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Vicious circle

Stress of one lawsuit can put physicians at risk for another

From the February 1995 ACP Observer, copyright © 1995 by the American College of Physicians.

By Deborah Gesensway

When a physician-owned malpractice insurance company in Michigan decided to try to study whether the stress and strain of battling a malpractice suit affects how well doctors practice, the results confirmed a disturbing guess--doctors who are being sued are more likely to be sued again.

PICOM Insurance Co. of Okemos, Mich., found that about 14% of its physician clients who have been sued for malpractice reported another "loss" (the patient encounter that led to the filing of a malpractice suit) occurring in the first three months after the first suit began. About 10% of the sued doctors had a "loss" in the second three-month period.

And although the risk of having another lawsuit-causing incident or encounter continued to decrease over time, the insurance company found that there seemed to be one period later in the process where the risk appeared to increase again: About 8% of the sued physicians reported a problem about a year after the first suit began--at about the time the expert witnesses' depositions tend to take place.

"I can say with confidence there is a statistical relationship between being sued and the chance of being sued again," said Theodore L. Passineau, JD, senior health care advisor to PICOM and the study's author. As to why there seems to be this correlation and why it appears to decrease over time, at least with his company's physicians, Mr. Passineau said he can only speculate it has something significant to do with stress.

Given all that is known today about the effects of malpractice litigation on doctors--the depression, isolation and decreased self-confidence about one-third of all doctors report feeling--"it seems unlikely this wouldn't spill over into the professional setting," Mr. Passineau said.

Physicians' perceptions

Physician-health experts have long campaigned for better recognition of what they call "malpractice stress syndrome." Only about half of all professional liability insurance carriers and state medical societies offer some sort of emotional and psychological support services for physicians sued for medical malpractice, according to an April 1994 report by the American College of Obstetricians and Gynecologists (ACOG). And only a small percentage of sued physicians seek out these services, despite the nearly unanimous opinion of physician-health experts that support groups and peer counseling can do no end of good for people feeling more stressed than usual.

"Doctors are not used to being care-getters. They are used to being caregivers." said the Rev. Edward G. Reading, assistant director of the Physician Health Program at the Medical Society of New Jersey. "The thought of being given care means they are not a good person. That's how they perceive it." The stress that grows out of a malpractice suit can be particularly difficult for doctors to deal with, he said, because of the way they tend to perceive the suit.

"When architects or lawyers get sued for malpractice, they don't respond the same way," Mr. Reading said. "It's a professional attack, but doctors perceive it as a personal attack. ... Doctors do not separate who they are from what they do." In his many years of experience counseling physicians in trouble, Mr. Reading said he has consistently seen that about one-third of physicians seem to go into a significant clinical depression after being sued. That depression usually lasts a couple of weeks, but sometimes much longer, he said.

In studies beginning in the mid-'80s, psychiatrist Sara C. Charles, MD, and her colleagues in Chicago found that nearly all sued physicians acknowledge some adverse physical or emotional reaction regardless of the outcome of the case. More than half of those physicians reported suffering from of two clusters of symptoms suggestive of either a major depressive disorder or a stress syndrome that includes pervasive anger and some combination of these symptoms: irritability, insomnia, fatigue, gastrointestinal trouble, headache, frustration or inner tension.

Many of these physicians, the studies found, admitted to feeling indecisive and unable to concentrate, and others said they felt a "loss of nerve" in some clinical situations. "Even if symptoms lasted only a few weeks," Dr. Charles concluded in an article in the American Journal of Psychiatry, "there was an undeniable impact on the physician's ability to practice."

Fighting fear with knowledge

Physicians who don't cope well with their litigation-caused stress also tend to make less-than-optimal defendants, said Beatrice C. Holt, vice president for risk management and marketing at Connecticut Medical Insurance Co., in Glastonbury, Conn.

"From the company's point of view," she said, "physicians who understand the process and are able to handle the emotional side of it are going to be better defendants. ... If you are angry, you are not going to return anybody's calls. You are not going to prepare for deposition. You are not going to say, "I can work to defend myself."

Her company invites all newly sued physicians to participate in an evening workshop given twice a year. That workshop--which they used to call a support group until they found the label tended to turn off many physicians--is run by a lawyer, a psychiatrist and an internist who has been through a malpractice suit. The trio spends time explaining the legal process, because some of the stress is clearly related to fear of the unknown, Ms. Holt. said. And they then explore ways of coping with all the stresses that will arise as the suit winds its way through the process--from how it may feel when you see your name in the newspaper to what to tell your children.

A big part of the message, Ms. Holt said, is explaining what is meant when attorneys say you should not talk about the suit to anyone. There is a major difference between talking about the details of a lawsuit and talking about how it makes you feel, she said.

Mr. Reading said this has also been a major emphasis of litigation stress support groups he has run in New Jersey. "We have had physicians who have not told their spouses they were getting sued because they were told not to talk about it with anybody. We tell them they must talk to someone about how it feels to be sued. On a practical level, the home front is place that you can probably get your best support."

In addition to talking to people about the experience and looking for peer counseling or a support group, Michigan's Mr. Passineau recommends newly sued physicians try to keep control of their hours, make increased use of second opinions and consultations, emphasize their people skills, shore up their personal relationships, monitor their use of alcohol and other drugs and make it a priority to maintain balance in their professional and personal lives.

And, said Mr. Reading, doctors must figure out the kinds of things they need to do for themselves to help them cope with these litigation stressors over the long haul. Lawsuits typically run as long as five or six years.

"I talk about it this way to the doctors," Mr. Reading said: "You've got in-laws that you really dislike. They call you up and say they are coming for the weekend, and seven years later, you are still having breakfast with them in the morning and they are not working. That's the way you have to learn how to live with the malpractice suit."

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