Portal de Periódicos da CAPES

The Scarlet Letter M

2007; Lippincott Williams & Wilkins; Volume: 29; Issue: 7 Linguagem: Inglês

10.1097/01.eem.0000285235.10210.b0

1552-3624

Edwin Leap,

FigureWe doctors are experts at death. I always used to say, “Don't mess with an ER doctor. We know where all the important parts are and where to stick sharp things!” (ER nurses tend to talk about potassium and insulin.) Turns out, it's actually true. We are dangerous. Doctors are good at killing, mostly themselves. Male physicians, it turns out, have up to a three times greater relative risk of suicide than the general population and female physicians up to six times! And when we do it, we do it right. We know the best pills to take and how to take them, and we know exactly where the bullet should go. We've known for a long time that doctors have lots of stresses that lead to suicide. But I guess I didn't realize until fairly recently how much malpractice litigation plays into physicians' thoughts of self-harm. I've heard different numbers about how much more likely we are to kill ourselves after malpractice suits. It appears to be a sizeable increase over our baseline tendency to hurry ourselves into eternity. That is, when we get sued, we think about killing ourselves more than ever. Sometimes it's when the suit is brought, sometimes it is as it's being litigated, sometimes it's after a judgment or settlement. Regardless of the timing, a malpractice suit does something to us. It's easy to see. We spend years and years learning to be competent, meticulous, cautious. We study and study, and become terribly upset over grades that would leave our non-medical friends ecstatic. We spend years face down in books, absorbing everything to get into medical school and then to survive it. Then what happens? In the course of seeing patients, we make a mistake or are accused of making a mistake. But we don't like to make mistakes. We're told we mustn't, shouldn't, can't make mistakes. So the first strike against our psyches is the error or perception of error. Then we're told that the alleged error caused harm. Holy smoke! What about primum non nocere? First, do no harm! We might have hurt someone! We try to never hurt anyone. We struggle to anesthetize wounds and anesthetize people. We don't want to cause so much as the pain of a needlestick. We slather patients with local anesthetic creams and pump them with sedatives to avoid the discomfort of splinter removal or the anxiety of draining an abscess. When we find that we may have hurt someone, or heaven forbid, killed someone, we're devastated. It flies in the face of everything we have been taught to do. It is the antithesis of what we hoped to be. Then we learn that our alleged error and alleged harm will be the subject of that little bit of public theater known as litigation. We'll be hauled before attorneys for depositions, before administrators for answers, and before juries and judges for evaluation of our decisions. We may face financial punishment. These days, we may even face civil or criminal punishment or the loss of our practice privileges. And it will all end up in the local paper. Subsequently, we'll suffer the quiet indignity of having other physicians look at us and whisper, if only to themselves, “I would never have done that!” We know that we'll be judged by our colleagues at least as harshly as we are by the public. The case may even show up, in some veiled fashion, at grand rounds or at a morbidity and mortality conference. For physicians in less equitable practices, even the hint of litigation may result in a talk, some warning, some suggestion not to do anything like that again “or else.” So in the end, all of the effort and compassion, the hard work and motivation, the hopes of a spotless career, are derailed, even if temporarily, by one event, by one error. And we fear that we will wear a scarlet letter M of malpractice for the rest of our lives. For many physicians, medicine is the single most important validation of their lives. It is the thing that has defined them throughout adulthood and that they intended to define them forever. Doctor, physician, healer, professional. These are the words that come to mind. Malpractice, however, replaces them with assailant, defendant, killer, quack. Worse, the lawsuit often uses words like willful, malicious, and premeditated in describing the evil actions of what is obviously an evil doctor. (Even as the plaintiff's attorney says, “It's not personal, you know. It's just business!”) So malpractice takes that validation and, if we aren't careful, shatters it into a million pieces. Threatening loss of work, loss of money and livelihood, loss of reputation, it ends in loss of self-image, loss of self-worth. For all too many physicians, that loss compounds the other stresses of practice, and makes death seem a reasonable, even desirable, alternative. And so, after a period of sadness and detachment, the stored pills are swallowed, the chamber checked for a live round, and a life of great achievement and service is brought to an abrupt end. It's so unnecessary. Brothers and sisters, we are good people. And the reason that malpractice makes physicians consider suicide is that we care, perhaps too much, about our careers. It is a high and amazing calling, medicine. It gives us the chance to support ourselves and our families, and to do so much good in a world that is so bad! Still, at the end of the day, it is still a job. And our lives are worth so much more than a job alone. As a profession, and as individuals, as colleagues and friends of other physicians, we have to reclaim our identity and worth, separate from hospitals and clinics, procedures and incomes, emergency departments and positions. We have to deny anyone the power to take our worth from us. No attorney or lawsuit, no plaintiff, however genuinely or falsely injured, should have the power to make us contemplate ending our own lives. The truth is, we will make mistakes. We may even cause harm. But we practice an imperfect science in an imperfect world on imperfect people. It is fraught with potential errors and disasters every day that we walk through the door to work, every time we touch a sick or injured human. But the greatest mistake we can make has nothing to do with missed diagnoses or medication doses, botched procedures or wound infections. The greatest mistake is to believe our worth as individuals has anything to do with any of that. Lawsuit or no, everyone reading this is loved, loved by parent or child, by spouse or friend, by lover or sibling, or by someone who loves you from afar and has yet to reveal it. Everyone reading this is loved by God, who knew you were going to make the very mistake you made and loves you anyway. Let's reach out to those who are sued. Give them a handshake or an embrace, a friendly smile and an understanding ear. Remind them of all the good they have done and of all the good they have yet to do. And we should tell them the stories of our own lawsuits so they won't feel so utterly alone. As individuals and as a profession, we need to stop making malpractice litigation seem like the worst thing in the whole world of medicine. Because in the end, it's nowhere near as horrible as having the world denied a good doctor through suicide. Conferences Listed on EM-News.com Listings of meetings in emergency medicine and related fields are now listed on Emergency Medicine News' web site, em-news.com. To view the listings, click on Events Calendar. To list a meeting in Emergency Medicine News and on the web site, send the name of the meeting, date, location, sponsor, and contact information, including a phone number to Emergency Medicine News, 333 Seventh Ave., 19th Fl., New York, NY 10001; [email protected].