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C H A P T E R 2

Medical Malpractice Stress Syndrome

S. Sandy Sanbar, M.D., Ph.D., J.D.
Marvin H. Firestone, M.D., J.D.

GOLDEN RULES
1. Medical malpractice lawsuits are extremely stressful.
2. The allegation of medical malpractice may be extremely traumatic to the
accused physician.
3. The primary manifestations of medical malpractice stress syndrome are
psychological symptoms (e.g., acute or chronic anxiety and depression),
and the secondary manifestations are physical symptoms.
4. The accused physician must acknowledge that he or she may be suffering
from a medical malpractice stress syndrome.
5. The distressed physician should seek support, understanding, and comfort
from immediate family members, close friends, defense counsel, and
professional colleagues.
6. The physician needs help to acknowledge and address the fears of medical
malpractice stress.
7. The accused physician must continually be reminded that being sued for
medical negligence is a predictable hazard of medical practice in our
times.
8. Education of the sued physician about medical malpractice stress is the
key to dealing with the fear of litigation.

The purpose of this chapter is to provide an overview of the medical mal-

practice stress syndrome (MMSS), its symptoms, diagnosis, and manage-
ment in hopes of providing physicians who are suffering from, or who are
caring for other litigation-stressed physicians, with the necessary tools to
effectively manage this disorder.

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10 Physicians and Malpractice

CASE PRESENTATION
Dr. Ray Sunshine is a 43-year-old second-generation family physician.
While in medical school, Dr. Ray met and fell in love with his classmate,
Angela. They got married the same month they graduated from medical
school. He and his wife have three children, two daughters and a son.
After Dr. Ray and his wife graduated from medical school at the
University of Florida, Dr. Ray completed a residency training program in
Family Medicine; Angela also trained at the University of Florida as an
Emergency Physician. He has been practicing medicine for 12 years,
working with his wife, Angela, and his father, Christopher, at the Family
Medical Clinic, in Sun City, Florida.
On January 13, 2001, at approximately 1:00 P.M., Dr. Ray returned
from lunch to resume his work at the Clinic. His nurse approached
Dr. Ray and informed him that the Sheriff (a patient treated by his
father) was here to see him. The Sheriff was ushered into Dr. Ray’s
office. The two of them exchanged greetings. Apologetically, but in a
businesslike manner, the Sheriff served Dr. Ray with a summons and
complaint, alleging medical malpractice. The Sheriff told Dr. Ray that
he was being sued by one of his patients. The Sheriff said goodbye and
walked out of the office.
Dr. Ray was stunned, shocked, and dismayed. He could not believe that
he was being sued by one of his patients. He had never been sued before.
He could not think of having done wrong to his patients. He thought to
himself: “All my patients love me. Who would do such a horrible thing?”
He had flashbacks of many patients that he had treated in the last few
years. He gently placed the petition on his desk without opening it, and he
stepped away from his desk, all the time staring at the petition.
His forehead became sweaty, as did the palms of his hands. His hands
were shaking and his body felt like it was trembling all over. His chest felt
tight and he could not breathe deeply enough. He had goose bumps all
over. He became weak and nauseated. His lunch-filled stomach felt heavy,
and he was afraid he might vomit any time. He felt momentarily unstable
on his feet and dizzy. Dr. Ray could not believe what was happening to him.
Nurse Susan knocked at his door and entered the office to inform
Dr. Ray that his first afternoon patient has been waiting to see him. The
doctor, now visibly pale and diaphoretic, did not look back to acknowledge
the nurse’s presence. Instead, he walked two steps and sat in a nearby
chair, with his head bent forward. He felt ashamed and did not want to
tell his nurse what had happened. He took his handkerchief out of his
back pocket and wiped his forehead.
The nurse, realizing that there was something wrong, asked the doctor
if he felt all right. The doctor did not answer at first, but then he told the
nurse to cancel all his patients for the rest of the day because he was not
feeling well. The nurse then informed Angela, Dr. Ray’s wife, that Dr. Ray
was not feeling well.
Angela excused herself and ran to her husband’s office. He was
still sitting in the chair, staring at his desk. “Honey,” she said, “What is
the matter? What is bothering you? Are you hurting anywhere?”
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Medical Malpractice Stress Syndrome 11

Dr. Ray could not talk. He felt lonely even in his wife’s presence. Guilt
feelings were running through his mind. Angela asked him what the
Sheriff was doing here. Dr. Ray stared at the petition on his desk and
nodded ever so slightly. Angela walked toward the desk, picked up the
envelope, opened it, and slowly read allegations of negligence and gross
negligent acts by her husband. She was shocked herself, but she quickly
realized that her husband was suffering from an acute stress disorder.
Angela called her father-in-law, Dr. Christopher, who was in his office,
and informed him about Dr. Ray. He rushed to Dr. Ray’s office and
expressed concern and when he was informed of the lawsuit, he told his
son that when he was sued by one of his patients for medical malpractice,
he likewise suffered symptoms of distress throughout the five years of
litigation, until the lawsuit ended in his favor.
Dr. Ray’s malpractice litigation lasted three years, during which time
both his wife and father were extremely sympathetic and supportive.
Nevertheless, Dr. Ray suffered distress symptoms throughout the course
of the litigation. The trial ended with a defense verdict. Dr. Ray was
relieved, but continued to suffer from symptoms similar to those who
have post-traumatic stress disorder.1

STRESS OF MEDICAL MALPRACTICE LITIGATION

Medical malpractice lawsuits are extremely stressful. They are predictable
hazards of medical practice. Some medical professionals view malpractice
lawsuits as an inherent part of providing medical care. Indeed, no individ-
ual physician is immune from medical malpractice, and the majority of
physicians are affected, directly or indirectly, by patients alleging negligent
professional care as the cause for their injuries.
It is known that litigation distress may affect any individual who is involved
in litigation. There are predictable effects of medical malpractice lawsuits on
the defendant physicians characterized by the medical malpractice stress syn-
drome, a unique variation of the well-accepted litigation stress syndrome.
Even though medical malpractice lawsuits are common, most physicians
are ill-prepared to deal with the devastating psychological effects of medical
malpractice litigation on the physicians, their families, and their medical
practices.
The stress of medical malpractice litigation may directly contribute to
physical illness of the physician, as well as dissatisfaction with medical
practice leading to burnout and early retirement. Tragically, if the reaction
of the physician is extreme, depression may lead to suicide.

MANIFESTATIONS OF MMSS
An allegation of medical malpractice (or charges of unprofessional or
unethical conduct by a physician’s peers) may be extremely traumatic to the
accused physician, regardless of whether or not the allegation has merit.
The emotional turmoil that results can be debilitating.
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12 Physicians and Malpractice

The primary manifestations of medical malpractice stress syndrome are

psychological symptoms (e.g., acute or chronic anxiety and depression), and
the secondary manifestations are physical symptoms. The physical symp-
toms may be manifestations of a new disorder or may represent an aggrava-
tion of a preexisting disorder.

ANXIETY SYMPTOMS
The accused physician may develop excessive worry, which would occupy
over 50% of waking hours. The physician may have difficulty controlling the
worry. When such worry symptoms last over six months, it is characterized
as persistent or chronic.
The physician may complain of restlessness, tiredness, difficulty
concentrating, irritability, tense muscles, and/or insomnia. Such anxiety
symptoms interfere with the physician’s daily life both at work and
at home.
Some physicians develop feelings of anger, bitterness, shock, dismay,
guilt, shame, irritability, frustration, distrust, loneliness, and diminished
self-esteem; and the physician may manifest hyperactivity.
The accused physician may react by emotionally distancing himself/herself
from family members, friends, and professional colleagues. Interest in
work, food, recreation, and sex may be diminished. The accused physician
may become insecure, may develop concerns about ability and competency
to make decisions, may compulsively order unnecessary tests on patients,
and may have thoughts of changing careers.
The physician may resort to alcohol, or self-medication, in an attempt to
self-medicate many of the uncomfortable symptoms. The accused physician
who is already suffering from a preexisting medical illness, such as coronary
artery disease, diabetes, hypertension, or gastrointestinal disease, may
exacerbate or aggravate those disorders, thereby causing more physical
symptoms and signs related to those disorders.

CONSULTATION WITH TREATING PHYSICIAN

The accused physician must acknowledge that he or she may be suffer-
ing from a medical malpractice stress syndrome. It is sometimes difficult
for the physician to formally seek medical or psychiatric attention from a
colleague. Especially when the symptoms of anxiety and depression are
severe, or where there are thoughts of suicide, the distressed physician
should seek prompt psychiatric assistance.
Management and control of the symptoms of MMSS under the supervi-
sion of a treating physician should never be underestimated. The ameliora-
tion of the stress symptoms will lead to a feeling of wellbeing, confidence,
and behavioral control, thereby reversing the agonizing mental turmoil.
Reduction of stress symptoms will also allow the physician to think and act
with greater objectivity, to remain focused, and to maintain a more healthy
perspective on the litigation process.
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Medical Malpractice Stress Syndrome 13

DISCUSSIONS WITH FAMILY, CLOSE FRIENDS,

AND COLLEAGUES
A friend in need is without question a friend indeed. The distressed physi-
cian should seek support, understanding, and comfort from immediate
family members, close friends, and professional colleagues. In particular,
open and candid discussions with one’s spouse, and maybe even the children,
may reassure all the family members. This can lead to greater support and
understanding of any unusual behavior.
Discussions with physician colleagues, particularly those who have been
through malpractice litigation, can be helpful. Reaching out to family,
friends, and professional colleagues for emotional support should not be
construed as a sign of weakness. Just the opposite, it is the imprimatur of a
wise and strong person, one who is not afraid to confront reality, no matter
how harsh it may seem.

MEETING WITH DEFENSE COUNSEL

This topic is discussed in detail in Chapter 8. The meeting(s) between the
accused physician and the defense counsel can be extremely helpful in
educating the physician about the legal system and addressing fears and
concerns about the litigation. The physician who develops rapport and trust
with the attorney, who gains a thorough understanding of the legal process,
and who assists the legal counsel to understand the factual issues related to
the alleged negligence claim, will benefit immensely by gaining confidence,
thereby reducing the stress of litigation.

MANAGEMENT OF MMSS
In March 2005, at the 45th Annual Conference of the American College of
Legal Medicine, in Las Vegas, Dr. Louise B. Andrew, who is an expert in
this area, presented the S. Sandy Sanbar Lecture, which dealt with this per-
sonal, sensitive, and difficult subject of malpractice litigation stress, and the
following discussion is derived in part from that excellent lecture, as well as
from the selected references at the end of this chapter.
Dr. Andrew noted the following four essentials of management of MMSS:
1. Replace mystery with knowledge.
2. Replace shame with confidence.
3. Provide insight into the players and drama while being enacted.
4. Provide tools and strategies for combating the emotional and physical
stress of litigation.
Dr. Andrew pointed out that charging the physician with malpractice is
perceived as a “wound to the heart.” In every known bad medical treatment
outcome, the physician blames self long before the patient begins to blame.
Hence, the physician already has a wound to self-esteem by the time
the legal claim is made. Every step in the legal process, while ostensibly
designed to reveal the truth and serve justice is perceived by the physician
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14 Physicians and Malpractice

as an attempt to prove intentional wrongdoing by the physician. This is

related to the psychological vulnerabilities of the accused physician and the
lack of understanding of the legal process.
The physician needs help to acknowledge and address the fears of
medical malpractice stress, all of which are appropriate to the situation.
These include:
1. Loss of control.
2. Loss of livelihood.
3. Loss of reputation.
4. Loss of assets.
5. Loss of significant supporters.
6. Lack of knowledge about the process and potential outcomes.
Education is the key to dealing with fear. The physician should be
encouraged to:
1. Attend supportive educational meetings.
2. Read available materials on litigation stress support.
3. Seek advice from experienced colleagues, malpractice and estates
lawyers, counselors, or consultants.
4. Ask questions, and acknowledge that this is not the physician’s
sphere of expertise.
The physician can do a number of things, including:
1. Begin to transform one’s personal definitions.
2. Pay more attention to one’s own needs.
3. Assemble a personal survival kit.
4. Pay more attention to the needs of one’s principal supporters.
5. Reframe the case as a “Passion Play,” and hone one’s acting skills for
the court drama. According to Dr. Andrew, the physician should
recognize that he or she is an actor involved in a malpractice law-
suit “drama” which is not of the physician’s own making nor under
his/her control. The arcane script is written by people who have long
been dead, by morbid “poets,” and by modern-day pirates. Indeed,
only part of the physician’s professional persona is involuntarily
involved in the “Passion Play.”
It is important, according to Dr. Andrew, to arm the physician with psy-
chological armor. The physician should be taught that, to the extent that he
or she forgets the actual goal of the plaintiff (money), and accepts the stated
goal (justice), he or she can and will be disempowered. Therefore, to the
extent possible, the physician should ignore what the other side says or does
and focus on the fact that the plaintiff is only entitled to money.
The physician must remember that knowledge is power and must be
acquired. The physician should be encouraged to access resources, including
counselors and consultants in litigation stress and witness preparation, talk
to close colleagues, and attend support groups. Physicians who have been
involved in malpractice litigation should share their experiences and their
successes with their colleagues.
The accused physician must continually be reminded that being sued for
medical negligence is a predictable hazard of medical practice in our times.
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Medical Malpractice Stress Syndrome 15

Medical malpractice litigation is one of the most stressful events of the life of
any physician. But it is survivable and surmountable. It can be an experience
from which the physician can actually become a better doctor. Nietzsche said,
“What does not destroy me, makes me stronger.”
The physician can derive therapeutic benefit from the following:
1. Being actively involved with the defense attorney team.
2. Participating in official discovery requests.
3. Assisting in identifying qualified experts.
4. Performing medical literature research to determine nuances of
medical care.
5. Attending as many depositions and as much of the trial as feasible.
6. Preparing diligently for appearances by thoroughly knowing the
medical records and the medical literature.
7. Becoming educated and comfortable in dealing with the tactics of
the plaintiff’s attorney and the time and scheduling difficulties
required by legal proceedings.
8. Becoming educated about medical malpractice stress and its
effects on the physician.
9. Recognizing that there are inherent conflicts of interest between
the insurer and the physician.
10. Being prepared to seek counsel by a private attorney if conflicts
are perceived with being represented by an insurance company
appointed attorney or if claims are not covered or if an excess
judgment beyond coverage is possible.

FURTHER READING

Andrew, Louise, Managing Medical Malpractice Stress, 2003, last accessed

February 26, 2006; http://www.magmutual.com/risk/malpractice-stress1.html
Charles SC; Wilbert JR; Franke KJ, Sued and nonsued physicians’ self-reported
reactions to malpractice litigation. Am. J. Psychiatry 142(4):437–440(1985).
Charles SC, How to handle the stress of litigation. Clin. Plast. Surg. 26(1):
69–77(1999).
Charles SC, Coping with a medical malpractice suit. West. J. Med. 174(1):
55–58(2001).
Reading EG, Malpractice stress syndrome: a new diagnosis? Md. Med. J. 36(3):
256–257(1987).
Reading EG, The malpractice stress syndrome. N. J. Med. 83(5):289–290(1986).

REFERENCE

1. Diagnostic criteria from the Diagnostic and Statistical Manual of Mental

Disorders,4th Edition, with text revision (APA 2000) (DSM-IV-TR) for Acute Stress
Disorder (DSM-IV-TR 308.3) and Post-Traumatic Stress Disorder (DSM-IV-TR
309.81) other than Criterion A (the stressor), describe the signs and symptoms suf-
fered by physicians who suffer MMSS.
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