Dealing with Bad Patient Outcomes

Wavebreak Media Ltd/123RF.com

When you learn that your patient has had a bad outcome, it devastates you. It won't matter whether the outcome was preventable or your fault; you always feel responsible.

Being a physician is enjoyable, but you are constantly vulnerable. Your decisions suspend the sword of Damocles. At some point, one will go poorly, and your stability will end.

Working in a high-liability specialty for the past nine years, I have received the news of bad outcomes several times. It never gets easier—and frankly I think that if it does, it's a good sign that I should probably quit clinical medicine.

Below is the process I go through and a few tips I wish I knew earlier on. Hopefully, it will help you when you receive this news.

Steps For Getting Through the Process:

1. Panic. Allow this to happen. When you receive the news, you will spend the day wringing your hands, pacing the halls and being a train wreck. You will pinch the bridge of your nose while squinting. Images of lawyers, courtrooms, and jail will dance through your mind. (Unless you did something criminal, you aren’t going to jail.) You will sleep restlessly.

You cannot control this. Guilt, anxiety, regret, and sorrow knot in your chest.

This is like grief - you cannot fight it. You have to go through its stages in order to be whole again. It will come out in one form or another, so just let it happen.

This feeling, too, will pass.

2. Avoid vices. Alcohol, drugs, food, whatever your vice is, do not use it. This will never help you and it’s how addictions are born, fueled, or furthered.

3. Set aside a time to review the chart. Don’t do it the second you’re informed of the case; your judgment and objectivity are not reliable at this point. Clear your schedule at a future time, find a quiet place, go through the record and get all of your questions answered.

Return to it only to answer specific questions and then leave it alone.

4. Gain perspective. Let the facts and timeline of events sift out.

It may be that you didn’t make a mistake. Or maybe, you did exactly what you should have done at that moment and you would do it again tomorrow. And some bad outcomes are sometimes inevitable; they would have occurred regardless of the care given.

Or, maybe you did make a mistake, but it was very reasonable based on the information available to you at that time. Maybe any provider would have made the same mistake in your position.

I review charts for private companies and co-workers and have learned that bad outcomes are almost never completely the fault of one person; there’s usually a combination of factors, people, and broken systems that lead to them. Weigh these and consider your role among them.

Put the case in perspective - both in terms of that case and then of your entire career. Aren’t there literally thousands of patients you’ve seen that have had good outcomes? Haven’t there been loads of people you’ve helped or lives you've saved?

There are always things one can improve upon, but one case does not define you or your competency.

5. Seek objective opinions. Don’t ask people who are going to tell you what you want to hear. Ask people who are objective using the facts you’ve obtained.

What would they have done? Was what you did reasonable?

When these people offer insights, let them talk. Listen. Incorporate what they’re saying into your narrative of what occurred.

Ask: Is what I did reasonable? What would you have done differently? Remember, everything they're going to tell you is through the retrospectoscope.  They already know that there's been a bad outcome so it's easy to say: "Oh, I would have done this test or asked that question!" because they already know the answer.

You don't need to know how perfectly they would have managed the case. What you need to know is whether what you did, at that point in time, given the information you had was appropriate or not.

6. Take part in the hospital or legal pageantry professionally. Avoiding investigations spells guilt. Getting there and being defensive or accusatory spells guilt. Go there, give the facts, and move on.

The hospital or legal proceedings aren’t fun, but they aren't that bad. By the time you actually have to take part in a formal process, you’ll have been through the case so many times that a deposition is more of an irritating formality than it is intimidating.

Also, you've been through medical school and residency. You know what it's like to have your thoughts publicly dissected. Same thing here - you've done this before, you held it together, you survived.

And you'll survive again. The proceedings are just formalities.  Often times, the people moderating the proceedings aren't physicians, and you're the only expert in the room. Answer only the questions being asked and move on. Realize that your judgment of yourself and your care is not related to any judgment they render - you know your role in the case and what you truly could have impacted.

You will decide how you feel about the case through introspection; the outcome of any proceeding is independent of your sense of guilt.

7. Give it as much time as it needs to heal. Think about this the way you think about grief. It moves at its own pace and goes through its own stages. You don't just jump to "Acceptance." If you try to force the healing, you’ll miss an important step.

Some providers have a PTSD-like experience after a bad outcome: An unnatural fear of opening email or mailboxes; knocks on the door become potential subpoenas. Some doctors don't want to work in the same area where they saw their patient or see patients with similar symptoms. Some experience recurrent dreams of guilt, persecution, and loss; intrusive, repetitive thoughts of death and dying; substance abuse; irritability and depressive symptoms. Others succumb to over-testing and over-utilization of consultants to avoid decision-making. You will perceive that everyone knows the case and thinks you’re an awful physician.

I know physicians who have spent months to years impacted by patient deaths—even deaths they couldn’t have possibly controlled. If it persists and you’re not able to function, your life is derailed by unrelenting symptoms, find a mental health professional.

Physicians should learn to look at bad outcomes like they do paying taxes—it’s not a matter of if, but when. And, like paying taxes, the more you understand and plan, the better off you are.

No one is perfect, medicine is challenging and our healthcare system is complicated. It’s just a matter of time before the pieces line up against you. But the opinion of what your role in a case was is ultimately yours.  Regardless of the outcome of a case, no one can judge you as you will judge yourself.

The best thing you can hope for is that when you review your care, you can honestly say to yourself “If I saw the same patient tomorrow, I would do exactly the same thing.”