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Malpractice and Suicide (July EMN column)

We doctors are experts at death. I always used to say, ‘don’t mess with an ER doctor; we know where all the important parts are and where to stick sharp things!’ (ER nurses tend to talk about potassium and insulin).

Turns out, it’s actually true. We are dangerous. Doctors are good at killing; but mostly themselves. Male physicians, it turns out, have up to three times greater relative risk of suicide than the general population, and females up to six times! And when we do it, we do it right. We know the best pills to take and how to take them and we know exactly where the bullet should go.

We’ve known for a long time that doctors have lots of stresses that lead to suicide. But I guess I didn’t realize until fairly recently how much malpractice litigation plays into physicians’ thoughts of self-harm.

I’ve heard different numbers about how much more likely we are to kill ourselves after malpractice suits. But statistics aside, it appears to be a sizeable increase over our baseline tendency to hurry ourselves into eternity. That is, when we get sued, we think about killing ourselves more than ever. Sometimes it’s when the suit is brought, sometimes as it’s being litigated, sometimes after a judgment or settlement. Regardless of the timing, a malpractice suit does something to us.

I suppose it’s easy to see. We spend years and years learning to be competent, meticulous, cautious. We study and study, and become terribly upset over grades that would leave our non-medical friends ecstatic. We spend years face down in books, absorbing everything to get into medical school, and to survive it.

Then what happens? In the course of seeing patients, we make a mistake, or are accused of making a mistake. But we don’t like to make mistakes. We’re told we mustn’t, shouldn’t, can’t make mistakes. So the first strike against our psyches is the error or perception of error.

Second, we’re told that the alleged error caused harm. Holy Smokes! What about ‘primum non nocere?’ First do no harm! We might have hurt someone! We try to never hurt anyone. We struggle to anesthetize wounds and anesthetize people. We don’t want to cause so much as the pain of a needle-stick. We slather patients with local anesthetic creams and pump them with sedatives to avoid the discomfort of a splinter removal, or the anxiety of draining an abscess. When we find that we may have hurt someone, or Heaven forbid, killed someone, we’re devastated. It flies in the face of everything we have been taught to do. It is the antithesis of what we hoped to be.

Then third, we learn that our alleged error, and alleged harm, will be the subject of that little bit of public theater known as ‘litigation.’ We’ll be hauled before attorneys for depositions, before administrators for answers and before juries and judges for evaluation of our decisions. We may face financial punishment. These days, we may even face civil or criminal punishment, or loss of our practice privileges. And it will all end up in the local paper.

Subsequently, we’ll suffer the quiet indignity of having other physicians look at us and whisper, if only to themselves, ‘I would never have done that!’ We know that we’ll be judged by our colleagues at least as harshly as we are by the public. The case may even show up, in some veiled fashion, at grand rounds, or at morbidity and mortality conference.

For physicians in less equitable practices, even the hint of litigation may result in some little talk, some warning, some suggestion not to do anything like that again ‘or else.’

So in the end, all of the effort and compassion, the hard work and motivation, the hopes of a spotless career, are derailed, even if temporarily, by one event; by one error. And we fear that we will wear a scarlet letter ‘M’ for malpractice for the rest of our lives.

For many physicians, medicine is the single most important validation of their lives. It is the thing that has defined them throughout adulthood, and that they intended to define them forever. ‘Doctor, physician, healer, professional.’ These are the words that come to mind. Malpractice, however, replaces them with ‘assailant, defendant, killer, quack’. Worse, the lawsuit often uses words like ‘willful, malicious, premeditated,’ in describing the evil actions of what is obviously an evil doctor. (Even as the plaintiff’s attorney says ‘it’s not personal, you know, it’s just business!’)

So malpractice takes that validation and, if we aren’t careful, shatters it into a million pieces. Threatening loss of work, loss of money and livelihood, loss of reputation, it ends in loss of self-image, loss of self-worth. And for all too many physicians, that loss compounds the other stresses of practice, and makes death seem a reasonable, even desirable, alternative. And so, after a period of sadness and detachment, the stored pills are swallowed, the chamber checked for a live round, and a life of great achievement and service is brought to an abrupt end.

But it’s so unnecessary. Brothers and sisters, we are good people. And the reason that malpractice makes physicians consider suicide is that we care, perhaps too much, about our careers. It is a high and amazing calling, medicine. It gives us the chance to support ourselves and our families and to do so much good in a world that is so bad! Still, at the end of the day, it is still a job. And our lives are worth so much more than a job alone.

As a profession, and as individuals, as colleagues and friends of other physicians, we have to reclaim our hearts. We have to reclaim our identity and worth, separate from hospitals and clinics, procedures and incomes, emergency departments and positions. We have to deny anyone the power to take our worth from us. No attorney or lawsuit, no plaintiff, however genuinely or falsely injured, should have the power to make us contemplate ending our own lives.

The truth is, we will make mistakes. We may even cause harm. But we practice an imperfect science in an imperfect world on imperfect people. It is fraught with potential errors and disasters every day that we walk through the door to work, every time we touch a sick or injured human.

But the greatest mistake we can make has nothing to do with missed diagnoses or medication doses, botched procedures or wound infections. The greatest mistake is to believe our worth as individuals has anything to do with any of that.

Lawsuit or no, everyone reading this is loved; loved by parent or child, by spouse or friend, by lover or sibling, or by someone who loves you from afar, and has yet to reveal it. Everyone reading this is loved by God, who knew you were going to make the very mistake you made, and loves you anyway.

Let’s reach out to everyone who gets sued. Give them a handshake or embrace, a friendly smile and an understanding ear. Remind them of all the good they have done, and of all the good they have yet to do. And we should tell them the stories of our own lawsuits so they won’t feel so utterly alone. As individuals and as a profession, we need to stop making malpractice litigation seem like the worst thing in the whole world of medicine. Because in the end, it’s nowhere near as horrible as having the world denied a good doctor through suicide.

Please see my website, www.edwinleap.com, for further comments on this column, on my experiences with litigation, and on the inestimable value of each and every human.

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Edwin

11 Comments

Paul Driscoll Jr.

2007-07-15 13:08:13 Reply

Thank you Doctor.
I’d like to also point out that inquisitions by one’s board of registration have an equally cooling affect.

Having gone through one over a period of six years I can tell you that the only thing to help you is God. Specifically God as TRUTH.

Have a great day!

jb

2007-07-15 13:48:17 Reply

Some (very) respectful disagreement here about one point you made- the point about how we are viewed by colleagues. I believe that the more typical response of other physicians is “There but by the grace of God goes me.” We know that the correlation between bad outcomes and bad doctoring is quite low, and that any given interaction between doctor and patient can result in a disaster through nobody’s fault. Some of these can result in litigation, and we all know this. A series of these no doubt may lead to professional ostracism, and after a series a degree of ostracism might be justified (or required if others are to keep their insurance in force), especially if the doctor’s routine practice is on the edge. My experience in >2 decades of practice of high risk medicine (surgery) is that very few get this far unscathed, and my colleagues would not view me as a “malpracticer,” but as a competent caring physician who got unlucky.

I agree wholeheartedly that the physician’s self perception can be as you describe, and lead to disastrous consequences, including suicide.

rlbates

2007-07-16 13:32:31 Reply

I can know of a half dozen physicians who committed suicide. Not all were connected to malpractice. The reasons make it no less sad. Even the ones I only “knew of” but had not met hit me hard. I felt as though I had lost a family member. So very sad.

Louise B Andrew MD JD FACEP

2007-07-16 21:24:58 Reply

Of course, we’ll never know the exact cause of any physician suicide, and most are certainly multifactorial (http://www.emedicine.com/emerg/topic952.htm). Albeit litigation is not known to be a terribly common stimulus, it is nonetheless a deplorable one for all the reasons you mention. Your reader’s comment about the reaction of other physicians is also spot-on. Those who have been sued or had a close call will say “There but for the grace…go I”. Those who have not MIGHT say that, but may also nurture the fantasy that good docs don’t get sued and place themselves in that category. If they are not in practice themselves, but rather in administrative positions, this is a dangerous fantasy for the rest of us! Unemployment, uninsurability, licensure restrictions (and of course, jail sentences which are not invariably earned) all add to the sense of shame, isolation, and hopelessness that may lead to depression, despair and suicide by physicians. So thanks for reminding us NOT to prejudge (or postjudge) a physician who has had an encounter with the legal system, and to extend a hand, an ear and an understanding heart to all who have been scathed by it. We can be lifesavers outside the ED as well as within.

jo is glad

2007-07-17 19:45:23 Reply

Terrific article on a secret subject. The intensity of the pain generated by a lawsuit is because being a physician is not just what we do, but who we are. I am a jury trial survivor whose daily personal hell lasted seven years until we “won.” It is supremely difficult to walk back into an already stressful job that earned you the lawsuit with the haze of self doubt and the allegations of incompetance swirling around. Isolation. Don’t discuss it with anyone. My attorney commented that quitting the ER would be an “admission of guilt in court,” thus closing the trap on escape. In this scenario suicide makes sense. The only way I got through every day was holding fast to my faith. God has used my experience to give me a ministry of encouragement to those suffering from trials. He gave me a list of things to DO that I share with others that I call “Encouragement for a Trial.” I find that in comforting others, my personal hurts find healing. I will email the handout and pray that many many more will be encouraged. Dr. Dobson’s Physician Magazine published a brief version in the letters to the editor a few years ago.

Jim Rodden

2007-07-21 15:44:12 Reply

I practiced emergency medicine for years just up the road from you in western NC. I enjoyed it a great deal until the later years and I mark the decline at my malpractice suit. I was never suicidal but I was consumed with rage and depression. I got a certain amount of support from family and friends but a sense of shame prevented me from discussing it much. In retrospect talking it out with a professional who understood would have been very beneficial and even now just writing this feels better. Since my suit two of my friends were sued and I tried repeatedly to get them to talk about it but they declined I suspect for the same reasons I was reluctant. Their depression was evident and they quit their practices over it and left town. I don’t have much in the way of answers and I’m still quite angry over a system that’s so destructive to physicians and society.

animal guy

2007-07-23 06:55:08 Reply

Have just started reading some of these ER blogs.
I am not a doc of any kind, however spent 13 years of my life tending to sick cattle on a large dairy and can sew with the best of you. Have also done my share of OB and ER type work.
I also experienced some of the same emotions as you during my tenure on the farm. Experiencing death on a regular basis is not pleasant, I also knew my patients even though they could not speak, and I celebrated success and mourned failure. However, I could practice my art, which as any good practitioner knows; there is art and god given talent as well as book learning and experience, without fear of career or life ending litigation.
I have also had a white light experience while under the care of an excellent surgeon. He was concerned with litigation (even though my wife assured him otherwise) until I was cognizant enough to discuss the ordeal after I departed ICU and was on minimum pain meds.

My response ” Doc, That’s why we call it practicing medicine, Based on what you have said, there is nothing you could have done to prevent the code; and you practiced the right way as I am still here.”

My mantra while on the farm, for everyone I lost, I saved many others because I knew what to do or not do the next time.

Lola, RN

2007-09-09 00:23:10 Reply

Ed, Thank you so much for writing this article. My husband and I have been enjoying your column for years now, and your words have been a source of inspiration for us both. I am an RN in the ED and my husband a doc in another ED. My husband had a terrible case about two weeks before your article on suicide was published. He was beside himself, angry and emotionally upset because he had watched a young patient bleed into her brain right in front of him. The usual reflections took place. “What else could I have done?”, “Will she ever recover?”, “Did I do something wrong?”. No physician (or nurse for that matter) gets up in the morning intending to harm someone. We go out there everyday trying to do our best to help people and make the well, closing the door on the grim reaper. I have told my husband in the past that you cannot interfere with a patient’s destiny. You cannot interfere with God’s plan no matter what you do! People will die, and some will be young and in the prime of their lives. Our society demands that physicians save everyone, and it better be in a timely fashion because there is a movie that they have tickets to in an hour. This cannot be done, and whoever is promoting this trash should be beaten. Anyway, my husband went and talked to a religious figure about his grief, and was consoled somewhat. I caught him saying “I need to be here for my kids”, and then I got worried. I was truly fearful that he was going to do something to harm himself. He is lucky to work with a group of physicians who are very supportive, and he broke down and talked to some of them about it. He was afraid to initially because I think you have all been told NEVER to discuss any case that may be malpractice with a colleague. He greatly improved after venting to myself as well as a few of his partners. He does bring it up now and again, and of course the threat of a malpractice case looms heavy over his head though he mentions it less. Thank you for your article, which also helped him cope a little better, and realize that he wasn’t a terrible doctor, something I am sure he said to himself over and over.

Supremacy Claus

2008-01-01 23:06:58 Reply

I bet lawsuit claims cause suicidal and homicidal ideas more often than anti-depressants. Because most claims are weak, they are defective products. They must carry plain black box warnings, or the failure to warn should be added to any counter-suit.

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2012-01-13 07:41:10 Reply

G’Day! Edwinleap,
Thanks for your thoughts, Illinois medical malpractice lawyers face long trials steeped in endless expert testimony, caveats in civil procedure and usually hundreds of thousands of dollars at risk, all the result of emotionally heart wrenching cases involving deaths, amputations, paralysis, brain damage, and almost always, pain and suffering. Among the critical roles that attorneys play in medical malpractice cases, the role of proving pain and suffering is one of the most challenging.
Thanks

Jona Petruskanon

2012-03-26 22:09:57 Reply

how many calories in a grapefruit, Amazing! This blog looks just like my old one! It’s on a entirely different topic but it has pretty much the same page layout and design. Outstanding choice of colors!

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