, trial, and tribulation that may last for many months and usually for several years.
The Risk Management Foundation of the Harvard Medical Institutions, one of the two largest medical malpractice insurers in the state of Massachusetts, has a highly enlightened view of the needs of physicians experiencing the stress of malpractice litigation. The foundation has long recognized the devastating impact on the lives of those being sued and the extremely high morbidity rate among doctors going through this process. The foundation offers supportive psychotherapy to physicians who have been sued and those who have been party to a medical error or adverse clinical outcome that could lead to litigation.
For the past seven years, I have been the principal psychiatric contact with the foundation and the treating or referring therapist for these physicians and other health care workers. These services are paid for directly by the insurance foundation. I am authorized to offer these services with no strings attached. I do my work with full confidentiality. Sessions are viewed as privileged conversations and are thus protected from discovery at the time of a trial.
This is especially important because sued health care providers are warned not to talk to anyone about their lawsuit. All conversations that are not protected by privilege are discoverable at a trial, and those to whom physicians have talked can be subpoenaed to testify about the content of the conversation. This warning heightens the isolation experienced by the sued individuals and makes even more valuable the opportunity to talk in confidence about what took place between doctor and patient and about the experience of being sued.
Referrals are made to me primarily by claims managers at the foundation, but they can also be made by risk managers at the hospitals or medical organizations where the health care provider works or by lawyers assisting in the litigation defense. Self-referral is also encouraged through printed material, tape recordings, and publications distributed to covered physicians and other health care workers about the availability of psychotherapeutic support.
Confrontation with malpractice litigation is often a devastating, shocking event. One sampling of physicians revealed that more than 20 percent viewed the experience as the most stressful event in their entire lives.
Physicians often choose medicine as a profession not only out of scientific interest but also out of a deep personal need Caring for the sick and vulnerable can be a meaningful and successful way to satisfy strong emotional needs, both conscious and unconscious, including mastery of helplessness, illness, and vulnerability. Along with the emotional and intellectual satisfaction, medicine usually offers a challenging, stimulating career with financial rewards and social respect. A lawsuit can strike at the heart of a physician's pride and self-respect. Further, physicians are often highly driven, self-sufficient individuals, with little opportunity for peer support.
One study revealed that nearly 40 percent of sued physicians developed a constellation of symptoms suggestive of a full-blown major depressive disorder, while an additional 20 percent were subject to symptoms of an adjustment disorder. Two-thirds of the sued physicians experienced significant symptoms of anger, change in mood, inner tension, depressed mood, and frustration. Half experienced fatigue, insomnia, and irritability. A quarter experienced difficulty concentrating, feelings of worthlessness and guilt, decreased sex drive, low self-esteem, indecision, and decreased appetite. Doctors so stressed represent poor witnesses in their own defense and can even undermine the success of their case. Clinical practice often suffers as well.
The value of psychotherapy in this situation is clear. My role is to assist in re-establishing healthy coping skills and re-establishing self-esteem. I aid in facilitating the grief work around the loss of the doctor's sense of well-being and competence. Quite frequently, the threat of litigation also stirs up significant underlying personality conflicts that have been previously buried or compensated for through the doctor's choice of career and success at this work.
One doctor I treated was an isolated, lonely outsider as a child. He felt like a naïve country boy observing the sophisticated, talented city children around him. His career in medicine challenged him, helped him feel valued, and helped bridge the social gap he suffered as a child. He finally was connected to people. His ability to take care of strangers, whom he used to fear, enabled him finally to feel worthwhile.
Another doctor grew up with a sister with chronic medical difficulties. Family life revolved around caring for the disabled child The sibling was a source of both frustration and concern, prompting her sister to choose a career of caring for others and thereby master powerful feelings of anxiety, helplessness, and rage from her childhood.
In these situations, the emotional determinants that led to the choice of medicine as a career also mean that success, appreciation, and approval for doing good are vital to the doctor's self-esteem. As things fall apart, the doctor is unexpectedly thrust back to the old feelings of insecurity and often re-experiences profound self-doubt, depression, or anxiety.
My experience working with sued physicians has created a variety of opportunities for me. I have given many talks to physicians helping them to anticipate the stress of malpractice litigation. I have worked with malpractice insurers to coach claims representatives and lawyers in how to recognize stress in their clients and how to assist them through support and referral. My work has fostered an interest in managing medical errors and in physician disability, areas I hope to continue to explore and research.
Kenneth M. Settel, M.D., is co-chair of the Ad Hoc Committee on Corporate and Organizational Consultation. He is on the faculty of PINE and serves as a clinical instructor in psychiatry at Harvard Medical School. He works with Harvard Risk Management Foundation offering support to physicians sued for malpractice.
We as psychoanalysts have a particularly valuable perspective on malpractice litigation support. We are trained and skilled in understanding the role of unconscious meaning and developmental influence on reactions to traumatic situations. The work of support can be helpful beyond assisting in the process of mastering trauma and mourning loss by examining the unique significance of the lawsuit or adverse clinical outcome in the unconscious life and developmental history of the health care worker.
It is the rare enlightened malpractice insurer that recognizes the value of therapy, not only for better preparing defendants to represent their interests at trial, but in reducing the risk of physicians' lives, the loss of their self-esteem, and even their withdrawal from medicine.