OOn my last shift, I arrived to find our emergency room full and our waiting room overflowing with suffering patients. Half of our ER beds were occupied by “boarding patients”—patients who were sick enough to require hospitalization, but for whom an inpatient bed was not available at our hospital or any other in the state. These boarders included a critically ill infant with respiratory distress from RSV, a moribund elderly woman on a ventilator, and a teenager who was held under security surveillance in the emergency room for three days awaiting transfer to a psychiatric bed. In the hour of my arrival I was tending to four new critically ill patients who joined the ranks of our boarders in the ER as there was no intensive care unit to accommodate them. The minute-by-minute bedside care they would ask of us indefinitely meant even less attention to the other sick patients.
An experienced nurse whispered to me in a moment of overwhelming: “I can’t do this anymore. It’s not worth my license.” And I thought grimly, and not for the first time: This is a dangerous situation. For our patients and for us.
As a physician who coaches other physicians through the stress of malpractice lawsuits, I am aware of a truth that has gone unspoken in public discussions about why healthcare workers quit.
What has been released so far is very true: we are burned out and overwhelmed. Violence against healthcare workers occurs regularly. We’re weary of the daily roadblocks erected by unrelenting health insurers, error-prone electronic medical records, and C-suite executives who have little understanding of the boots’ perspective on the ground. We’ve worked through COVID-19 and staffing shortages, with systems crumbling around us. And when there is an outcome that causes pain and distress to patients and their families, we are not only crushed by those mistakes, we become their faces.
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Misconduct litigation is a sensitive issue that needs to be discussed openly. Even among physicians, although litigation is extraordinarily common, it carries an air of shame and secrecy. Personal experiences in litigation are rarely discussed. Many doctors have no understanding of how litigation actually works. But malpractice litigation happens to many good doctors. For example, a survey found that over 80% of currently practicing OB-GYNs and general surgeons have been sued at least once.
For many, the initiation of a legal proceeding or disciplinary investigation is almost as significant as the outcome. The formal accusation of a misconduct, whether or not a misconduct has occurred, marks the beginning of a long cycle of shame and psychological distress for the physician who has devoted his life to his profession and genuinely cares about his patients’ outcomes. The opportunity to talk – to heal, to explain, to listen, to soothe – with the patient or his family is lost; Lawyers are now attacking or defending for us. Adding to the distress of a serious adverse outcome for her patient is now the fear of personal assets at risk, the potential loss of license or livelihood, and the stigma of permanent public record of the litigation; Worry is common, as is the shame of being judged incompetent by patients and colleagues alike. This fear is not generally voiced by physicians, who are cautioned by their attorneys and insurers not to talk about it, but is used heavily during the trial by opposing attorneys who are well-versed in the psychological distress that litigation creates in the accused. You know that a very stressed doctor is more likely to make a mistake in testimony, push for a settlement just to end his ordeal, or appear poorly on the witness stand as a witness at trial.
Serious Medical Errors Do Occur naturally, and the risk increases when our healthcare system is frayed. Discussing the impact of litigation on healthcare workers should in no way diminish the suffering of patients or their families when an error occurs. In the past, however, many wrongdoing lawsuits filed have not involved a true error. The majority of lawsuits filed end in non-payment, and when cases go to court, doctors have the upper hand in over 85% of cases. It is important to recognize, however, that medical malpractice litigation stress is a leading cause of burnout, drug use, divorce, and mental health crises among clinicians, whether or not an error has occurred and regardless of a case’s ultimate outcome.
Physicians as a group have a remarkably higher suicide rate than the general population, and a 2011 study of over 7,000 U.S. surgeons found that recent malpractice lawsuits were “strongly associated with burnout, depression, and recent suicidal thoughts.” Another 2020 JAMA study showed that “civil law issues were a significant risk factor for suicide among healthcare professionals.” For a doctor whose identity has flipped to be “the good doctor” but is now a defendant, an internal crisis brews that often goes unaddressed.
Medical providers often receive minimal support from their institutions during litigation; The result is a general distrust between hospital management and staff. Doctors and nurses are keenly aware of the recent RaDonda Vaught case, in which a nurse was convicted of involuntary manslaughter over a medication error, although faulty medication delivery systems in hospitals have also contributed. Clinicians often expect to be “thrown under the bus” once the litigation wheel begins to turn.
Regardless of litigation, medical errors themselves are associated with increased suicidality among physicians. We measure our intrinsic worth not by the number of times we’ve been right, but by the few times we’ve been wrong. And today, our dangerously understaffed situation is leading to more undesirable events—and in a vicious circle, the impact of those events will drive even more of us away.
All of this has always been part of our job, but the more we’re tasked with the impossible and blamed when we can’t achieve it, the more aware we are that every misconduct lawsuit needs a face, and that face will soon be be ours . What we openly say about the health flight is true: we’re overwhelmed, we’re burned out, we can’t help everyone who needs our help. People are dying who wouldn’t die if only we had the time and resources to do our jobs the way we were taught.
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