The recent horrendous case of a lady gynecologist in Rajasthan putting an end to her life , following charges of murder being leveled against her by the Police after the death of a patient due to PPH , has prompted me to re-publish this presentation I wrote a couple of years ago. The issue has now occupied center-stage, and it is imperative to brain-storm on it.

WHAT IS MEDICO-LEGAL STRESS SYNDROME?

Very few of us are aware of the existence and increasing incidence of this well-defined syndrome–MLSS. It is time we recognize it, analyze it and do everything in our power to mitigate and manage it effectively. In the USA, it is referred to as MMSS viz. Medical Malpractice Stress Syndrome. I am averse to using the word ‘malpractice’ as it connotes ‘wrong-doing’ and ‘guilt’ which is ‘alleged’ and not proven and hence prefer the more generic term –‘medico-legal’.

Medico Legal Stress Syndrome (MLSS) is strikingly similar to what psychiatrists call Post Traumatic Stress Disorder (PTSD)
PTSD is caused by unexpected, extreme, sudden traumatic stressors such as war, terrorist attacks, car crashes, unexpected death of a beloved one, and so on.
MLSS refers to a set of symptoms common among those doctors facing medico-legal trauma including legal notices from patients alleging negligence in treatment ; facing cases before Consumer Forums for compensation , complaints before Medical Councils ; Police enquiries leading to criminal prosecution ; patient aggression and so on. It includes the impact on the family of the doctor as well.

PREDICATABLE BUT TRAUMATIC HAZARD

We are all aware of the exponential rise of medical litigation in India in the last 2 decades especially after the medical profession was brought under the purview of the Consumer Protection Act. The need for accountability of doctors got carried to an extreme, and over a period of time transformed into hostility against doctors. As a result, most doctors developed a sense of insecurity and a sense of vulnerability to unfounded allegations of negligence by patients. Large awards of compensation by courts aggravated the situation further.

Though facing a malpractice litigation is now considered a predictable hazard of medical practice, most doctors are ill-prepared to deal with the devastating psychological effects of such a situation where there is an unexpected outcome, especially death of a patient.

WHY MEDICO-LEGAL STRESS IS UNIQUE

Allegations of malpractice are uniquely stressful to doctors because they are perceived as an assault on their competence and integrity and strike at the core of their self-image and self-esteem, especially those who may have spent a life-time impacting the lives of their patients who come to them for treatment. They may be extremely traumatic regardless of whether or not the allegations have merit. The emotional turmoil can be debilitating.

Allegations of malpractice and legal notice from a patient can trigger off emotional reactions in the recipient which may range from shock, anger, anxiety; denial, frustration and even guilt.

As doctors we are trained to fight with disease, but in this situation we are required to fight for our own survival AGAINST the patient and not FOR the patient!
We are used to being respected and appreciated for helping people with their medical problems and not being denigrated.
IMPACT ON THE AFFECTED DOCTOR

Michael H. Gendel, Medical Director of the Colorado Physician Health Program, sums up the situation beautifully in the newsletter of the CPHP:

“Among the stressful aspects of a malpractice suit is the unalterable and disturbing fact that one of our patients believes that we harmed him or her .Even in cases of a clear bad outcome, the physician may or may not have erred in providing treatment, but regardless of fault we usually feel guilty. If sued we start receiving documents that refer to us as “defendants”. And list the harmful things that we are accused of doing or failing to do. Many doctors feel stricken to see their names associated with such accusations, even if they recognize the hyperbole and stylizing of the language. Our self esteem is painfully punctured

When we are sued for malpractice our professional integrity is shaken. We feel unsafe, and we may dread going to work. Without understanding why, we may feel ashamed. Self-confidence may suffer, and regardless of the facts, we may question our competence and assume our fellow-professionals will question as well. We may feel betrayed and wonder if we can trust any patient”

In the US one study revealed that 95 % of doctors reported significant emotional or physical reactions to being sued. Closer home, being a close witness to hundreds of such situations involving colleagues who have unfortunately got caught up in a medico-legal tangle, I can corroborate the observations of Michael H. Gendel, and confirm that the impact of medico-legal problems on individual doctors is no different here in India.

I can vouch for the same, having personally faced such situations in a couple of cases of patient aggression with threats to sue and a legal notice as well on one occasion. Those who have faced similar problems will, I am sure, confirm the above observations.

Undoubtedly, the stress may continue long after the conclusion of the case even if the doctor was exonerated by the court. Facing litigation is a no-win situation for the doctor i.e. the trial itself is the punishment, no matter the outcome of the case. As they say, the process is the punishment.

MEDICO-LEGAL STRESS SYNDROME

Classically, the syndrome includes the following symptoms, though not all are necessarily present in each and every case:

The concerned doctor is stunned ,bewildered and disoriented.
The initial response is of disbelief and denial—”This can’t be happening to me!”
The legal processes which lie ahead are unfamiliar territory and to which he is not used to. Hence there is a fear of the unknown.
SYMPTOMS

MENTAL : Anger, outrage, excessive worry , frustration, distrust, negative self-image, depression, grief for the patient involved, Apathy, decreased interest in recreation/work, sense of having been assaulted , fear of being sued , fear of financial losses and loss of professional reputation.

PHYSICAL : Fatigue, inability to concentrate, insomnia, loss of sex drive , alcohol consumption or drug use , anorexia , GI symptoms.

While most cases can be handled with effective stress management, a few are known to progress to extreme levels.

Not uncommon to become insecure of his clinical / surgical skills
Becoming suspicious of patients and ordering unnecessary tests He may feel betrayed and wonder if he can trust any patient.
Hesitation to take on difficult or demanding cases
I know of a Physician who was so terrified following litigation that he stopped treating indoor patients and would only treat outdoor patients. I know of a surgeon who stopped doing surgery for several months and of course there was this Gynec-surgeon couple who ended up in divorce following prolonged litigation in an a malpractice case which was decided against them .

The wife of a neurosurgeon who faced litigations in multiple forums, following the death of a patient after spine surgery, told me that her husband now spends a sleepless night before the day of any surgery.

OCCURRENCE OF EXTREME SELF-HARM – ENDING ONE’S LIFE

As in the recent case of the Rajasthan gynecologist, the shocking occurrence of suicide should make us all ashamed. It is clearly a blot on the medical Associations and the colleagues of the doctor , on account of the fact that apparently the hapless victim had no confidence in their ability to protect him or her. This is something that should never happen!!!

It is extremely important for a doctor facing any medico-legal problem to be able to discuss it with some of his own colleagues, preferably those who have developed adequate know-how of such matters.

Many years ago the Association of Medical Consultants, Mumbai (AMC) identified the non-existence of a support system for a member who had to deal with the profound stress of patients challenging their competence and alleging negligence.

Quite literally, they had no one to turn to and were left to fend for themselves. In fact, I remember the days when most doctors were very secretive about the whole thing and sometimes, even did not let their family members know and very few even sought the moral support of their peers! Such was the feeling of shame and guilt and sense of stigma.

It was very clear thus that we needed to create a support system to help the doctor to face the attendant problems and minimize, if not eliminate the stress and improve the eventual outcome.

Accordingly, almost 40 years ago, a Medico-Legal Cell was constituted by AMC to spear-head this “support system” dedicated to the affected member .The comprehensive assistance integrated professional indemnity insurance through a tailor-made group insurance closely monitored by AMC, 24x 7 helpline, and generated a feeling in the member that he was not alone in his crisis and could share his fears and concerns (many times ‘imaginary’) and find answers to his queries.

DOS AND DON’TS FOR COLLEAGUES OF THE AFFECTED DOCTOR:

Empathize with him or her. Hindsight is always 6/6. The chain of events could have occurred with you as well. Hence don’t be judgmental. Offer whatever help you can. Merely doing that can also provide comfort.
Offer to scan the literature and provide him/her with reference which could possibly help defend the case.
In case supporting affidavit is required to show that there was no deviation in the standard of care, do not hesitate to give the same. Especially in consumer courts you are extremely unlikely to be summoned to the court for cross examination.
In case you detect symptoms or signs of MLSS, as listed above, help him or her to meet a counselor.
It is true that only a fraction of what needs to be done is currently on offer to doctors and we need to do much more to handle the Medico Legal Stress Syndrome affecting the member.

SELF-HELP GROUPS

Medical Associations should aim to establish self-help groups to make available advice from members who have faced similar problems so as to provide psychological, emotional and social support and develop mechanisms to cope up with the impact of the crisis. The efficient handling of the original problem with appropriate logistic support obviously ought to be central to the efforts.

IMPACT ON FAMILY MEMBERS

Family members could be part of the group. It is equally important to understand the trauma which the spouse and members of the family undergo and they have to be considered when trying to manage the problem. The members of the family also get involved –and in some cases even more than the doctor. Hence, management efforts must include the family. Sharing experiences could be a source of strength and hope .Essentially, the self-help group conveys to the affected doctor: “Others have gone through the same thing you’re going through, and they’ve survived and “so can you!”

The group would also help the doctor to counteract negative feelings by reminding him that litigation is about ‘compensation’ and not ‘competence’ and as a lawyer advised:”Don’t take this accusation personally, it is a professional hazard and the cost of doing business!”

Undoubtedly, a strong risk-management programme which emphasizes ethical practice of Medicine and prophylaxis for pre-empting medico legal problems , ought to form the bedrock of such a system .
In conclusion, Medico-legal Stress Syndrome must be pre-empted as far as possible by providing maximum support to a member who may have a potential to develop it and mechanisms to cope with the problem should be studiously developed. Help of Psychiatric colleagues should be enlisted as well

No doctor is immune to medico-legal problems.
Medico legal problems can be expected in the career of any doctor.
We have to learn to take these problems in our stride and not get overrun by them. You have help at hand –you are not alone.
Overcoming the crisis can make you a stronger person and a better doctor.

I have always believed and said it several times , that if an Association does not help a member in his most traumatic situation, it is not worth the paper on which its Constitution is written.

THE AUTHOR