Dr Brett Mann, GP at Ilam Medical Centre and medical educator in the GP training programme, looks at the implications for doctors after making a mistake.

A registrar recently asked: “How can I be a confident doctor after making a serious mistake resulting in injury to a patient?”  

Most if not all doctors know that sudden sick feeling of anxiety and dread when hearing that a patient they have looked after has experienced a serious adverse event – usually one the doctor did not consider. For the reporting year of 2018-2019 health and disability service providers reported 916 adverse events to the Health Quality and Safety Commission.¹ Some of these resulted in major disability or death.  

When the patient is disabled or dies, it is easy to understand the doctor’s severe self-recrimination, painful rumination, feelings of inferiority and loss of confidence. Fear of medicolegal consequences and the often protracted and sometimes injurious nature of complaint procedures² may make return to emotional equilibrium more difficult. There are a number of issues to address and things to keep in focus to help doctors recover from these situations. 

The wider social context 

Doctors should remember that they are not the only group in our society regularly facing the risk of responsibility for mistakes that result in serious injury or death, eg police, fire fighters, the armed forces, some politicians, and others. It is vital for the good of society that individual members are willing to serve society by stepping into these roles and part of that service is living with the risk of being seriously criticised and occasionally having to grapple with the burden of personal guilt resulting from one’s human imperfection. 

Society and its doctors also have to accept that there is a limit to what doctors can learn from books and other formal educational activities. These activities can never fully prepare doctors for the myriad complexities of clinical practice. It is a painful and unpalatable reality that some things will only be learned in the crucible of clinical experience. Young doctors especially, should never blame themselves for being learners.

Who or what is responsible

The doctor immediately involved in a medical error is an easy target for blame. It is easy to be over-burdened with blame even though much or all of the responsibility lies elsewhere. It is important to look at exactly what happened. Sometimes there is no fault, with a poor outcome simply part of the unpredictability of life.

Doctor psychodynamics

Unrealistic personal expectations 
It should be remembered that no doctor has a perfect memory and no doctor is immune from the risk of serious medical error given the right circumstances. 

On one hand doctors must do all they can to avoid mistakes, and learn as much as possible from those that happen. On the other, human imperfection must be acknowledged and integrated into doctors’ understanding of themselves and their colleagues. While this difficult process of integration may not be fully achieved, unrealistic expectations contribute to excessively harsh self-judgments, shame and reluctance to acknowledge mistakes.  

Splitting
Splitting is the psychological process of ‘all or nothing’ thinking, dividing assessment of events into, good or bad, black or white, with little psychological space between. If the doctor bears some responsibility for the error, it is important to avoid ‘splitting’ in which the doctor passes wide-ranging judgment upon him or herself as ‘bad’, ‘incompetent’ or ‘a failure’.  It is important for a doctor not to automatically assume that he or she is less competent, less professional, less a ‘good doctor’ than other colleagues.  Mostly it will mean the doctor is human, imperfect, just like everyone else. 

Parent-child dynamics
The doctor’s response to an adverse event or complaint may stem from reactivation of childhood reactions to criticism from a parent. Personal introspection will commonly identify feeling like the ‘inadequate, bad, child’ criticised by ‘the competent, good parent’. Simply recognising the presence of this disempowering dynamic can be liberating as the doctor recognises that the dynamic should be ‘adult to adult’, on a more equal footing, that the criticisers are fallible imperfect human beings who can make big mistakes just like everyone else, and that the doctor has many strengths and capacities.

Patient psychodynamics

Projection and displacement
The natural response of most patients to suffering caused by a medical error is anger and blame. This anger may be intensified by unconsciously repressed emotion associated with the patient’s own imperfections and ultimate mortality. This emotion is then projected onto the doctor. Patient anger can also intensified by displacement in which unresolved anger from a previous experience is ‘added’ to the current situation.  

While it is difficult to know to what degree these dynamics are present in a specific case, awareness of both may help doctors take less personal responsibility for some of the anger directed their way particularly when it seems excessive and without mercy.  

Inadequate supervision 

I remember as a first year house surgeon making a diagnosis of biliary colic in a patient that turned out to have a ruptured duodenal ulcer. The patient ended up in intensive care with adult respiratory distress syndrome. I had discussed the case with the surgeon on call, nevertheless, the surgical registrar was harshly critical of my diagnosis the next day. I was disturbed but not devastated realising that the problem was more lack of adequate supervision of an inexperienced junior doctor. 

Gaps in medical education 

Sometimes doctors blame themselves or are blamed by others for mistakes that are more accurately recognised as imperfections of medical education. Nevertheless, while striving to improve medical education, it is important to accept that it also will never be perfect.

Systems error

It is well recognised that many other causes of error could be avoided by better systems.  Improvement requires further development of more user-friendly information technology systems that easily and clearly highlight problems to beware of with particular illnesses, and interactions of medications with specific illnesses. Medicine is increasingly complicated and no doctor can remember everything relevant to their scope of practice so, while better information technology systems are increasingly important, they will never be perfect either. 

Self-care 

Once a complaint occurs, emotional support is essential and can be sought from a spouse, trusted friends and colleagues. An understanding empathic colleague can ‘join’ the doctor through relating his or her own experiences leaving the doctor feeling less isolated and alone. Medical Protection internal surveys have shown that colleagues provide the most effective support for doctors who have received complaints.

Medicolegal advice

Seek medicolegal advice early in a complaint process, irrespective of whether or not the Health and Disability Commissioner or the Medical Council is involved. Medicolegal advice will provide perspective on how to respond appropriately to the complaint and helps the doctor avoid falling into unforeseen traps at a time of great stress and when thinking processes may be less reliable.

Distraction 

It is important to avoid rumination by using distraction. The brain tends to keep posting unfinished business on the internal ‘computer screen’. This is normally useful and adaptive but easily leads to harmful rumination when there is nothing further you can do at present about the situation. Stopping rumination by using thought blocking and consciously focusing on something else, especially something positive, helps avoid wasting emotional energy. 

Postcard technique

The ‘postcard technique’ is a very helpful strategy from neurolinguistic programming. When the unresolved problem fills the ‘internal screen’ it is difficult to see the positives so the problem is shrunk to postcard size and put in the corner of the ‘internal screen’. This allows the positives to be seen at the same time: your other considerable clinical skills, your successful diagnoses and lives saved, and your other grateful patients and their families. This helps maintain perspective.

Psychological help

Doctors should not be reluctant to promptly seek psychological help but often are. They should be quick to see their own general practitioners regarding stress and mood issues and avoid temptations to self-medicate with alcohol or prescription drugs. In addition, Medical Protection and the Medical Assurance Society offer a well-received jointly funded counselling service for stressed doctors.³ Psychotherapy and/or cognitive behavioural therapy is likely to be very useful in addressing these thinking patterns and other psychodynamics unique to the doctor, that exacerbate suffering.

List of things to keep in mind

Most people can only keep one or two things in mind at once. This is a problem when you may need four, five or more ‘handles’ to grasp to maintain your emotional equilibrium. It is very helpful to write a list of thoughts or ways of thinking about the situation that have eased the burden. Keep the list close by. This list concretises intangible thoughts, helps the doctor remember them and see them ‘all at once’, and can be perused whenever the doctor is feeling destabilised.

Self-care

Maintaining healthy dietary, sleep, and exercise patterns is very important. Consideration should be given to reducing workload until emotional equilibrium and confidence improves. Making sure there are enjoyable activities outside of work to look forward to each week will help provide relief from the stress.

Conclusion 

Doctors provide a vital service to their communities and ease the suffering and save lives of many more people than they ever unintentionally injure. Society and its doctors need to address unrealistic expectations. They should better recognise that doctors and the systems they work in are imperfect, and that the complexities of the human condition always exceed the ability of doctors to get it right every time.

Recovery for the doctor may be complex. Detailed consideration of who or what is responsible, avoiding the doctor’s own harmful psychodynamics, awareness of the psychodynamics of patient anger, using some basic psychological tools, combined with comprehensive psychological support can markedly reduce the doctor’s suffering. Good self-care and early medicolegal advice is essential.

In the end, it is important to take the long-term perspective realising that one day the intensity of the current situation will be over and the whole unpleasant event will have retreated to the margins of the doctor’s life. The doctor will have survived and be wiser for the experience and will have paid the emotional price that most doctors pay serving society as a member of this demanding but very rewarding profession.


¹Learning from adverse events 2019. Health Quality & Safety Commission New Zealand. 
²Cunningham W, Dovey S, The effect on medical practice of disciplinary complaints: potentially negative for patient care NZMJ 113:464-7 (2000).
³Cunningham W, Cookson T, Addressing stress related impairment in doctors. A survey of providers’ and doctors’ experiences of a funded counselling service in New Zealand NZMJ 122 No 1300 (2009).