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THE relationship between stress and performance was illustrated to me as a bell curve in one medical school lecture; the lecturer explained that, basically, too little stress can lead to complacency, yet too much stress is an equal impairment to performance. Stress under this model has the potential to be either constructive or destructive.
We are told that mistakes, errors of judgement and undesirable outcomes are part of learning and an opportunity for growth, yet, as doctors, it can be hard to view them this way. Our decisions have the potential to make a significant impact on someone’s life, we aim to help, but can inadvertently harm. In the 2013 beyondblue survey, 18.7% of doctors described this fear of making a mistake as an important source of stress. In part, this is due to a culture of increasing complaints and litigation in which the level of stress can easily become destructive.
One of the difficulties of practising medicine is navigating uncertainty. For me, it can be an unsettling moment at the end of the day, when other thoughts, jobs and distractions start to clear and from this thought-mist emerges a “what if?”. As one of my surgeon friends said: “surgery is great, until something goes wrong”. When something goes wrong, it can be one of the most vulnerable times of a doctor’s life, a sense of vulnerability that is only increased by the awareness of potential subsequent civil or disciplinary proceedings. It is easy to feel a kind of powerlessness. With the need to continue patient care, the tendency can be to push such worries to one side and just hope it doesn’t happen to us.
When I started at Avant as a Doctor in Training Medical Advisor, people asked me if my stress levels around the practice of medicine had increased. Perhaps they thought that being immersed in the medico-legal world would bring the inherent background fears of medicine to the surface by surrounding me with reminders of our shared professional vulnerability as doctors. The answer to this question is both “yes” and “no”.
Entering into the medico-legal world did increase my stress, but being in the privileged position of observing and assisting in medico-legal issues, without personally experiencing them, enabled me to better keep this stress constructive.
Starting as a GP registrar is a difficult process; patient after patient present with problems you have never seen – even humble plantar warts were at first a management mystery – and it is exhausting to be constantly discovering the unfamiliar and solving what you don’t know. It comes as some relief then, when after a time, you have developed processes and begin to recognise patterns.
After starting my medico-legal work, I was reminded of the inherent danger of over-reliance on these same patterns and how this could lead to early blinkering and missed diagnoses. I saw the worst outcome of a forgotten follow-up. I came to know the result of an eroded patient boundary. I recognised the burden on those who knew they had done harm. I felt stressed, but it was a stress that caused me to go back to my own clinical work and re-evaluate.
I learned to take a step back from reaching an overly quick diagnosis with its risk of bias, to question my confidence in a reassuring test result if the clinical signs were not equally reassuring, to develop my own safety nets around follow-up, to be willing to spend longer with patients and understand what is actually meant by keeping “good” notes.
A patient once came to me anxious to avoid in himself the heart attack his father had suffered. In taking a history, I could define both modifiable and non-modifiable risk factors and so was able to educate and plan around improving the modifiable risks. I feel that this shifted his amorphous worries to a more constructive stress; a level of stress was still a necessary motivator to get him exercising and improving his diet, but hopefully, this was something manageable and productive.
Similar to my patient, I have come to a better understanding of my own modifiable risk factors, as well as an improved ability to delineate and accept what is beyond my control; even the best mechanisms cannot always prevent an undesirable outcome, and I am not required to be perfect to protect myself or patients.
Nash and colleagues have described how GPs, after experiencing a complaint, believed that the “law required them to make perfect decisions”; the burden of the pressure to be impossibly perfect is considerable. We know from various studies that complaints and the fear of complaints can have a significant impact on doctors’ mental health, with the potential for causing functional impairment, increased suicide risk and changes in practice. Interestingly, there are also behavioural changes noted in doctors who did not have a complaint themselves but observed a colleague experience a complaint. There have been several studies that found that litigation or the complaint process may lead to changes in the way that medicine is practised, resulting in “defensive practice” and a greater number of “unnecessary” tests and investigations. As a doctor in training, or new fellow, the issue can be particularly acute; with increasing responsibilities and expectations comes an increased perception of risk, but not necessarily the confidence and knowledge that equip us for handling this risk.
Ensuring the stressors around clinical decision making in the medico-legal context remain at constructive levels requires more than just actions on the part of individual doctors. Systemic changes in complaint processes to increase transparency, efficiency and fairness are important. However, on an individual level, gaining a deeper understanding and, therefore, engagement with the medico-legal world has assisted me.
It is not possible for all doctors to undertake work within a medical defence organisation, yet, perhaps pulling the medico-legal bogeyman from under the bed and shining light on it could benefit doctors more broadly, with unknown fears and imagined consequences often far worse than the reality. Instead of seeing this cynically as turning doctors into lawyers and taking them away from clinical medicine, we can see it in the same light as my patient, as empowering ourselves and thereby better managing and understanding the inherent stress of risk.
Dr Nicole Fardell joined Avant in 2017 as the company’s first Doctor in Training Medical Advisor, a 12-month role which she combines with part-time work as a GP Registrar. She is also working to complete a Masters of Health Law.
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Thanks for a great article. While many of us tend to focus on medico-legal risks, it is actually intra-professional and institutional intolerance of risk and error that may affect us more. We have developed institutional “risk management” systems that are error-intolerant, and encourage closing down of judgmement rather than development. I agree with the comment above – about the importance of practicing our craft without fear. Constant fear leads to poor decisions and burnout.
Great article Nicole – excellent points.
We, as doctors, are humans and will, hopefully not, make mistakes. We all tend to be perfectionists in all that we do. But the prevailing environment doesn’t help that even for trivial stuff doctors are blamed left, right & centre.
We have been exposed even to vexatious complaints. We understand that there are risk and try to minimise them. Medicine is an art & a science. Let it not be one of defensive type. Hopefully we can continue to practice our craft without the fear.
Your last sentence is very much what we all should learn.
Agree with your comments. Having been on both sides of the complaints process as an referee for AHPRA and a practicing clinician, gives you empathy with both the complainant and the doctor. For many of us, our colleagues and partner are our greatest counsellors and support.
Agree with your comments. Having been on both sides of the complaints process as an referred for AHPRA and a practicing clinician, gives you empathy with both the complainant and the doctor. For many of us, our colleagues and partner are our greatest counsellors and support.