If Patient Safety is Important to Medical Regulators, Physician Well-Being Can’t Be Ignored
I’ve started some of my previous pieces with a vignette — a short story that I used to introduce and illustrate the main point of the rest of the piece. This time I’ve decided to flip the script; I’m going to lead with my conclusions, which are based on my conversations with colleagues, the writing of others brave enough to speak of their experiences, as well as the medical literature. Then, once I’ve established my main points, I’ll tell you a story from my own experience that highlights their implications.
The first point I want to make is that for patients to receive safe medical care, it’s important that the people who are delivering that care are well themselves. It’s much more likely that harm will come to patients if the care they are receiving is from workers who are burned out, exhausted, or otherwise not well mentally. My second point is that medical regulators, who claim that their highest priority is patient safety, can make patients less safe by perpetuating a toxic work culture that prioritizes blaming individuals over doing thorough, evidence-based safety analysis. Medical regulators further contribute to unsafe conditions by punishing physicians who seek support for their own mental health. None of these points are original and I’m certainly not the first to make these claims — they are supported by the opinions, analysis, and research of other experts.
It’s no secret that burn out, mental illness, and suicide amongst physicians and medical trainees has become a major crisis in medicine. It is a complex issue with multiple contributing factors. In response to this crisis, medical regulators and others in charge have admonished doctors to be more resilient, to somehow achieve a better work-life balance, and to seek mental health assistance when needed. This directive to seek help sounds good, but there is a very important caveat: if a physician does receive mental health support, those same regulators also require that they disclose it. The doctor is then placed under punitive scrutiny. You can have cancer as a physician, but not anxiety or depression.
Given the unrelenting pressures of working in the medical system and the reluctance of doctors to access supports, the reality is that there are a lot of physicians who regularly provide care to patients while barely holding it together themselves. This was certainly true for me and remains so for many of my colleagues. When you work in a system that makes it clear that your health and safety are not a priority, it’s an uphill battle to stay well.
When patients receive poor medical care, the blame most often falls on an individual physician. This is appropriate in rare cases; it is true that incompetent or predatory doctors do exist in small numbers. Yet research into medical safety incidents has shown that it’s much more common that multiple factors, both individual and systemic, play interwoven roles that lead to unfortunate outcomes. It’s hardly ever just one person’s fault. In fact, this is what we teach in medical training: that whole systems must be scrutinized and improved to prevent medical mistakes.
Unfortunately, medical regulators almost never take this approach. Instead, they expect physicians to be perfect and, when something inevitably goes wrong, individual doctors are singled out and blamed without any acknowledgment of the multiple factors involved. As a result of all this, physicians operate within a culture of fear — scared to get help when they need it and afraid to acknowledge and learn from mistakes when they happen. If we wish to prioritize patient safety in medicine, our best chance is to identify all the factors that contribute to making people unsafe and then work hard to mitigate each of them. Good medical safety analysis is focused on learning and improving, not on finding an individual to blame.
Now, onto the vignette:
~February 2018
It’s first thing in the morning when I arrive at a small, quaint conference centre. This will be the first time in months that I’ll be meeting together with other doctors. That used to be routine for me, but there hasn’t been much interacting with colleagues since my professional regulator suspended my medical license. I’ve spent a lot of quiet, lonely, and shame-filled days at home, so this morning I’m both nervous and excited. I’ve been feeling so isolated that any opportunity to spend time with other physicians is appealing — despite the subject of the course. I take a deep breath, smooth down the front of a work-appropriate skirt that I haven’t worn in months, and step into the building.
As everyone checks in and receives a nametag that reveals only our first name, I’m keenly aware that there is shame associated with simply attending this course. Most of the attendees have been mandated to be here by their professional regulator because they’ve been accused of some sort of transgression. Under different circumstances, this course on maintaining appropriate professional boundaries with patients could be viewed as a learning opportunity or a rare chance for professional and personal reflection, but everyone here knows that is not how our regulators see it. Instead, this will be a punishment and sanction, a black mark on our records. Completion of this course will be a demonstration of our remediation. We’re all doctors, and therefore used to being high-fliers with big expectations of ourselves — but now we’ve been labelled by our regulators as a risk to patients. Perhaps as a result, this gathering is much quieter than any other medical course I’ve been to. As everyone takes a seat, it is as if a blanket of shame, interwoven with muted anger, has settled over the room.
One of the facilitators reviews the agenda and we’re told that on the last day of the course there will be a small group session where we will be expected to share about the events that brought us here, and to describe what we’ve learned from the course that will prevent something similar from happening in the future. We’re encouraged to be open and reflective. I experience a jolt of anxiety as I imagine trying to explain to a group of fellow physicians about how I ended up here. I doubt that any of them will have found themselves in a disaster quite like mine: where I was lured, coerced, extorted, and raped by a serial predator who was also my patient, and then accused by my regulator of sexually abusing him.
Despite all our early hesitancies and shame, the course itself is engaging and the facilitators are genuine and kind. As the attendees warm up to each other, we have several good discussions, talk about boundaries, and perform some role-playing exercises to practice our skills. During these sessions we also can’t help but to talk about our regulators, and how aggressive and deceitful they are in their accusations. While most of the physicians are willing to acknowledge that they crossed a professional line with a patient, many feel that it goes much too far to accuse them of doing any significant harm. Most of the attendees are angered by the one-sided way their cases have been handled and feel bullied by their regulators into complying with unjust sanctions to keep their licences.
Several of the physicians say that both their mental health and their practice of medicine have been impacted for the worse by their regulators’ actions. Now, they live in fear of doing anything that might displease a patient — even if that translates into not delivering the best medical care — because they don’t trust the system to be fair. As a result of what they have experienced, some of the attendees say that they have started to order unnecessary tests or medications just to keep patients happy. We all know that these practices are not just a poor use of resources, but sometimes they can be unsafe. Others admit that they now actively avoid treating difficult patients who are more likely to complain, or complex patients where something is more likely to go wrong. However, this means that these patients — often those most in need of diligent medical care — will have more difficulty getting help and, as a result, will be at increased risk. This is the kind of medicine that, as trainees, we’d promised ourselves we wouldn’t practice, yet here we are.
The bottom line is that none of my fellow attendees want to have another run-in with their regulator, and their actions and medical practice will become focused principally on that goal — even at the expense of the well-being of their patients. It also means that my colleagues will avoid getting mental health support for themselves, as this would get them into even more trouble.
The time goes by quickly and soon it is the last day of the course. In the time that we’ve spent together, most of the attendees have said very little about the specific circumstances that brought them here, and I’m sure we’re all curious to know each other’s stories. I’m assigned to a small group made up of a half-dozen men and myself. A facilitator is the only other woman in the room. We each take a seat and a brave man sitting beside me offers to go first. One by one, we work our way around the room, telling our stories. This means that I’ll be the last to share.
As I listen, what strikes me first is that each person’s story is unique. In many ways, it seems strange that all these physicians have been sent to the same course to answer for such disparate circumstances. If there is a common thread, it’s that several people describe a boundary issue with a patient when they weren’t taking good care of themselves. One physician describes trying to manage a much-too-busy practice without adequate supports when he accepted a patient’s proposal to collaborate in a business deal. Another doctor speaks about being in the middle of a painful divorce when he had an affair with a patient he met briefly in a walk-in clinic. A gentle rural family physician admits that he was tired and hungry when he accepted an elderly couple’s offer to share home-cooked food after a home visit.
Finally, everyone turns to me. I take a deep breath and tell a short version of the coercion and violence that I experienced at the hands of my patient. I tell my group that I was too afraid to ask for help so, for a long time, suicide seemed like the only way I might escape from the control of this violent man who had threatened my life and that of my family, while claiming membership in a notorious gang. I talk about some of the factors that contributed to my vulnerability to his manipulations — the under-resourced, toxic hospital environment where I worked, the burn out that I experienced, and my neglect of my own mental health. In the past boundaries had been very important to me, but I was so burned out that I didn’t have the strength to keep this skilled manipulator out of my head. I tell my group it’s entirely possible that I’ll never be allowed to practice medicine again as my regulator seems determined to revoke my license. Unlike the other attendees, I didn’t come to this course because I was told to — my regulator has shown no interest in remediating me — I’m just doing my best to move forward and trying to understand how it was that I ended up in this hell. When I finish my story, I tell my group that I wish that I had taken much better care of myself. Then none of this would have happened.
Everyone stares at me in stunned silence. As I feared, my story was much different and worse than anyone else’s. It is as if no one knows quite what to say at first, but when they do speak, my group responds first as physicians should: “Are you and your family now safe from this man?” “Do you still have thoughts of ending your life?” “Are you getting help for your mental health?” Then they respond as the humans that we all are: “Surely your license won’t be revoked.” “In the end, your regulator will see that it was you, not him, who was harmed.” “Through all this, I think you will discover that you are stronger than you ever thought you could be.” The responses of my fellow physicians at this boundaries course are in stark contrast to how the doctors at my professional regulator responded to the same story. There was no medical practice or humanity from them.
Driving home later that day, I think about those physicians in my group. Yes, each of us made a mistake, but not one doctor at that course seemed incompetent or predatory. I’ve met several predators as a psychiatrist, and none of my co-attendees came close to fitting that description. No one intended to harm a patient and, in many cases, it wasn’t even the patient that filed a complaint. In every case there were multiple factors — related to the physician, the patient, and the system — that contributed to what transpired. Each doctor had failed in some way, but they hadn’t done it alone.
It’s now been several years since that course, and I’ve thought about it many times since. Perhaps the biggest take-away lesson for me was the importance of physician health and well-being to good medical practice. As I’ve learned in spades, you’re best able to care for others — and at the same time protect yourself — when you are well. The truth is that in an over-burdened, toxic system almost any doctor could and will find themself crossing a professional line with a patient at some point in time. It is well established that, across many professions and settings, people have much more difficulty maintaining good professional and personal boundaries when they are overwhelmed, burned out, or unwell. A lot can be learned when people feel safe enough to admit to mistakes and are able to openly discuss their struggles. The kind of reflection we did at that course should be a regular practice for everyone in medicine, not a sanction meted out to the few who by chance get flagged by their regulator.
If it is indeed true that the health of doctors is so important to good patient care and safety, then medical regulators should do a thorough analysis of all the factors that contribute to physician burn out and mental illness and set out to make each one better. It is clear from the literature that one major factor is the practices of medical regulators themselves. Their current actions might give the appearance and illusion of improving patient safety, but, in multiple ways, the research shows that these practices can make patients less safe. If physicians continue to be afraid to get help for themselves and must practice within a regulatory system that they don’t trust to be thorough or fair, then that system that is supposed to be protecting the public is instead putting patients at risk.
