Fear Itself
One of the earliest and most common emotional reactions to adverse patient outcomes is fear. Physicians and nurses remind me regularly that fear pops up whether or not a medical error is involved, and whether or not folks think they might have prevented the adverse patient outcome.
My anecdotal sense is borne out by research. Though we might wish it weren’t so, fear is an important element of many physicians and nurses’ response to bad outcomes they didn’t -- often couldn’t -- foresee.
This would not be a problem except for one thing: unprocessed fear can become disabling in a variety of ways. It often slows us down, distracts us in our workplace and personal life, tires us out, and can morph into PTSD, anxiety, and depression in healthcare providers.
Question for today: what is the nature of the fears -- because they are definitely multiple -- that accompany medical errors, patient safety events, or simply unexpected adverse outcomes, and what can we begin to do about them?
Fear of the unknown
When a patient safety event occurs or an unforeseen adverse outcome arises, a physician or nurse may suddenly become an actor in a type of play for which they have never rehearsed. The processes of root cause analysis or internal investigation feel unfamiliar to many of us and may vary from one institution to the next. Take the investigative process up a notch to a malpractice lawsuit and the unfamiliarity plus the fear it provokes rise exponentially.
While many hospitals now aim to embody the principles of “just culture,” old habits die hard. It will take time for the notion that errors emanate from the systems we work in as much as, if not more than, the individual worker to become the culturally prescribed norm. It will take prolonged, concerted effort for all of us to fully understand that after an unexpected outcome, even when an honest error is involved, the healthcare givers require as much support as the patient and family.
Even in places where that change occurs, no matter how much we trust the people we work with, many of us fear that we will be harshly judged. Perhaps that is partly because we harshly judge ourselves.
Walk Toward Your Fear
What do research psychologists, mischievous older siblings, and makers of horror movies all have in common? They get that fear of the unknown is part of human nature. No doubt, it may provide an evolutionary advantage in some situations. For me, however, it was an important source of anxiety in the midst of my own response to an unexpected patient outcome.
For years, right on through a malpractice lawsuit, I leaned hard on the mantra, “Walk toward your fear.” Maybe that can serve you, too. Reciting these words helped me to release the tendency to fight, flee, or freeze brought on by fear. All it took was just one or two small steps toward my fear to leave me neither fighting nor fleeing, but not frozen either, at least for the moment.
What did those baby steps look like?
Tiny things. Taking a deep breath before dialing for the first appointment with my defense lawyer. Asking my medical director what to do next. Talking with a former defendant who I heard had aced it on the witness stand about how she’d done it. Basically, a whole lot of micro-steps that added up little by little to making the unknown no longer unknown. Because at the very least, once the unknown is not unknown, fear of the unknown is no longer.
Imposter syndrome
Nothing will bring out fear that you are on the wrong career path, even the wrong life path, faster than a terrible patient outcome. This fear multiplies exponentially if you wonder if you might possibly have prevented the outcome. Events like these make it easy to believe that we somehow slipped through the sieve and simply don’t belong among our talented classmates and colleagues.
We fear reprisal. We fear that people are speaking ill about us behind our backs. We fear that we don’t have what it takes, and we conclude that we never belonged here to begin with.
As internist Dr. Dana Corriel so beautifully captured in her recent, highly personal blog post — “Hi, I’m Your Doctor, and I’m a Recovering Imposter” — physicians are particularly prone to this special fear.
Well, guess what? We’ll never shake off imposter syndrome without a communal change in mindset. I view imposter syndrome as directly rooted in perfectionism. And as I’ve said before, perfectionism is tied to all sorts of other ills. It’s not good for us; it’s not good for patients.
Want to know something else I’ve learned the hard way? An unexpected outcome and/or malpractice litigation -- besides being deeply difficult -- are a profound opportunity for growth. I kid you not. Never will you encounter a more demanding invitation to relinquish your perfectionism.
Doing that, of course, will bring out another fear all together, of course -- fear of change! Trust me, though, giving up perfectionism - not synonymous with giving up on excellence -- is totally worth it.
Fear of loss of livelihood or license
Many physicians faced with a malpractice lawsuit or nurses confronted with a patient safety event experience fear that they will lose their professional license. They worry about loss of income and wonder whether they’ll be able to provide for themselves or their family. They worry that they will lose the respect of their colleagues resulting in a loss of referrals.
With little to no information about how common malpractice lawsuits are, or who among their mentors and colleagues has been through it, physicians especially have no way to put their personal experience in perspective. They often find it impossible to contextualize this moment in the larger arc of a physician’s career and contribution to society.
Reality on the ground is that the majority of physicians in the United States, including the very best, will confront litigation, some more than once, and will not lose their livelihood or license as a result. Without communal support, however, many have no way to know that. And that is precisely why I find this conversation to be so crucial, and commit my time to it!
Have you experienced these fears? What have I missed? I’d love to hear. Do me a favor and let me know in the comments, or reach out to me one-on-one by e-mail.