• Rosalind Kaplan, MD

What Are We So Afraid Of?

Doctors are some of the most highly educated and skilled professionals in society. We spend at least seven years post college training to care for patients. We put in more hours in those years than I imagine those in any other profession do, since we work night and day, weekdays, weekends and holidays. We face life and death situations over and over and over again, building up 'mental muscle', in order to handle crisis at any turn. We learn to face all kinds of hardship and adversity. And yet, as Danielle Offri pointed out in her book, How Doctors Feel, fear is one of the primal and salient feelings doctors struggle with every day.

What are we afraid of? I think there is a long, long list. Going back to medical school, and even before, there was fear of failure, of not being good enough. To get into med school, we had to be the very best students, get the very best test scores, manage our time better than everyone else so that we could fit in the service and the research, present ourselves flawlessly at interviews, and, on top of all that, stand out in some way- personality, compassion, talent, brilliance- something had to 'pop', because the competition is fierce. Then once we were in, we had to keep up and learn heaps of material and continue to show our compassion. The fear of looking stupid became a big thing in group sessions and rounds. Terrifying. But even more terrifying was looking stupid or incompetent when with patients!

Then there were boards. Fear of failing medical school courses was realistic for some people, but fear of failing some part of the boards was realistic for a much larger group.

Once we made it to residency, the fear of failure and of looking bad was still there, but there was a much bigger fear, one that would stick and accompany us through the rest of our careers: the fear of hurting a patient, or even killing a patient. Most decisions, of themselves, were small- whether to get a lab test, which of two similar medications...but they added up, and some diagnostic or treatment errors, particularly on critical care rotations, could be devastating. Of course, there was supervision, but we had medical licenses and made initial decisions on our own.

Along with the fear of making mistakes came the fear of being sued. For me, this didn't sink in until late in training, when it actually happened. I was named, along with dozens of other residents and attendings, in a wrongful death suit. The patient, a young woman with lupus, renal failure and sepsis, spent many months in the hospital, and was seen by almost every medicine resident in our program at some point. The attorneys 'dragged the net' and named everyone who had ever signed a note in her chart. I had only seen her once, when on call, for a fever. Eventually, many of our names were dropped from the suit, but it made me realize how easy it was to become involved in a malpractice suit, and how frightening it could be. I've been lucky to have had minimal contact with attorneys through my career, but have had a couple of threats of suits, and even those have caused extreme stress. An actual suit could easily throw me into complete panic mode.

You'd think all this is plenty to worry about. But there is lots more. There is potential violence from patients. I have seen thousands of patients in my thirty years of practice. Even in the highest-risk urban areas, I have generally felt quite safe. But I did once have a patient pull a knife on me in clinic during a psychotic episode. Another delusional patient held me 'hostage', saying he had a bomb in his bag, which turned out to be false. In an upscale suburban practice, I had a patient threaten to kill me for having a driver's license revoked, and another patient smear feces on the walls of my exam room while intoxicated. Patients have yelled at me and used hateful language both in person and on the phone. Given recent gun violence in hospitals and medical offices, it's something we have to think about. When working for health systems, I believe we should have the right to discharge a patient and be offered protection against them if we feel at all threatened. However, in my experience, institutions are sometimes more concerned with potential unsubstantiated claims of abandonment from these patients than they are with protecting their physicians. More than once, I have been instructed by risk management personnel to continue caring for patients for a period of time after I expressed feeling threatened. I think this is something we, as physicians, should fear.

Speaking of medical systems, I am hearing now that physicians are afraid of their own institutions. They are increasingly afraid to speak up about policies and practices that are unsafe or detrimental to patient care, or situations that are contributing to poor physician health and wellness.

I spoke to a colleague last week who told me that she was very worried about the patient safety in her practice. She is aware of many errors with lab specimens and a lack of timely response to abnormal lab values. She brought this up to the team in the office repeatedly and solutions were discussed but nothing has changed over many months. She asked me what I thought the next step was. I suggested it be escalated to a higher level of authority in the institution. She stated that she was afraid to do that because of the risk of retribution by the current office manager, who already has made her daily life more difficult after she reported another issue with workflow in the office a year earlier.

Trainees are also reluctant to give honest feedback about their programs unless it is done anonymously. A fellow told me about a situation in which she received a negative evaluation after

reporting issues regarding physician safety at a site where she practiced and trained. In this case, she did not have the opportunity to give the feedback anonymously, but felt it was necessary to bring the issue to her program director's attention before another trainee was sent to the site.

And here's a serious concern, and one that's been talked about quite a bit regarding physician wellness. We know doctors are encountering a mental health crisis. There are lots of doctors out there who need help with depression, anxiety or symptoms of mental and physical exhaustion right now. But they're afraid to admit it. They're afraid to ask for help, or even talk amongst themselves for fear of stigma, or even worse, losing their positions or their licenses.

Why should we be afraid of getting help that could improve our health, prevent more serious illness in physicians, and prevent poor patient care? The simple fact is that people have been blindsided when they've asked for help. I know a doctor who got voluntary mental health care for severe depression. He took himself out of his practice of medicine specifically because he knew he wasn't well. He got help. He got better. He came back to practice. Success story, right? So he talked about it openly, hoping to help others. There were no 'incidents', no complaints against him. Next thing you know, his State Board of Medicine is 'investigating.' Why? This is exactly why people don't ask for help or talk openly.

A friend of mine is suffering extreme stress in her primary care practice. She's in private therapy, on medication. She needs her schedule decompressed and just some simple kindness at work, which she's really not getting. In fact, she, as the most junior person at work, is the 'dumping ground.' If she could ask for what she needs, she could likely avoid having to leave work entirely, and avoid a deeper depression. But she's afraid to ask, because she's seen other people get pegged as 'crazy' at work, and she doesn't want that following her. She's trying to stick it out and hoping it will all just miraculously get better. I'm worried that her facade is going to crumble if she doesn't do something soon, but I see her point.

And I haven't even touched on the issue of Physician Assistance Programs, those entities that are supposed to help impaired doctors, but work with the State Board and/or with health systems and thus are not confidential. While doctors who have addiction issues may be more likely to stay clean when participating in such programs, they are often used for issues other than addiction, for which they are not intended. In addition, the statistics don't tell us whether those doctors who participate are treated fairly across the board regarding jobs and licenses, so anyone going that route needs to know what the track record is for the program they are entering.

This is the new state of AFRAID for doctors. It's way too much. We were carrying around so much fear before. Now we are not just afraid of not doing a good job, or of hurting patients, or making mistakes and being sued. We're afraid of our patients hurting us. And other doctors hurting us. And our institutions hurting us. And even treatment hurting us. I think we need to catch a break from all this. There are other choices for doctors backed into corners. We don't need to live in fear.

I'll be exploring the potential effects of fear, combined with bullying, secondary trauma and increased workload in my next post. Don't worry, though. There are some answers. I'll be talking about alternative choices in medicine and fighting the system, too. Stay with me!

#medicalerrors #patientsafety #secondarytrauma #patientcare #physicianburnout #primarycare #physiciansuicide #physicianwellness #medicaladministration #health #physician

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