Barry Bub, MD

The author reports no financial relationships relevant to this article.

Editors’ note: This article appears under the “Focus on professional liability” series banner even though Dr. Bub’s discussion does not directly address matters of being sued. Our, and his, belief is that good communication brings a significant added benefit of lowering a physician’s litigation risk.

• It was tiring to try and think logically as the guy threw more and more facts at me.—An adolescent with cancer¹
  

Consider the findings of two surveys of radiology residents and attending mammographers on breaking bad or troubling news to patients:

• 16% of residents and 4% of mammographers “didn’t feel confident communicating with patients who displayed strong emotional responses”
  
• 86% of residents and 81% of staff experienced “some or moderate stress communicating the need for biopsy”
  
• The majority of all respondents “hadn’t received feedback about their communication skills or communication training after medical school”
  
• 68% to 78% of respondents expressed interest in “improving their communication.”²
  

Breaking what you might perceive as “bad” news is never easy; even experienced practitioners may find the task stressful, as the results of these two surveys reveal. Physicians having been trained to do no harm, few find themselves at ease revealing information that has the potential to disappoint or upset, even devastate.

In this article, I offer an approach to breaking bad news in a manner that lessens the trauma to the patient and buffers you from the stress, and distress, of delivering it. The box near the end of this article gathers pearls for giving bad news based on my work and the experiences of others.

We are not unaffected by this task

Most of us find the act of breaking bad news a professional burden that we could just as soon do without. When we perceive an element of personal responsibility, our burden becomes greater: We may experience fear, guilt, or shame—and, for some, that leads to psychological stress disorders and burnout.

How do we cope, being occasional messengers of bad news?

We avoid. An obvious strategy. Consider Dr. D., a radiologist who heads a breast imaging center. He confides that many physicians ask him to inform their patients when he notes an abnormality on their mammogram. Still other physicians, Dr. D. points out, simply have their nurses call patients with troubling results.

Or we run. Another widely used strategy is to break the news and bolt. One cancer survivor lamented: “As soon as I started to cry, he ran off to fetch his nurse. Don’t you know doctors flee from suffering?”

Keeping matters in balance—that is the challenge

How do we maintain our sensitivity, humanity, and connection while, simultaneously, limiting our own vulnerability and pain? Many of us have wrestled with this issue from the earliest days of training:

• In the hospital’s predawn stillness, she confided fears about surgery to me, the medical student. I tried to reassure her. They operated. Finding extensive metastases, they closed immediately. That evening, aching for her, I cried.
  
• “Don’t worry,” another student reassured me. “It gets easier.”
  
• I hope not. If it does, I’ll have lost my humanity.³
  

There are more questions to challenge us: How do we break bad news in a way that is least traumatic to the recipient? How can we be honest and open yet, when pressed, offer some hope when—objectively—there is little cause for optimism? How do we communicate important information regarding treatment options, prognosis, and so forth, at a time when the patient is least able to absorb it?

Simultaneously, how do we handle our feelings of impotence, failure, and, perhaps, guilt—when every expression, gesture, word, and silence are potentially filled with meaning to those who are receiving the news?

David Lenz, an artist, in a commentary on his award-winning painting, “Sam and the Perfect World,” wrote:

• My wife Rosemarie had just given birth to our son Sam, and although he appeared perfectly healthy, something, nevertheless, didn’t seem right. There was an awkward silence in the room, no words of congratulation or comments about how cute he was—even though he was cute. Five minutes later the diagnosis was given: Sam has Down syndrome. “Are you going to keep him?” a nurse asked. Later that evening someone else came by to “console” us.
  
• “It’s every mother’s worst nightmare,” she said.
  
• Welcome to the world, Sam.⁴
  

Many in our profession advocate a disingenuous connection/separation approach to giving bad news—a so-called detached concern. Our professional journals recommend that we examine and control our emotions in the interest of “objectivity”

 

⁵ and invest in deep and surface acting (of empathy).⁶ I disagree with this advice⁷ ; instead, I advocate that we notice, validate, and park our emotions. Later, we take time to integrate our emotions through self-care. Rather than relying on “the art of medicine” to communicate bad news, we should approach this task as a serious professional challenge and incorporate principles of trauma counseling, psychotherapy, and chaplaincy into the practice of medicine. Instead of distancing from our emotions and our patients, we draw closer.

Here is how one physician handles breaking bad news.

CASE

Dr. Bob, we’ll call him, typifies the overworked primary care physician. Yet, when a lab or imaging report that reveals an abnormal result lands on his desk, he, not a nurse, calls the patient. He waits a few days if the test or study was ordered by another physician; in that situation, he often reaches a frightened, confused person who had already been called by the specialist’s nurse.

When that happens, Dr. Bob invites the patient, and a close relative, to schedule an office visit with him. In the interim, he forms a liaison with the specialist so that they can function as a team.

At the office visit, Dr. Bob refuses to prognosticate. Instead, he recommends that they take matters “one step at a time.” His approach is positive and reassuring but not overly optimistic. His message is clear: “You are not alone. I will be a supportive presence throughout your journey.”

Two notable things about Dr. Bob: First, he does not suffer burnout or what some have called “compassion fatigue”; to the contrary, the relationship he forges with his patients and their loved ones, and the gratitude and loyalty he receives from them, sustain and reward him.

Second, Dr. Bob has never been sued.

The key to Dr. Bob’s success is that he does not shy from breaking bad news. Instead, he views the occasion as an opportunity for healing. His approach is to detach from the outcome but not from the patient. He relieves fear and isolation, and offers, as one patient said it, “candor with hope.”

Summon your personal strengths to succeed

But taking this approach requires a shift from the standard biomedical philosophy—a three-pronged cultivation of personal resources. Here is how you can make that shift.

First, cultivate equanimity—that evenness of mind

Consider that destruction is an inherent component of creation. There can’t be light without darkness, birth without death, joy without suffering, perfection without imperfection. The Sufi mystic, Rumi, said it succinctly: “A butterfly needs two wings to fly.”

Recognize that not all news is equally bad. The spectrum runs from merely inconvenient to utterly devastating; how the news is perceived and received is highly subjective. Avoid projecting your personal perspective onto the recipient:

• I was totally perplexed. I had just broken the news that Mrs. Smith had an incurable colon cancer, and they responded by nodding, then asking me whether I preferred a chocolate cake or an apple pie for their next visit because it was their custom to bring home-baked goodies for the staff.
  
• After her death, Mr. Smith faithfully continued this tradition. Then one day he arrived for his regular appointment unshaven, distressed and sans cake. He had lost weight and looked every bit of his 78 years. Something was very wrong.
  
• “She’s gone, she’s gone,” he lamented.
  
• At last he’s grieving flashed through my mind, so I responded: “Yes, it’s been about 9 months now, hasn’t it?”
  
• “No, just two weeks…she said she was my girlfriend…just 29 years old…moved in last month then left taking my money,” he cried.
  

What seems an obvious tragedy may not be unwelcome:

• She assumed the mantle of a grieving widow. Only years later did she write that she had been secretly relieved that her husband was killed in an automobile accident. He had been abusive and she was planning to leave him anyway.
  

Seemingly innocuous news can be most unwelcome:

• It was my birthday, and we were about to celebrate with a dinner of leg of lamb and roast potatoes. My cell phone rang. It was my internist calling; my LDL cholesterol was mildly elevated and my dexa scan demonstrated slight osteopenia. The tone of his voice was matter-of-fact but I felt awful: I am getting old.
  

Because bad is so subjective, we cannot presume, without inquiry, what the impact of our words will be on another person.

Realize that long-term well-being doesn’t depend on good vs. bad news:

 

• What do Chuck Close and Dan Gottlieb have in common? Each was a healthy young adult when suddenly becoming paraplegic—Chuck from a spinal artery thrombosis, Dan from a serious accident. Each adapted to his condition. Chuck developed a unique style of painting that established his fame as an artist. Dan, a psychotherapist, became an author, teacher, and highly regarded radio interviewer. Each has recently stated that he has never been happier.
  

Contrast this condition with that of some lottery winners. Many go on to financial and social ruin and come to regret the day that they heard the “good” news.

Remind yourself of hidden opportunities. Bad news triggers a crisis—an unwelcome, unstable situation with obvious danger. Less apparent is the potential for positive personal transformation and gain:

• “It was the best thing that could have happened to me,” she said, lying with her right foot propped up, ankle heavily bandaged with pins and rods protruding. “Yes, it’s a horribly fractured ankle but I had been rushing, rushing, rushing, and when I fell down the steps, it was as if an angel was forcing me to slow down, be present to my family. I really think this fractured ankle was the best thing that could have happened—it may even have saved my marriage.”
  

In terms of our own equanimity, news is just news; until the entire scenario is played out, we can’t know with certainty what is bad or good. Recipients of news are entitled to their own reactions even if they seem inappropriate to us. Our role is to support our patients empathetically, without judgment or prejudice.

Second, cultivate yourself as a healer

You may not always be able to cure but you can always facilitate healing. In addition to a treatment plan, remind yourself to create a parallel healing plan, listing the interventions that will help the recipient integrate losses and become as functionally whole as possible.

Your ability to heal depends as much on who you are as what you do:

• Work through your own trauma stories and you reduce the likelihood that you either attempt to rescue, or flee from engagement with, patients when their problems trigger painful memories for you
  
• Accept your imperfections as an inseparable aspect of your humanity
  
• Learn to accept life as a journey, with suffering and death being inevitable, and bad news ceases to be so exceptional
  
• Deepen your own joy, mindfulness, and faith and you find meaning in your work even when you cannot cure
  
• Have realistic expectations of your abilities and try to cultivate a realistic attitude in your patients:
  

• In Western culture there is a belief, conscious or not, that medicine can save us from the death that lies in wait for us… In a study conducted in 2006 among Israeli doctors, 68% of the participants reported that patients had unrealistic expectations of them. The study reflects unrealistic expectations of medicine in general.⁸
  

Third, cultivate skills to break really bad news

Sometimes news is so bad, so overwhelming, that it has the potential to trigger an acute stress reaction (ASR) and even posttraumatic stress disorder (PTSD) in the recipient. Typically, this is life-threatening news—a diagnosis of HIV infection or cancer; abortion or stillbirth; or the sudden, unexpected death of a loved one. The result is shock, horror, disorientation, and memory distortion.

So how can you approach a situation in which you must offer very bad news? To begin, the box, below “Pearls for breaking bad news…,” provides a set of skills and tools for delivering bad news.

In addition, as much as possible, break bad news in increments, so that the patient has time to cope and adjust. And there is more to keep in mind:

• Provide a safe, supportive environment
  
• Relieve the isolation that trauma inflicts by forging a relationship that is a partnership
  
• Relieve helplessness by empowering and assisting the patient to seek useful consultants, resources, and supports (One example: A patient who has breast or ovarian cancer can call the SHARE [Self-help for Women with Ovarian or Breast Cancer] hotline: [866] 891-2392)
  
• Over time, although not initially, help provide meaning to the experience for your patient and for you.
  

 

The author reports no financial relationships relevant to this article.

Editors’ note: This article appears under the “Focus on professional liability” series banner even though Dr. Bub’s discussion does not directly address matters of being sued. Our, and his, belief is that good communication brings a significant added benefit of lowering a physician’s litigation risk.

• It was tiring to try and think logically as the guy threw more and more facts at me.—An adolescent with cancer¹
  

Consider the findings of two surveys of radiology residents and attending mammographers on breaking bad or troubling news to patients:

• 16% of residents and 4% of mammographers “didn’t feel confident communicating with patients who displayed strong emotional responses”
  
• 86% of residents and 81% of staff experienced “some or moderate stress communicating the need for biopsy”
  
• The majority of all respondents “hadn’t received feedback about their communication skills or communication training after medical school”
  
• 68% to 78% of respondents expressed interest in “improving their communication.”²
  

Breaking what you might perceive as “bad” news is never easy; even experienced practitioners may find the task stressful, as the results of these two surveys reveal. Physicians having been trained to do no harm, few find themselves at ease revealing information that has the potential to disappoint or upset, even devastate.

In this article, I offer an approach to breaking bad news in a manner that lessens the trauma to the patient and buffers you from the stress, and distress, of delivering it. The box near the end of this article gathers pearls for giving bad news based on my work and the experiences of others.

We are not unaffected by this task

Most of us find the act of breaking bad news a professional burden that we could just as soon do without. When we perceive an element of personal responsibility, our burden becomes greater: We may experience fear, guilt, or shame—and, for some, that leads to psychological stress disorders and burnout.

How do we cope, being occasional messengers of bad news?

We avoid. An obvious strategy. Consider Dr. D., a radiologist who heads a breast imaging center. He confides that many physicians ask him to inform their patients when he notes an abnormality on their mammogram. Still other physicians, Dr. D. points out, simply have their nurses call patients with troubling results.

Or we run. Another widely used strategy is to break the news and bolt. One cancer survivor lamented: “As soon as I started to cry, he ran off to fetch his nurse. Don’t you know doctors flee from suffering?”

Keeping matters in balance—that is the challenge

How do we maintain our sensitivity, humanity, and connection while, simultaneously, limiting our own vulnerability and pain? Many of us have wrestled with this issue from the earliest days of training:

• In the hospital’s predawn stillness, she confided fears about surgery to me, the medical student. I tried to reassure her. They operated. Finding extensive metastases, they closed immediately. That evening, aching for her, I cried.
  
• “Don’t worry,” another student reassured me. “It gets easier.”
  
• I hope not. If it does, I’ll have lost my humanity.³
  

There are more questions to challenge us: How do we break bad news in a way that is least traumatic to the recipient? How can we be honest and open yet, when pressed, offer some hope when—objectively—there is little cause for optimism? How do we communicate important information regarding treatment options, prognosis, and so forth, at a time when the patient is least able to absorb it?

Simultaneously, how do we handle our feelings of impotence, failure, and, perhaps, guilt—when every expression, gesture, word, and silence are potentially filled with meaning to those who are receiving the news?

David Lenz, an artist, in a commentary on his award-winning painting, “Sam and the Perfect World,” wrote:

• My wife Rosemarie had just given birth to our son Sam, and although he appeared perfectly healthy, something, nevertheless, didn’t seem right. There was an awkward silence in the room, no words of congratulation or comments about how cute he was—even though he was cute. Five minutes later the diagnosis was given: Sam has Down syndrome. “Are you going to keep him?” a nurse asked. Later that evening someone else came by to “console” us.
  
• “It’s every mother’s worst nightmare,” she said.
  
• Welcome to the world, Sam.⁴
  

Many in our profession advocate a disingenuous connection/separation approach to giving bad news—a so-called detached concern. Our professional journals recommend that we examine and control our emotions in the interest of “objectivity”

 

⁵ and invest in deep and surface acting (of empathy).⁶ I disagree with this advice⁷ ; instead, I advocate that we notice, validate, and park our emotions. Later, we take time to integrate our emotions through self-care. Rather than relying on “the art of medicine” to communicate bad news, we should approach this task as a serious professional challenge and incorporate principles of trauma counseling, psychotherapy, and chaplaincy into the practice of medicine. Instead of distancing from our emotions and our patients, we draw closer.

Here is how one physician handles breaking bad news.

CASE

Dr. Bob, we’ll call him, typifies the overworked primary care physician. Yet, when a lab or imaging report that reveals an abnormal result lands on his desk, he, not a nurse, calls the patient. He waits a few days if the test or study was ordered by another physician; in that situation, he often reaches a frightened, confused person who had already been called by the specialist’s nurse.

When that happens, Dr. Bob invites the patient, and a close relative, to schedule an office visit with him. In the interim, he forms a liaison with the specialist so that they can function as a team.

At the office visit, Dr. Bob refuses to prognosticate. Instead, he recommends that they take matters “one step at a time.” His approach is positive and reassuring but not overly optimistic. His message is clear: “You are not alone. I will be a supportive presence throughout your journey.”

Two notable things about Dr. Bob: First, he does not suffer burnout or what some have called “compassion fatigue”; to the contrary, the relationship he forges with his patients and their loved ones, and the gratitude and loyalty he receives from them, sustain and reward him.

Second, Dr. Bob has never been sued.

The key to Dr. Bob’s success is that he does not shy from breaking bad news. Instead, he views the occasion as an opportunity for healing. His approach is to detach from the outcome but not from the patient. He relieves fear and isolation, and offers, as one patient said it, “candor with hope.”

Summon your personal strengths to succeed

But taking this approach requires a shift from the standard biomedical philosophy—a three-pronged cultivation of personal resources. Here is how you can make that shift.

First, cultivate equanimity—that evenness of mind

Consider that destruction is an inherent component of creation. There can’t be light without darkness, birth without death, joy without suffering, perfection without imperfection. The Sufi mystic, Rumi, said it succinctly: “A butterfly needs two wings to fly.”

Recognize that not all news is equally bad. The spectrum runs from merely inconvenient to utterly devastating; how the news is perceived and received is highly subjective. Avoid projecting your personal perspective onto the recipient:

• I was totally perplexed. I had just broken the news that Mrs. Smith had an incurable colon cancer, and they responded by nodding, then asking me whether I preferred a chocolate cake or an apple pie for their next visit because it was their custom to bring home-baked goodies for the staff.
  
• After her death, Mr. Smith faithfully continued this tradition. Then one day he arrived for his regular appointment unshaven, distressed and sans cake. He had lost weight and looked every bit of his 78 years. Something was very wrong.
  
• “She’s gone, she’s gone,” he lamented.
  
• At last he’s grieving flashed through my mind, so I responded: “Yes, it’s been about 9 months now, hasn’t it?”
  
• “No, just two weeks…she said she was my girlfriend…just 29 years old…moved in last month then left taking my money,” he cried.
  

What seems an obvious tragedy may not be unwelcome:

• She assumed the mantle of a grieving widow. Only years later did she write that she had been secretly relieved that her husband was killed in an automobile accident. He had been abusive and she was planning to leave him anyway.
  

Seemingly innocuous news can be most unwelcome:

• It was my birthday, and we were about to celebrate with a dinner of leg of lamb and roast potatoes. My cell phone rang. It was my internist calling; my LDL cholesterol was mildly elevated and my dexa scan demonstrated slight osteopenia. The tone of his voice was matter-of-fact but I felt awful: I am getting old.
  

Because bad is so subjective, we cannot presume, without inquiry, what the impact of our words will be on another person.

Realize that long-term well-being doesn’t depend on good vs. bad news:

 

• What do Chuck Close and Dan Gottlieb have in common? Each was a healthy young adult when suddenly becoming paraplegic—Chuck from a spinal artery thrombosis, Dan from a serious accident. Each adapted to his condition. Chuck developed a unique style of painting that established his fame as an artist. Dan, a psychotherapist, became an author, teacher, and highly regarded radio interviewer. Each has recently stated that he has never been happier.
  

Contrast this condition with that of some lottery winners. Many go on to financial and social ruin and come to regret the day that they heard the “good” news.

Remind yourself of hidden opportunities. Bad news triggers a crisis—an unwelcome, unstable situation with obvious danger. Less apparent is the potential for positive personal transformation and gain:

• “It was the best thing that could have happened to me,” she said, lying with her right foot propped up, ankle heavily bandaged with pins and rods protruding. “Yes, it’s a horribly fractured ankle but I had been rushing, rushing, rushing, and when I fell down the steps, it was as if an angel was forcing me to slow down, be present to my family. I really think this fractured ankle was the best thing that could have happened—it may even have saved my marriage.”
  

In terms of our own equanimity, news is just news; until the entire scenario is played out, we can’t know with certainty what is bad or good. Recipients of news are entitled to their own reactions even if they seem inappropriate to us. Our role is to support our patients empathetically, without judgment or prejudice.

Second, cultivate yourself as a healer

You may not always be able to cure but you can always facilitate healing. In addition to a treatment plan, remind yourself to create a parallel healing plan, listing the interventions that will help the recipient integrate losses and become as functionally whole as possible.

Your ability to heal depends as much on who you are as what you do:

• Work through your own trauma stories and you reduce the likelihood that you either attempt to rescue, or flee from engagement with, patients when their problems trigger painful memories for you
  
• Accept your imperfections as an inseparable aspect of your humanity
  
• Learn to accept life as a journey, with suffering and death being inevitable, and bad news ceases to be so exceptional
  
• Deepen your own joy, mindfulness, and faith and you find meaning in your work even when you cannot cure
  
• Have realistic expectations of your abilities and try to cultivate a realistic attitude in your patients:
  

• In Western culture there is a belief, conscious or not, that medicine can save us from the death that lies in wait for us… In a study conducted in 2006 among Israeli doctors, 68% of the participants reported that patients had unrealistic expectations of them. The study reflects unrealistic expectations of medicine in general.⁸
  

Third, cultivate skills to break really bad news

Sometimes news is so bad, so overwhelming, that it has the potential to trigger an acute stress reaction (ASR) and even posttraumatic stress disorder (PTSD) in the recipient. Typically, this is life-threatening news—a diagnosis of HIV infection or cancer; abortion or stillbirth; or the sudden, unexpected death of a loved one. The result is shock, horror, disorientation, and memory distortion.

So how can you approach a situation in which you must offer very bad news? To begin, the box, below “Pearls for breaking bad news…,” provides a set of skills and tools for delivering bad news.

In addition, as much as possible, break bad news in increments, so that the patient has time to cope and adjust. And there is more to keep in mind:

• Provide a safe, supportive environment
  
• Relieve the isolation that trauma inflicts by forging a relationship that is a partnership
  
• Relieve helplessness by empowering and assisting the patient to seek useful consultants, resources, and supports (One example: A patient who has breast or ovarian cancer can call the SHARE [Self-help for Women with Ovarian or Breast Cancer] hotline: [866] 891-2392)
  
• Over time, although not initially, help provide meaning to the experience for your patient and for you.
  

 

The author reports no financial relationships relevant to this article.

Editors’ note: This article appears under the “Focus on professional liability” series banner even though Dr. Bub’s discussion does not directly address matters of being sued. Our, and his, belief is that good communication brings a significant added benefit of lowering a physician’s litigation risk.

• It was tiring to try and think logically as the guy threw more and more facts at me.—An adolescent with cancer¹
  

Consider the findings of two surveys of radiology residents and attending mammographers on breaking bad or troubling news to patients:

• 16% of residents and 4% of mammographers “didn’t feel confident communicating with patients who displayed strong emotional responses”
  
• 86% of residents and 81% of staff experienced “some or moderate stress communicating the need for biopsy”
  
• The majority of all respondents “hadn’t received feedback about their communication skills or communication training after medical school”
  
• 68% to 78% of respondents expressed interest in “improving their communication.”²
  

Breaking what you might perceive as “bad” news is never easy; even experienced practitioners may find the task stressful, as the results of these two surveys reveal. Physicians having been trained to do no harm, few find themselves at ease revealing information that has the potential to disappoint or upset, even devastate.

In this article, I offer an approach to breaking bad news in a manner that lessens the trauma to the patient and buffers you from the stress, and distress, of delivering it. The box near the end of this article gathers pearls for giving bad news based on my work and the experiences of others.

We are not unaffected by this task

Most of us find the act of breaking bad news a professional burden that we could just as soon do without. When we perceive an element of personal responsibility, our burden becomes greater: We may experience fear, guilt, or shame—and, for some, that leads to psychological stress disorders and burnout.

How do we cope, being occasional messengers of bad news?

We avoid. An obvious strategy. Consider Dr. D., a radiologist who heads a breast imaging center. He confides that many physicians ask him to inform their patients when he notes an abnormality on their mammogram. Still other physicians, Dr. D. points out, simply have their nurses call patients with troubling results.

Or we run. Another widely used strategy is to break the news and bolt. One cancer survivor lamented: “As soon as I started to cry, he ran off to fetch his nurse. Don’t you know doctors flee from suffering?”

Keeping matters in balance—that is the challenge

How do we maintain our sensitivity, humanity, and connection while, simultaneously, limiting our own vulnerability and pain? Many of us have wrestled with this issue from the earliest days of training:

• In the hospital’s predawn stillness, she confided fears about surgery to me, the medical student. I tried to reassure her. They operated. Finding extensive metastases, they closed immediately. That evening, aching for her, I cried.
  
• “Don’t worry,” another student reassured me. “It gets easier.”
  
• I hope not. If it does, I’ll have lost my humanity.³
  

There are more questions to challenge us: How do we break bad news in a way that is least traumatic to the recipient? How can we be honest and open yet, when pressed, offer some hope when—objectively—there is little cause for optimism? How do we communicate important information regarding treatment options, prognosis, and so forth, at a time when the patient is least able to absorb it?

Simultaneously, how do we handle our feelings of impotence, failure, and, perhaps, guilt—when every expression, gesture, word, and silence are potentially filled with meaning to those who are receiving the news?

David Lenz, an artist, in a commentary on his award-winning painting, “Sam and the Perfect World,” wrote:

• My wife Rosemarie had just given birth to our son Sam, and although he appeared perfectly healthy, something, nevertheless, didn’t seem right. There was an awkward silence in the room, no words of congratulation or comments about how cute he was—even though he was cute. Five minutes later the diagnosis was given: Sam has Down syndrome. “Are you going to keep him?” a nurse asked. Later that evening someone else came by to “console” us.
  
• “It’s every mother’s worst nightmare,” she said.
  
• Welcome to the world, Sam.⁴
  

Many in our profession advocate a disingenuous connection/separation approach to giving bad news—a so-called detached concern. Our professional journals recommend that we examine and control our emotions in the interest of “objectivity”

 

⁵ and invest in deep and surface acting (of empathy).⁶ I disagree with this advice⁷ ; instead, I advocate that we notice, validate, and park our emotions. Later, we take time to integrate our emotions through self-care. Rather than relying on “the art of medicine” to communicate bad news, we should approach this task as a serious professional challenge and incorporate principles of trauma counseling, psychotherapy, and chaplaincy into the practice of medicine. Instead of distancing from our emotions and our patients, we draw closer.

Here is how one physician handles breaking bad news.

CASE

Dr. Bob, we’ll call him, typifies the overworked primary care physician. Yet, when a lab or imaging report that reveals an abnormal result lands on his desk, he, not a nurse, calls the patient. He waits a few days if the test or study was ordered by another physician; in that situation, he often reaches a frightened, confused person who had already been called by the specialist’s nurse.

When that happens, Dr. Bob invites the patient, and a close relative, to schedule an office visit with him. In the interim, he forms a liaison with the specialist so that they can function as a team.

At the office visit, Dr. Bob refuses to prognosticate. Instead, he recommends that they take matters “one step at a time.” His approach is positive and reassuring but not overly optimistic. His message is clear: “You are not alone. I will be a supportive presence throughout your journey.”

Two notable things about Dr. Bob: First, he does not suffer burnout or what some have called “compassion fatigue”; to the contrary, the relationship he forges with his patients and their loved ones, and the gratitude and loyalty he receives from them, sustain and reward him.

Second, Dr. Bob has never been sued.

The key to Dr. Bob’s success is that he does not shy from breaking bad news. Instead, he views the occasion as an opportunity for healing. His approach is to detach from the outcome but not from the patient. He relieves fear and isolation, and offers, as one patient said it, “candor with hope.”

Summon your personal strengths to succeed

But taking this approach requires a shift from the standard biomedical philosophy—a three-pronged cultivation of personal resources. Here is how you can make that shift.

First, cultivate equanimity—that evenness of mind

Consider that destruction is an inherent component of creation. There can’t be light without darkness, birth without death, joy without suffering, perfection without imperfection. The Sufi mystic, Rumi, said it succinctly: “A butterfly needs two wings to fly.”

Recognize that not all news is equally bad. The spectrum runs from merely inconvenient to utterly devastating; how the news is perceived and received is highly subjective. Avoid projecting your personal perspective onto the recipient:

• I was totally perplexed. I had just broken the news that Mrs. Smith had an incurable colon cancer, and they responded by nodding, then asking me whether I preferred a chocolate cake or an apple pie for their next visit because it was their custom to bring home-baked goodies for the staff.
  
• After her death, Mr. Smith faithfully continued this tradition. Then one day he arrived for his regular appointment unshaven, distressed and sans cake. He had lost weight and looked every bit of his 78 years. Something was very wrong.
  
• “She’s gone, she’s gone,” he lamented.
  
• At last he’s grieving flashed through my mind, so I responded: “Yes, it’s been about 9 months now, hasn’t it?”
  
• “No, just two weeks…she said she was my girlfriend…just 29 years old…moved in last month then left taking my money,” he cried.
  

What seems an obvious tragedy may not be unwelcome:

• She assumed the mantle of a grieving widow. Only years later did she write that she had been secretly relieved that her husband was killed in an automobile accident. He had been abusive and she was planning to leave him anyway.
  

Seemingly innocuous news can be most unwelcome:

• It was my birthday, and we were about to celebrate with a dinner of leg of lamb and roast potatoes. My cell phone rang. It was my internist calling; my LDL cholesterol was mildly elevated and my dexa scan demonstrated slight osteopenia. The tone of his voice was matter-of-fact but I felt awful: I am getting old.
  

Because bad is so subjective, we cannot presume, without inquiry, what the impact of our words will be on another person.

Realize that long-term well-being doesn’t depend on good vs. bad news:

 

• What do Chuck Close and Dan Gottlieb have in common? Each was a healthy young adult when suddenly becoming paraplegic—Chuck from a spinal artery thrombosis, Dan from a serious accident. Each adapted to his condition. Chuck developed a unique style of painting that established his fame as an artist. Dan, a psychotherapist, became an author, teacher, and highly regarded radio interviewer. Each has recently stated that he has never been happier.
  

Contrast this condition with that of some lottery winners. Many go on to financial and social ruin and come to regret the day that they heard the “good” news.

Remind yourself of hidden opportunities. Bad news triggers a crisis—an unwelcome, unstable situation with obvious danger. Less apparent is the potential for positive personal transformation and gain:

• “It was the best thing that could have happened to me,” she said, lying with her right foot propped up, ankle heavily bandaged with pins and rods protruding. “Yes, it’s a horribly fractured ankle but I had been rushing, rushing, rushing, and when I fell down the steps, it was as if an angel was forcing me to slow down, be present to my family. I really think this fractured ankle was the best thing that could have happened—it may even have saved my marriage.”
  

In terms of our own equanimity, news is just news; until the entire scenario is played out, we can’t know with certainty what is bad or good. Recipients of news are entitled to their own reactions even if they seem inappropriate to us. Our role is to support our patients empathetically, without judgment or prejudice.

Second, cultivate yourself as a healer

You may not always be able to cure but you can always facilitate healing. In addition to a treatment plan, remind yourself to create a parallel healing plan, listing the interventions that will help the recipient integrate losses and become as functionally whole as possible.

Your ability to heal depends as much on who you are as what you do:

• Work through your own trauma stories and you reduce the likelihood that you either attempt to rescue, or flee from engagement with, patients when their problems trigger painful memories for you
  
• Accept your imperfections as an inseparable aspect of your humanity
  
• Learn to accept life as a journey, with suffering and death being inevitable, and bad news ceases to be so exceptional
  
• Deepen your own joy, mindfulness, and faith and you find meaning in your work even when you cannot cure
  
• Have realistic expectations of your abilities and try to cultivate a realistic attitude in your patients:
  

• In Western culture there is a belief, conscious or not, that medicine can save us from the death that lies in wait for us… In a study conducted in 2006 among Israeli doctors, 68% of the participants reported that patients had unrealistic expectations of them. The study reflects unrealistic expectations of medicine in general.⁸
  

Third, cultivate skills to break really bad news

Sometimes news is so bad, so overwhelming, that it has the potential to trigger an acute stress reaction (ASR) and even posttraumatic stress disorder (PTSD) in the recipient. Typically, this is life-threatening news—a diagnosis of HIV infection or cancer; abortion or stillbirth; or the sudden, unexpected death of a loved one. The result is shock, horror, disorientation, and memory distortion.

So how can you approach a situation in which you must offer very bad news? To begin, the box, below “Pearls for breaking bad news…,” provides a set of skills and tools for delivering bad news.

In addition, as much as possible, break bad news in increments, so that the patient has time to cope and adjust. And there is more to keep in mind:

• Provide a safe, supportive environment
  
• Relieve the isolation that trauma inflicts by forging a relationship that is a partnership
  
• Relieve helplessness by empowering and assisting the patient to seek useful consultants, resources, and supports (One example: A patient who has breast or ovarian cancer can call the SHARE [Self-help for Women with Ovarian or Breast Cancer] hotline: [866] 891-2392)
  
• Over time, although not initially, help provide meaning to the experience for your patient and for you.
  

 

Mary Jo Foster, herself a physician, sat down to pen a letter to her former obstetrician. Words flowed easily because, for months, she had thought of little else besides the events of the previous year.

Her letter has been abbreviated, with names and dates altered.

Eric David Foster
Born: May 15, 2003, Died: May 18, 2003

Does that name or do those dates mean anything to you? They should, but I doubt that they do. I, on the other hand, have been haunted by painful and awful memories of those 4 days, as I will be every day for the rest of my life. I hope that you have the courage and integrity to read this letter completely, because this is the only chance I have to reach you.

Do you remember my first visit? I had the impression then that you listened and understood when I related my complicated obstetric history, but that was the first and last time I felt that way. You seemed to forget about the uterine septum until I called you at 25 weeks’ gestation to report that I had gone into labor. My husband and I were so terrified, we left our sleeping 2-year-old son alone in the house to await the nanny in order to get to the hospital as soon as possible. Although we arrived there at 7 AM, we had to wait 2 horrifying hours for you to show up. By then it was too late, and Eric was delivered prematurely with extensive brain damage from ischemia and hemorrhage. Distraught, my heart breaking and my brain dazed from shock, trauma, surgery, and lack of sleep, I then had to plead and fight at the ethics committee meeting for the discontinuation of life support so Eric’s suffering could end.

A strongly worded letter if ever there was one; the patient’s emotional pain comes through loud and clear. Bear in mind that the obstetrician’s voice is silent; we do not hear his perspective.

That is intentional. The aim of this article is not to pass judgment or offer defense, but to draw attention to two specific consequences of a major traumatic experience—incomplete mourning and traumatic stress disorder.

In an earlier article, “The nightmare of litigation: A survivor’s true story,”¹ I presented the case of an obstetrician who was sued for medical malpractice. The trauma of the experience led him to develop an acute stress disorder, which evolved into posttraumatic stress disorder (PTSD). In this article, the focus is on the patient, who also develops PTSD after an adverse outcome—specifically, premature delivery and neonatal death.

A mourning process stuck in the anger stage

Letter continued

For the past year I have wanted to ask you…

• Why did you make me feel invisible during my pregnancy, after I went to so much trouble to explain my special situation?
  
• Why didn’t you seem to notice how terrified we were when I started bleeding? Instead, you took your time getting to the ER.
  
• Why didn’t you come to talk to me later in the day after the cesarean section? When you spoke to my husband, you mentioned that you had removed the uterine septum so I could go on to have a normal full-term pregnancy. How could you begin to talk about another pregnancy while my son was in pain, bleeding into his brain? You wrote him off the minute you left the OR, just like you peeled off your gloves and dropped them into the trash.
  
• Why didn’t you ask the chaplain to be at the ethics hearing as a support for us?
  
• At my postoperative checkup, why did you rip off the dressing and declare me “beautifully healed”? And why did you walk off before I could say anything?
  

A healthy mourning process comprises several stages, including denial, anger, sadness, and meaning-making, followed by acceptance and healing. This harsh letter is an indication that the patient is stuck in anger; healing is a long way off. Beneath the anger are other emotions, including sadness, shame, and guilt.

When the obstetrician ripped off the dressing and declared the patient healed, he was addressing the physical abdominal wound, but he completely overlooked the deeper, invisible, psychospiritual wounds arising from loss of a child—and from loss of safety, power, trust, faith, and meaning. The patient’s feelings are striking in their potency, but the obstetrician remained unaware of them. At the time of her postoperative visit, these psychological wounds had not even begun to heal. The self that had been preparing to be a mother had not yet integrated all the losses and realigned to the grim reality that she was now the parent of a dead baby.

 

Rather than further her healing, the obstetrician’s words alienated her and added yet another layer of wounding.

Letter continued

That hospital was my personal place in hell from the moment I entered until the day I was discharged. You and your office staff seemed totally oblivious to this fact. Now a year has passed—a year of pure devastation—and I still have pain and sadness that cannot be understood by anyone who has not experienced the death of a child. And I have anger at the incompetent ER staff and at myself for being “a good patient” and ignoring my intuition.

I deserved a physician who can remember who I am and my relevant history—one who would come to see me immediately and reassure me that everything possible would be done for my baby and me. I deserved a physician who can acknowledge the awfulness of such a loss and offer sympathy and support. And to make matters worse, you immediately retreated behind the fear of a lawsuit.

Grief, interrupted: When the business-as-usual world interferes

An outpouring of grief in the face of loss is normal; it mobilizes energy and is an integral part of the healing process. Emotional healing may seem protracted when it is viewed in the context of chronological time, and pressing demands frequently interfere with the process. In this case, demands included the need to attend an ethics meeting, arrange a funeral, care for a 2-year-old son, host parents-in-law who had arrived from out of town, and, the following week, throw a birthday party for her son.

Disenfranchised grief: How wrong words, or none, can slow healing

This patient found little validation or support for her grief from those who were around her:

• Medical personnel acted defensively and insensitively.
  
• Her in-laws kept busy, making idle chitchat while they fussed over the party and memorial arrangements.
  
• Her friends plied her with platitudes: “God needs an angel in heaven,” “God needed your son more than you do,” “We can’t know why God makes these decisions.”
  
• The priest performed the memorial service in ritualistic fashion. “He couldn’t even get Eric’s name right,” she lamented.
  
• Her return to work was marked by awkward cheeriness, “as if I had been on vacation.” Her boss’s comment? “Best hop right back in the saddle.”
  

All these people seemed invested in their own coping strategies. None provided comfort; empathy was absent. Any mourning that had to be done was done alone, behind closed doors and a fixed smile. Isolation, the hallmark of trauma, was pronounced. Only after she found a support group several months later was Dr. Foster able to openly mourn.

Three symptom clusters signal PTSD

Dr. Foster’s description of her postdelivery experience suggests to me that she sustained an acute stress disorder—a condition that involves feelings of intense fear, horror, disorientation, and helplessness in response to an unusually traumatic experience that threatens death or serious physical injury to self or others. In Dr. Foster’s case, the stress disorder progressed to PTSD—a pervasive chronic anxiety disorder characterized by three clusters of symptoms:

• Recurrent, intrusive recollections of events; recurrent flashbacks and dreams. “At night, after going to bed, I would see the fetal monitor showing my child’s heart rate running like a video stream in front of my eyes. This went on for months. It would take me 1 to 2 hours to force myself to fall asleep.”
  
• Persistent avoidance of stimuli associated with the event; numbness and detachment. “I had feelings of numbness and unreality but couldn’t really understand or process them. Eating became difficult, and I was unable to experience any pleasure. Survivor’s guilt plagued me. Why am I alive? I asked myself. I had some 30 years, but my son didn’t even have a chance.”
  
• Persistent symptoms of increased arousal; insomnia, hypervigilance, irritability, difficulty with concentration. “I returned to work after a month but could not focus or concentrate, so I took 2 additional months off. Whenever I heard the obstetrician paged at the hospital, I had a physical reaction. My muscles clenched, my skin flushed, and my heart raced. Eventually, I stopped working at that hospital because I couldn’t stand being there.”
  

PTSD is not rare in civilian life or in medicine. Journal articles attest to its occurrence in association with major illness and injury,² spontaneous abortion,³ and premature and traumatic birth.^4-8

In Dr. Foster’s case, PTSD went unrecognized and untreated.

How to avert, and alleviate, PTSD

As with any disaster, careful planning can mitigate consequences even though it cannot necessarily prevent PTSD. Prenatal visits offer a unique opportunity to build a trusting partnership with your patient and her partner. Skilled professional communication is essential. Anticipate common themes:

 

• Fear of failure and shame is an issue for many mothers-to-be. Here, your affirmations and good humor are helpful. Be very respectful of the patient’s interpersonal boundaries, both physical and emotional.
  
• Disempowerment is an inherent part of the patient experience; trauma aggravates this dynamic. Whenever feasible, shift some of your power to the patient by eliciting her wishes and offering her choices. Together, create a plan for delivery and postnatal care that reflects her desires. As you demonstrate competence and control, consciously deconstruct the image your patient may have of you as an infallible authority figure by selectively revealing a little of the personality behind the white coat.
  
• Feelings of isolation always occur with trauma. The bonds you cultivate with the patient during her pregnancy will alleviate this isolation, as will your message: You are not alone in this experience; we will deal with this together.
  

Other helpful practices

Allow the grieving couple space and privacy to ventilate and mourn any way they need to. This may include expressions of anger.

Listen silently and attentively even if you feel passive or uncomfortable doing so. Resist the urge to comfort the patient; even well-intentioned comforting can interrupt healing.

Validate the patient’s trauma. Be careful to avoid making the suggestion that you understand. No one but the patient can understand—suffering is always unique and personal.

Express a genuine and carefully worded sense of regret for the patient’s loss. Take care not to express personal negative feelings, such as those regarding a baby’s deformity. Your words may become permanently imprinted.⁹

Present any information and recommendations the patient needs in writing because, when a person is in shock, she may be unable to recall verbal messages. Also give written recommendations to one of the patient’s family members, if possible.

Avoid well-intentioned attempts to reassure a patient or to rationalize or offer premature hope. There is time for such things later.

Cultivate a referral network that includes social workers, chaplains, and psychotherapists trained to work with trauma victims, and when they are necessary, involve them as early as possible. Also familiarize yourself with local support groups and short-term cognitive group-therapy programs for grieving parents.¹⁰

Frame the gesture carefully if you feel the need to refer the patient to a psychotherapist or psychiatrist. It is better to emphasize to the patient that she has sustained a major trauma than to suggest there is something wrong with her. The latter will only add to her sense of personal failure and may trigger resistance or anger.

Take care of yourself! You need your own practices and rituals to sustain you in the work you do. Create your own network of support. Concentrate on expanding your resilience and strive to be comfortable with your emotions. If symptoms of burnout appear, seek help quickly.

The author thanks Amy Hyams and Anne-Marie Jackson, MD, for their assistance.

Recommended reading

• Bub B. Communication Skills That Heal: A Practical Approach to a New Professionalism in Medicine. Abington, UK: Radcliffe Publishing–Oxford; 2005.
  
• Herman J. Trauma and Recovery. London: Rivers Oram Press; 1997.
  
• Schneider J. Finding My Way: Healing and Transformation Through Loss and Grief. Colfax, Wisc: Seasons; 1994.
  

Mary Jo Foster, herself a physician, sat down to pen a letter to her former obstetrician. Words flowed easily because, for months, she had thought of little else besides the events of the previous year.

Her letter has been abbreviated, with names and dates altered.

Eric David Foster
Born: May 15, 2003, Died: May 18, 2003

Does that name or do those dates mean anything to you? They should, but I doubt that they do. I, on the other hand, have been haunted by painful and awful memories of those 4 days, as I will be every day for the rest of my life. I hope that you have the courage and integrity to read this letter completely, because this is the only chance I have to reach you.

Do you remember my first visit? I had the impression then that you listened and understood when I related my complicated obstetric history, but that was the first and last time I felt that way. You seemed to forget about the uterine septum until I called you at 25 weeks’ gestation to report that I had gone into labor. My husband and I were so terrified, we left our sleeping 2-year-old son alone in the house to await the nanny in order to get to the hospital as soon as possible. Although we arrived there at 7 AM, we had to wait 2 horrifying hours for you to show up. By then it was too late, and Eric was delivered prematurely with extensive brain damage from ischemia and hemorrhage. Distraught, my heart breaking and my brain dazed from shock, trauma, surgery, and lack of sleep, I then had to plead and fight at the ethics committee meeting for the discontinuation of life support so Eric’s suffering could end.

A strongly worded letter if ever there was one; the patient’s emotional pain comes through loud and clear. Bear in mind that the obstetrician’s voice is silent; we do not hear his perspective.

That is intentional. The aim of this article is not to pass judgment or offer defense, but to draw attention to two specific consequences of a major traumatic experience—incomplete mourning and traumatic stress disorder.

In an earlier article, “The nightmare of litigation: A survivor’s true story,”¹ I presented the case of an obstetrician who was sued for medical malpractice. The trauma of the experience led him to develop an acute stress disorder, which evolved into posttraumatic stress disorder (PTSD). In this article, the focus is on the patient, who also develops PTSD after an adverse outcome—specifically, premature delivery and neonatal death.

A mourning process stuck in the anger stage

Letter continued

For the past year I have wanted to ask you…

• Why did you make me feel invisible during my pregnancy, after I went to so much trouble to explain my special situation?
  
• Why didn’t you seem to notice how terrified we were when I started bleeding? Instead, you took your time getting to the ER.
  
• Why didn’t you come to talk to me later in the day after the cesarean section? When you spoke to my husband, you mentioned that you had removed the uterine septum so I could go on to have a normal full-term pregnancy. How could you begin to talk about another pregnancy while my son was in pain, bleeding into his brain? You wrote him off the minute you left the OR, just like you peeled off your gloves and dropped them into the trash.
  
• Why didn’t you ask the chaplain to be at the ethics hearing as a support for us?
  
• At my postoperative checkup, why did you rip off the dressing and declare me “beautifully healed”? And why did you walk off before I could say anything?
  

A healthy mourning process comprises several stages, including denial, anger, sadness, and meaning-making, followed by acceptance and healing. This harsh letter is an indication that the patient is stuck in anger; healing is a long way off. Beneath the anger are other emotions, including sadness, shame, and guilt.

When the obstetrician ripped off the dressing and declared the patient healed, he was addressing the physical abdominal wound, but he completely overlooked the deeper, invisible, psychospiritual wounds arising from loss of a child—and from loss of safety, power, trust, faith, and meaning. The patient’s feelings are striking in their potency, but the obstetrician remained unaware of them. At the time of her postoperative visit, these psychological wounds had not even begun to heal. The self that had been preparing to be a mother had not yet integrated all the losses and realigned to the grim reality that she was now the parent of a dead baby.

 

Rather than further her healing, the obstetrician’s words alienated her and added yet another layer of wounding.

Letter continued

That hospital was my personal place in hell from the moment I entered until the day I was discharged. You and your office staff seemed totally oblivious to this fact. Now a year has passed—a year of pure devastation—and I still have pain and sadness that cannot be understood by anyone who has not experienced the death of a child. And I have anger at the incompetent ER staff and at myself for being “a good patient” and ignoring my intuition.

I deserved a physician who can remember who I am and my relevant history—one who would come to see me immediately and reassure me that everything possible would be done for my baby and me. I deserved a physician who can acknowledge the awfulness of such a loss and offer sympathy and support. And to make matters worse, you immediately retreated behind the fear of a lawsuit.

Grief, interrupted: When the business-as-usual world interferes

An outpouring of grief in the face of loss is normal; it mobilizes energy and is an integral part of the healing process. Emotional healing may seem protracted when it is viewed in the context of chronological time, and pressing demands frequently interfere with the process. In this case, demands included the need to attend an ethics meeting, arrange a funeral, care for a 2-year-old son, host parents-in-law who had arrived from out of town, and, the following week, throw a birthday party for her son.

Disenfranchised grief: How wrong words, or none, can slow healing

This patient found little validation or support for her grief from those who were around her:

• Medical personnel acted defensively and insensitively.
  
• Her in-laws kept busy, making idle chitchat while they fussed over the party and memorial arrangements.
  
• Her friends plied her with platitudes: “God needs an angel in heaven,” “God needed your son more than you do,” “We can’t know why God makes these decisions.”
  
• The priest performed the memorial service in ritualistic fashion. “He couldn’t even get Eric’s name right,” she lamented.
  
• Her return to work was marked by awkward cheeriness, “as if I had been on vacation.” Her boss’s comment? “Best hop right back in the saddle.”
  

All these people seemed invested in their own coping strategies. None provided comfort; empathy was absent. Any mourning that had to be done was done alone, behind closed doors and a fixed smile. Isolation, the hallmark of trauma, was pronounced. Only after she found a support group several months later was Dr. Foster able to openly mourn.

Three symptom clusters signal PTSD

Dr. Foster’s description of her postdelivery experience suggests to me that she sustained an acute stress disorder—a condition that involves feelings of intense fear, horror, disorientation, and helplessness in response to an unusually traumatic experience that threatens death or serious physical injury to self or others. In Dr. Foster’s case, the stress disorder progressed to PTSD—a pervasive chronic anxiety disorder characterized by three clusters of symptoms:

• Recurrent, intrusive recollections of events; recurrent flashbacks and dreams. “At night, after going to bed, I would see the fetal monitor showing my child’s heart rate running like a video stream in front of my eyes. This went on for months. It would take me 1 to 2 hours to force myself to fall asleep.”
  
• Persistent avoidance of stimuli associated with the event; numbness and detachment. “I had feelings of numbness and unreality but couldn’t really understand or process them. Eating became difficult, and I was unable to experience any pleasure. Survivor’s guilt plagued me. Why am I alive? I asked myself. I had some 30 years, but my son didn’t even have a chance.”
  
• Persistent symptoms of increased arousal; insomnia, hypervigilance, irritability, difficulty with concentration. “I returned to work after a month but could not focus or concentrate, so I took 2 additional months off. Whenever I heard the obstetrician paged at the hospital, I had a physical reaction. My muscles clenched, my skin flushed, and my heart raced. Eventually, I stopped working at that hospital because I couldn’t stand being there.”
  

PTSD is not rare in civilian life or in medicine. Journal articles attest to its occurrence in association with major illness and injury,² spontaneous abortion,³ and premature and traumatic birth.^4-8

In Dr. Foster’s case, PTSD went unrecognized and untreated.

How to avert, and alleviate, PTSD

As with any disaster, careful planning can mitigate consequences even though it cannot necessarily prevent PTSD. Prenatal visits offer a unique opportunity to build a trusting partnership with your patient and her partner. Skilled professional communication is essential. Anticipate common themes:

 

• Fear of failure and shame is an issue for many mothers-to-be. Here, your affirmations and good humor are helpful. Be very respectful of the patient’s interpersonal boundaries, both physical and emotional.
  
• Disempowerment is an inherent part of the patient experience; trauma aggravates this dynamic. Whenever feasible, shift some of your power to the patient by eliciting her wishes and offering her choices. Together, create a plan for delivery and postnatal care that reflects her desires. As you demonstrate competence and control, consciously deconstruct the image your patient may have of you as an infallible authority figure by selectively revealing a little of the personality behind the white coat.
  
• Feelings of isolation always occur with trauma. The bonds you cultivate with the patient during her pregnancy will alleviate this isolation, as will your message: You are not alone in this experience; we will deal with this together.
  

Other helpful practices

Allow the grieving couple space and privacy to ventilate and mourn any way they need to. This may include expressions of anger.

Listen silently and attentively even if you feel passive or uncomfortable doing so. Resist the urge to comfort the patient; even well-intentioned comforting can interrupt healing.

Validate the patient’s trauma. Be careful to avoid making the suggestion that you understand. No one but the patient can understand—suffering is always unique and personal.

Express a genuine and carefully worded sense of regret for the patient’s loss. Take care not to express personal negative feelings, such as those regarding a baby’s deformity. Your words may become permanently imprinted.⁹

Present any information and recommendations the patient needs in writing because, when a person is in shock, she may be unable to recall verbal messages. Also give written recommendations to one of the patient’s family members, if possible.

Avoid well-intentioned attempts to reassure a patient or to rationalize or offer premature hope. There is time for such things later.

Cultivate a referral network that includes social workers, chaplains, and psychotherapists trained to work with trauma victims, and when they are necessary, involve them as early as possible. Also familiarize yourself with local support groups and short-term cognitive group-therapy programs for grieving parents.¹⁰

Frame the gesture carefully if you feel the need to refer the patient to a psychotherapist or psychiatrist. It is better to emphasize to the patient that she has sustained a major trauma than to suggest there is something wrong with her. The latter will only add to her sense of personal failure and may trigger resistance or anger.

Take care of yourself! You need your own practices and rituals to sustain you in the work you do. Create your own network of support. Concentrate on expanding your resilience and strive to be comfortable with your emotions. If symptoms of burnout appear, seek help quickly.

The author thanks Amy Hyams and Anne-Marie Jackson, MD, for their assistance.

Recommended reading

• Bub B. Communication Skills That Heal: A Practical Approach to a New Professionalism in Medicine. Abington, UK: Radcliffe Publishing–Oxford; 2005.
  
• Herman J. Trauma and Recovery. London: Rivers Oram Press; 1997.
  
• Schneider J. Finding My Way: Healing and Transformation Through Loss and Grief. Colfax, Wisc: Seasons; 1994.
  

Mary Jo Foster, herself a physician, sat down to pen a letter to her former obstetrician. Words flowed easily because, for months, she had thought of little else besides the events of the previous year.

Her letter has been abbreviated, with names and dates altered.

Eric David Foster
Born: May 15, 2003, Died: May 18, 2003

Does that name or do those dates mean anything to you? They should, but I doubt that they do. I, on the other hand, have been haunted by painful and awful memories of those 4 days, as I will be every day for the rest of my life. I hope that you have the courage and integrity to read this letter completely, because this is the only chance I have to reach you.

Do you remember my first visit? I had the impression then that you listened and understood when I related my complicated obstetric history, but that was the first and last time I felt that way. You seemed to forget about the uterine septum until I called you at 25 weeks’ gestation to report that I had gone into labor. My husband and I were so terrified, we left our sleeping 2-year-old son alone in the house to await the nanny in order to get to the hospital as soon as possible. Although we arrived there at 7 AM, we had to wait 2 horrifying hours for you to show up. By then it was too late, and Eric was delivered prematurely with extensive brain damage from ischemia and hemorrhage. Distraught, my heart breaking and my brain dazed from shock, trauma, surgery, and lack of sleep, I then had to plead and fight at the ethics committee meeting for the discontinuation of life support so Eric’s suffering could end.

A strongly worded letter if ever there was one; the patient’s emotional pain comes through loud and clear. Bear in mind that the obstetrician’s voice is silent; we do not hear his perspective.

That is intentional. The aim of this article is not to pass judgment or offer defense, but to draw attention to two specific consequences of a major traumatic experience—incomplete mourning and traumatic stress disorder.

In an earlier article, “The nightmare of litigation: A survivor’s true story,”¹ I presented the case of an obstetrician who was sued for medical malpractice. The trauma of the experience led him to develop an acute stress disorder, which evolved into posttraumatic stress disorder (PTSD). In this article, the focus is on the patient, who also develops PTSD after an adverse outcome—specifically, premature delivery and neonatal death.

A mourning process stuck in the anger stage

Letter continued

For the past year I have wanted to ask you…

• Why did you make me feel invisible during my pregnancy, after I went to so much trouble to explain my special situation?
  
• Why didn’t you seem to notice how terrified we were when I started bleeding? Instead, you took your time getting to the ER.
  
• Why didn’t you come to talk to me later in the day after the cesarean section? When you spoke to my husband, you mentioned that you had removed the uterine septum so I could go on to have a normal full-term pregnancy. How could you begin to talk about another pregnancy while my son was in pain, bleeding into his brain? You wrote him off the minute you left the OR, just like you peeled off your gloves and dropped them into the trash.
  
• Why didn’t you ask the chaplain to be at the ethics hearing as a support for us?
  
• At my postoperative checkup, why did you rip off the dressing and declare me “beautifully healed”? And why did you walk off before I could say anything?
  

A healthy mourning process comprises several stages, including denial, anger, sadness, and meaning-making, followed by acceptance and healing. This harsh letter is an indication that the patient is stuck in anger; healing is a long way off. Beneath the anger are other emotions, including sadness, shame, and guilt.

When the obstetrician ripped off the dressing and declared the patient healed, he was addressing the physical abdominal wound, but he completely overlooked the deeper, invisible, psychospiritual wounds arising from loss of a child—and from loss of safety, power, trust, faith, and meaning. The patient’s feelings are striking in their potency, but the obstetrician remained unaware of them. At the time of her postoperative visit, these psychological wounds had not even begun to heal. The self that had been preparing to be a mother had not yet integrated all the losses and realigned to the grim reality that she was now the parent of a dead baby.

 

Rather than further her healing, the obstetrician’s words alienated her and added yet another layer of wounding.

Letter continued

That hospital was my personal place in hell from the moment I entered until the day I was discharged. You and your office staff seemed totally oblivious to this fact. Now a year has passed—a year of pure devastation—and I still have pain and sadness that cannot be understood by anyone who has not experienced the death of a child. And I have anger at the incompetent ER staff and at myself for being “a good patient” and ignoring my intuition.

I deserved a physician who can remember who I am and my relevant history—one who would come to see me immediately and reassure me that everything possible would be done for my baby and me. I deserved a physician who can acknowledge the awfulness of such a loss and offer sympathy and support. And to make matters worse, you immediately retreated behind the fear of a lawsuit.

Grief, interrupted: When the business-as-usual world interferes

An outpouring of grief in the face of loss is normal; it mobilizes energy and is an integral part of the healing process. Emotional healing may seem protracted when it is viewed in the context of chronological time, and pressing demands frequently interfere with the process. In this case, demands included the need to attend an ethics meeting, arrange a funeral, care for a 2-year-old son, host parents-in-law who had arrived from out of town, and, the following week, throw a birthday party for her son.

Disenfranchised grief: How wrong words, or none, can slow healing

This patient found little validation or support for her grief from those who were around her:

• Medical personnel acted defensively and insensitively.
  
• Her in-laws kept busy, making idle chitchat while they fussed over the party and memorial arrangements.
  
• Her friends plied her with platitudes: “God needs an angel in heaven,” “God needed your son more than you do,” “We can’t know why God makes these decisions.”
  
• The priest performed the memorial service in ritualistic fashion. “He couldn’t even get Eric’s name right,” she lamented.
  
• Her return to work was marked by awkward cheeriness, “as if I had been on vacation.” Her boss’s comment? “Best hop right back in the saddle.”
  

All these people seemed invested in their own coping strategies. None provided comfort; empathy was absent. Any mourning that had to be done was done alone, behind closed doors and a fixed smile. Isolation, the hallmark of trauma, was pronounced. Only after she found a support group several months later was Dr. Foster able to openly mourn.

Three symptom clusters signal PTSD

Dr. Foster’s description of her postdelivery experience suggests to me that she sustained an acute stress disorder—a condition that involves feelings of intense fear, horror, disorientation, and helplessness in response to an unusually traumatic experience that threatens death or serious physical injury to self or others. In Dr. Foster’s case, the stress disorder progressed to PTSD—a pervasive chronic anxiety disorder characterized by three clusters of symptoms:

• Recurrent, intrusive recollections of events; recurrent flashbacks and dreams. “At night, after going to bed, I would see the fetal monitor showing my child’s heart rate running like a video stream in front of my eyes. This went on for months. It would take me 1 to 2 hours to force myself to fall asleep.”
  
• Persistent avoidance of stimuli associated with the event; numbness and detachment. “I had feelings of numbness and unreality but couldn’t really understand or process them. Eating became difficult, and I was unable to experience any pleasure. Survivor’s guilt plagued me. Why am I alive? I asked myself. I had some 30 years, but my son didn’t even have a chance.”
  
• Persistent symptoms of increased arousal; insomnia, hypervigilance, irritability, difficulty with concentration. “I returned to work after a month but could not focus or concentrate, so I took 2 additional months off. Whenever I heard the obstetrician paged at the hospital, I had a physical reaction. My muscles clenched, my skin flushed, and my heart raced. Eventually, I stopped working at that hospital because I couldn’t stand being there.”
  

PTSD is not rare in civilian life or in medicine. Journal articles attest to its occurrence in association with major illness and injury,² spontaneous abortion,³ and premature and traumatic birth.^4-8

In Dr. Foster’s case, PTSD went unrecognized and untreated.

How to avert, and alleviate, PTSD

As with any disaster, careful planning can mitigate consequences even though it cannot necessarily prevent PTSD. Prenatal visits offer a unique opportunity to build a trusting partnership with your patient and her partner. Skilled professional communication is essential. Anticipate common themes:

 

• Fear of failure and shame is an issue for many mothers-to-be. Here, your affirmations and good humor are helpful. Be very respectful of the patient’s interpersonal boundaries, both physical and emotional.
  
• Disempowerment is an inherent part of the patient experience; trauma aggravates this dynamic. Whenever feasible, shift some of your power to the patient by eliciting her wishes and offering her choices. Together, create a plan for delivery and postnatal care that reflects her desires. As you demonstrate competence and control, consciously deconstruct the image your patient may have of you as an infallible authority figure by selectively revealing a little of the personality behind the white coat.
  
• Feelings of isolation always occur with trauma. The bonds you cultivate with the patient during her pregnancy will alleviate this isolation, as will your message: You are not alone in this experience; we will deal with this together.
  

Other helpful practices

Allow the grieving couple space and privacy to ventilate and mourn any way they need to. This may include expressions of anger.

Listen silently and attentively even if you feel passive or uncomfortable doing so. Resist the urge to comfort the patient; even well-intentioned comforting can interrupt healing.

Validate the patient’s trauma. Be careful to avoid making the suggestion that you understand. No one but the patient can understand—suffering is always unique and personal.

Express a genuine and carefully worded sense of regret for the patient’s loss. Take care not to express personal negative feelings, such as those regarding a baby’s deformity. Your words may become permanently imprinted.⁹

Present any information and recommendations the patient needs in writing because, when a person is in shock, she may be unable to recall verbal messages. Also give written recommendations to one of the patient’s family members, if possible.

Avoid well-intentioned attempts to reassure a patient or to rationalize or offer premature hope. There is time for such things later.

Cultivate a referral network that includes social workers, chaplains, and psychotherapists trained to work with trauma victims, and when they are necessary, involve them as early as possible. Also familiarize yourself with local support groups and short-term cognitive group-therapy programs for grieving parents.¹⁰

Frame the gesture carefully if you feel the need to refer the patient to a psychotherapist or psychiatrist. It is better to emphasize to the patient that she has sustained a major trauma than to suggest there is something wrong with her. The latter will only add to her sense of personal failure and may trigger resistance or anger.

Take care of yourself! You need your own practices and rituals to sustain you in the work you do. Create your own network of support. Concentrate on expanding your resilience and strive to be comfortable with your emotions. If symptoms of burnout appear, seek help quickly.

The author thanks Amy Hyams and Anne-Marie Jackson, MD, for their assistance.

Recommended reading

• Bub B. Communication Skills That Heal: A Practical Approach to a New Professionalism in Medicine. Abington, UK: Radcliffe Publishing–Oxford; 2005.
  
• Herman J. Trauma and Recovery. London: Rivers Oram Press; 1997.
  
• Schneider J. Finding My Way: Healing and Transformation Through Loss and Grief. Colfax, Wisc: Seasons; 1994.
  

The author can be reached at [email protected]. Web site: www.processmedicine.com

The author reports no relevant financial relationships.

“I was stunned, bewildered, and disoriented. Surely this wasn’t happening to me. I felt cornered like a trapped animal and just had to escape so I spent most of the day wandering around in a daze. It was like living a dream—no, more like a nightmare.”

The victim of an accident, criminal assault, or terrorist attack? No, this was David, an obstetrician describing to me his reaction on being sued for medical malpractice. A day that started off as hectic but routine suddenly turned into a nightmare. Later, colleagues would tell him not to worry, that he’d be OK and that litigation was a “normal” part of medical practice. But it didn’t feel normal to him, as the memories of that day continued to replay in thoughts and dreams.

Malpractice liability may be omnipresent, but that doesn’t mean getting sued is a “normal” everyday hazard that Ob/Gyns should be able to take in stride. Litigation is frequently unfair, abusive, and traumatizing, and can cause acute stress disorder and even posttraumatic stress disorder (PTSD) in both physicians and patients.

David’s story

In this true story, an obstetrician suffering disabling litigation stress reclaims a sense of empowerment and control as he becomes aware of the nature of litigation stress. In the process, he learns how to listen, understand, and support patients, employees, and colleagues in times of stress.

During one-on-one telephone sessions, his trauma was acknowledged and named; his losses were identified and mourned in safety; and his isolation was relieved in a healing supportive relationship.

The initial shock

This was his first. “I was a litigation virgin,” he sardonically commented. “You know, when you’re jumping the waves in the ocean at high tide and then you become confident, you turn your back, and this big one hits you? It felt like that. I had just begun to relax, believing it wouldn’t happen to me. Then the lawsuit hit. It was a patient I’ve known for years. I delivered her other children and regarded her almost as a friend, someone I liked and trusted.

“I’ve made mistakes in the past but this wasn’t one of those times. It’s so unfair—instead of being grateful that I saved her 9.5-pound baby, she hunted down a lawyer on the Internet. The Web is full of them just waiting to pounce.”

The aftershocks

David recounted the journal articles¹ he’d looked up, which recommended that he share his feelings with a trusted colleague. Other articles cautioned against a possible “discoverable” confidence.² Colleagues’ attempts at reassurance did not really comfort him.

His wife was mostly supportive, but it was difficult for her to stay calm and objective since the lawsuit upset her, too. In fact, their relationship was quite strained.

David contacted me when it became increasingly difficult for him to see patients. He said that he felt he had to be constantly on guard, watching every word and action as if patients were an enemy waiting to ambush him. He dreaded going to work and wondered if he should quit obstetrics.

No, he did not want to see a psychiatrist or a psychotherapist. He wasn’t crazy, he wasn’t thinking of suicide or anything like that, he said, and the last thing he needed was the credential committee of his local hospital breathing down his neck.

He spoke in a a lifeless monotone, reciting the facts of the case as he had told and retold them many times. He sighed often and used negative expressions such as can’t, but, should, have to, if only. He was articulating a lament—an expression of suffering and loss, which is not uncommon among physicians^3,4 and patients.⁵ Within his narrative ran an unbroken thread of helplessness, grief, despair, and absence of meaning and hope.

 

Rather than premature reassurance and comfort, what David needed was to have his trauma named and acknowledged. Choosing my words carefully, I summarized his story and asked whether I had heard and understood him correctly. He verified that I had. Going a step further, I reflected back his underlying emotions as I had heard them—his feelings of fear, helplessness, sadness, isolation, betrayal, violation, anger, and injustice. Then I paused to create space for his response. Soon, the silence was interrupted by the sounds of his sobbing. When he regained his composure, David apologized for losing control. This lawsuit had been a huge strain, he explained.

Symptoms of acute stress reaction

I agreed, pointing out that he had probably experienced an acute stress reaction: feelings of intense fear, horror, and helplessness in response to an unusually traumatic event threatening death or serious physical injury to self or others.

This explained his fright and dazed disorientation on the day he learned of the litigation.⁶ While the lawsuit was not life-threatening, it threatened his identity, career, and survival as a physician.

Symptoms of PTSD

Usually acute stress reaction settles down, but sometimes it progresses beyond a month into posttraumatic stress disorder, a pervasive chronic anxiety disorder characterized by 3 clusters of symptoms:

• Recurrent, intrusive recollection of the events; recurrent flashbacks and dreams.
  
• Persistent avoidance of stimuli associated with the event; numbness, detachment, avoidance of patients.
  
• Persistent symptoms of increased arousal; insomnia, hypervigilance, irritability, difficulty with concentration.
  

I suggested that some level of posttraumatic stress disorder was the explanation for many of his symptoms.

“I am a rock” mentality may predispose to PTSD

Litigation, because of its protracted nature, is particularly retraumatizing. David concurred: “This explains why just opening a lawyer’s letter now causes my heart to pound.”

Unlike the military, physicians do not enter a stressful environment organized into teams. Should trauma and acute stress reaction occur, most physicians continue working despite their intense physical responses. There is little community support, so withdrawal and isolation is the norm, and this “norm” may predispose to posttraumatic stress disorder.

As a result, some physicians manifest behavioral problems such as being hyperreactive, aloof, or disruptive, or they abuse alcohol and drugs. Ironically, these behaviors probably lay groundwork for additional lawsuits.⁷

Counting up the losses

David asked what I meant by “losses.” I explained that the nature of trauma is to create loss.

• Together we listed his loss of:
  trust
  safety
  peace of mind
  sense of justice
  integrity of personal boundaries
  control
  self-esteem
  self-confidence
  passion
  idealism
  

Mourning these losses and releasing pent-up emotions of anger, grief, disappointment, frustration, shame, and guilt was essential.

The power to choose how to respond

While he could not stop the lawsuit, he did have the power to choose how to respond to it. It was his choice whether to be demolished by this lawsuit or to use it to grow personally and professionally. If he agreed, I would partner him in transforming his suffering into growth. On the other hand, should his symptoms not recede, he would need to see a psychiatrist.

By now I had:

• validated his trauma, losses, and suffering
  
• provided him a cognitive framework
  
• interrupted his lament
  
• created safety for him to express his emotions
  
• emphasized he was not helpless, and that he had choices
  
• offered to partner with him, thereby relieving his isolation
  
• role-modeled listening
  
• offered him hope and a sense of some control.
  

 

A set-up for litigation stress

Surveys reveal that many medical students are exposed to serious trauma such as sexual abuse or domestic violence prior to entering medical school.⁸ They then enter medical training, which has been described as a “neglectful abusive family system,”⁹ and which adds trauma and toxic shame—this continues into a career punctuated with acute episodes of severe trauma such as medical errors, unexpected death of patients, and litigation stress.

Breast cancer, traumatic birth cause acute stress

David read books on trauma¹⁰ and suffering,^11,12 and began to explore ways to apply his new insight. He read journal articles that described acute stress reaction in patients diagnosed with breast cancer,¹³ traumatic birth,¹⁴ and spontaneous abortion.¹⁵ Now he understood why patients sometimes left his office bewildered and disoriented, unable to retain any information, and why patients with chronic trauma experience functional somatic symptoms. He also learned how to respond more effectively.

The outcome: Self-empowerment

Together we studied his written narratives of patient encounters and did role plays of these encounters. He was a good student, and his ability to communicate empathy and support eventually matched his technical proficiency. Increasingly, not only patients, but also employees and colleagues turned to him for listening in times of stress. Their positive feedback enhanced his sense of well-being. His newly acquired empowerment and sense of control was key to his success.

Over the course of 8 months, he traveled full circle from trauma victim to healer.

Litigation stress: Take it seriously

When taken seriously, much can be done to transform litigation stress into physician empowerment. Studies need to be done on stress disorders in physicians, so as to refute the culture of denial that exists around the trauma inflicted by malpractice litigation. Innovative programs need to be developed to minimize the harmful effect of litigation and to support physicians suffering litigation stress.

The author can be reached at [email protected]. Web site: www.processmedicine.com

The author reports no relevant financial relationships.

“I was stunned, bewildered, and disoriented. Surely this wasn’t happening to me. I felt cornered like a trapped animal and just had to escape so I spent most of the day wandering around in a daze. It was like living a dream—no, more like a nightmare.”

The victim of an accident, criminal assault, or terrorist attack? No, this was David, an obstetrician describing to me his reaction on being sued for medical malpractice. A day that started off as hectic but routine suddenly turned into a nightmare. Later, colleagues would tell him not to worry, that he’d be OK and that litigation was a “normal” part of medical practice. But it didn’t feel normal to him, as the memories of that day continued to replay in thoughts and dreams.

Malpractice liability may be omnipresent, but that doesn’t mean getting sued is a “normal” everyday hazard that Ob/Gyns should be able to take in stride. Litigation is frequently unfair, abusive, and traumatizing, and can cause acute stress disorder and even posttraumatic stress disorder (PTSD) in both physicians and patients.

David’s story

In this true story, an obstetrician suffering disabling litigation stress reclaims a sense of empowerment and control as he becomes aware of the nature of litigation stress. In the process, he learns how to listen, understand, and support patients, employees, and colleagues in times of stress.

During one-on-one telephone sessions, his trauma was acknowledged and named; his losses were identified and mourned in safety; and his isolation was relieved in a healing supportive relationship.

The initial shock

This was his first. “I was a litigation virgin,” he sardonically commented. “You know, when you’re jumping the waves in the ocean at high tide and then you become confident, you turn your back, and this big one hits you? It felt like that. I had just begun to relax, believing it wouldn’t happen to me. Then the lawsuit hit. It was a patient I’ve known for years. I delivered her other children and regarded her almost as a friend, someone I liked and trusted.

“I’ve made mistakes in the past but this wasn’t one of those times. It’s so unfair—instead of being grateful that I saved her 9.5-pound baby, she hunted down a lawyer on the Internet. The Web is full of them just waiting to pounce.”

The aftershocks

David recounted the journal articles¹ he’d looked up, which recommended that he share his feelings with a trusted colleague. Other articles cautioned against a possible “discoverable” confidence.² Colleagues’ attempts at reassurance did not really comfort him.

His wife was mostly supportive, but it was difficult for her to stay calm and objective since the lawsuit upset her, too. In fact, their relationship was quite strained.

David contacted me when it became increasingly difficult for him to see patients. He said that he felt he had to be constantly on guard, watching every word and action as if patients were an enemy waiting to ambush him. He dreaded going to work and wondered if he should quit obstetrics.

No, he did not want to see a psychiatrist or a psychotherapist. He wasn’t crazy, he wasn’t thinking of suicide or anything like that, he said, and the last thing he needed was the credential committee of his local hospital breathing down his neck.

He spoke in a a lifeless monotone, reciting the facts of the case as he had told and retold them many times. He sighed often and used negative expressions such as can’t, but, should, have to, if only. He was articulating a lament—an expression of suffering and loss, which is not uncommon among physicians^3,4 and patients.⁵ Within his narrative ran an unbroken thread of helplessness, grief, despair, and absence of meaning and hope.

 

Rather than premature reassurance and comfort, what David needed was to have his trauma named and acknowledged. Choosing my words carefully, I summarized his story and asked whether I had heard and understood him correctly. He verified that I had. Going a step further, I reflected back his underlying emotions as I had heard them—his feelings of fear, helplessness, sadness, isolation, betrayal, violation, anger, and injustice. Then I paused to create space for his response. Soon, the silence was interrupted by the sounds of his sobbing. When he regained his composure, David apologized for losing control. This lawsuit had been a huge strain, he explained.

Symptoms of acute stress reaction

I agreed, pointing out that he had probably experienced an acute stress reaction: feelings of intense fear, horror, and helplessness in response to an unusually traumatic event threatening death or serious physical injury to self or others.

This explained his fright and dazed disorientation on the day he learned of the litigation.⁶ While the lawsuit was not life-threatening, it threatened his identity, career, and survival as a physician.

Symptoms of PTSD

Usually acute stress reaction settles down, but sometimes it progresses beyond a month into posttraumatic stress disorder, a pervasive chronic anxiety disorder characterized by 3 clusters of symptoms:

• Recurrent, intrusive recollection of the events; recurrent flashbacks and dreams.
  
• Persistent avoidance of stimuli associated with the event; numbness, detachment, avoidance of patients.
  
• Persistent symptoms of increased arousal; insomnia, hypervigilance, irritability, difficulty with concentration.
  

I suggested that some level of posttraumatic stress disorder was the explanation for many of his symptoms.

“I am a rock” mentality may predispose to PTSD

Litigation, because of its protracted nature, is particularly retraumatizing. David concurred: “This explains why just opening a lawyer’s letter now causes my heart to pound.”

Unlike the military, physicians do not enter a stressful environment organized into teams. Should trauma and acute stress reaction occur, most physicians continue working despite their intense physical responses. There is little community support, so withdrawal and isolation is the norm, and this “norm” may predispose to posttraumatic stress disorder.

As a result, some physicians manifest behavioral problems such as being hyperreactive, aloof, or disruptive, or they abuse alcohol and drugs. Ironically, these behaviors probably lay groundwork for additional lawsuits.⁷

Counting up the losses

David asked what I meant by “losses.” I explained that the nature of trauma is to create loss.

• Together we listed his loss of:
  trust
  safety
  peace of mind
  sense of justice
  integrity of personal boundaries
  control
  self-esteem
  self-confidence
  passion
  idealism
  

Mourning these losses and releasing pent-up emotions of anger, grief, disappointment, frustration, shame, and guilt was essential.

The power to choose how to respond

While he could not stop the lawsuit, he did have the power to choose how to respond to it. It was his choice whether to be demolished by this lawsuit or to use it to grow personally and professionally. If he agreed, I would partner him in transforming his suffering into growth. On the other hand, should his symptoms not recede, he would need to see a psychiatrist.

By now I had:

• validated his trauma, losses, and suffering
  
• provided him a cognitive framework
  
• interrupted his lament
  
• created safety for him to express his emotions
  
• emphasized he was not helpless, and that he had choices
  
• offered to partner with him, thereby relieving his isolation
  
• role-modeled listening
  
• offered him hope and a sense of some control.
  

 

A set-up for litigation stress

Surveys reveal that many medical students are exposed to serious trauma such as sexual abuse or domestic violence prior to entering medical school.⁸ They then enter medical training, which has been described as a “neglectful abusive family system,”⁹ and which adds trauma and toxic shame—this continues into a career punctuated with acute episodes of severe trauma such as medical errors, unexpected death of patients, and litigation stress.

Breast cancer, traumatic birth cause acute stress

David read books on trauma¹⁰ and suffering,^11,12 and began to explore ways to apply his new insight. He read journal articles that described acute stress reaction in patients diagnosed with breast cancer,¹³ traumatic birth,¹⁴ and spontaneous abortion.¹⁵ Now he understood why patients sometimes left his office bewildered and disoriented, unable to retain any information, and why patients with chronic trauma experience functional somatic symptoms. He also learned how to respond more effectively.

The outcome: Self-empowerment

Together we studied his written narratives of patient encounters and did role plays of these encounters. He was a good student, and his ability to communicate empathy and support eventually matched his technical proficiency. Increasingly, not only patients, but also employees and colleagues turned to him for listening in times of stress. Their positive feedback enhanced his sense of well-being. His newly acquired empowerment and sense of control was key to his success.

Over the course of 8 months, he traveled full circle from trauma victim to healer.

Litigation stress: Take it seriously

When taken seriously, much can be done to transform litigation stress into physician empowerment. Studies need to be done on stress disorders in physicians, so as to refute the culture of denial that exists around the trauma inflicted by malpractice litigation. Innovative programs need to be developed to minimize the harmful effect of litigation and to support physicians suffering litigation stress.

The author can be reached at [email protected]. Web site: www.processmedicine.com

The author reports no relevant financial relationships.

“I was stunned, bewildered, and disoriented. Surely this wasn’t happening to me. I felt cornered like a trapped animal and just had to escape so I spent most of the day wandering around in a daze. It was like living a dream—no, more like a nightmare.”

The victim of an accident, criminal assault, or terrorist attack? No, this was David, an obstetrician describing to me his reaction on being sued for medical malpractice. A day that started off as hectic but routine suddenly turned into a nightmare. Later, colleagues would tell him not to worry, that he’d be OK and that litigation was a “normal” part of medical practice. But it didn’t feel normal to him, as the memories of that day continued to replay in thoughts and dreams.

Malpractice liability may be omnipresent, but that doesn’t mean getting sued is a “normal” everyday hazard that Ob/Gyns should be able to take in stride. Litigation is frequently unfair, abusive, and traumatizing, and can cause acute stress disorder and even posttraumatic stress disorder (PTSD) in both physicians and patients.

David’s story

In this true story, an obstetrician suffering disabling litigation stress reclaims a sense of empowerment and control as he becomes aware of the nature of litigation stress. In the process, he learns how to listen, understand, and support patients, employees, and colleagues in times of stress.

During one-on-one telephone sessions, his trauma was acknowledged and named; his losses were identified and mourned in safety; and his isolation was relieved in a healing supportive relationship.

The initial shock

This was his first. “I was a litigation virgin,” he sardonically commented. “You know, when you’re jumping the waves in the ocean at high tide and then you become confident, you turn your back, and this big one hits you? It felt like that. I had just begun to relax, believing it wouldn’t happen to me. Then the lawsuit hit. It was a patient I’ve known for years. I delivered her other children and regarded her almost as a friend, someone I liked and trusted.

“I’ve made mistakes in the past but this wasn’t one of those times. It’s so unfair—instead of being grateful that I saved her 9.5-pound baby, she hunted down a lawyer on the Internet. The Web is full of them just waiting to pounce.”

The aftershocks

David recounted the journal articles¹ he’d looked up, which recommended that he share his feelings with a trusted colleague. Other articles cautioned against a possible “discoverable” confidence.² Colleagues’ attempts at reassurance did not really comfort him.

His wife was mostly supportive, but it was difficult for her to stay calm and objective since the lawsuit upset her, too. In fact, their relationship was quite strained.

David contacted me when it became increasingly difficult for him to see patients. He said that he felt he had to be constantly on guard, watching every word and action as if patients were an enemy waiting to ambush him. He dreaded going to work and wondered if he should quit obstetrics.

No, he did not want to see a psychiatrist or a psychotherapist. He wasn’t crazy, he wasn’t thinking of suicide or anything like that, he said, and the last thing he needed was the credential committee of his local hospital breathing down his neck.

He spoke in a a lifeless monotone, reciting the facts of the case as he had told and retold them many times. He sighed often and used negative expressions such as can’t, but, should, have to, if only. He was articulating a lament—an expression of suffering and loss, which is not uncommon among physicians^3,4 and patients.⁵ Within his narrative ran an unbroken thread of helplessness, grief, despair, and absence of meaning and hope.

 

Rather than premature reassurance and comfort, what David needed was to have his trauma named and acknowledged. Choosing my words carefully, I summarized his story and asked whether I had heard and understood him correctly. He verified that I had. Going a step further, I reflected back his underlying emotions as I had heard them—his feelings of fear, helplessness, sadness, isolation, betrayal, violation, anger, and injustice. Then I paused to create space for his response. Soon, the silence was interrupted by the sounds of his sobbing. When he regained his composure, David apologized for losing control. This lawsuit had been a huge strain, he explained.

Symptoms of acute stress reaction

I agreed, pointing out that he had probably experienced an acute stress reaction: feelings of intense fear, horror, and helplessness in response to an unusually traumatic event threatening death or serious physical injury to self or others.

This explained his fright and dazed disorientation on the day he learned of the litigation.⁶ While the lawsuit was not life-threatening, it threatened his identity, career, and survival as a physician.

Symptoms of PTSD

Usually acute stress reaction settles down, but sometimes it progresses beyond a month into posttraumatic stress disorder, a pervasive chronic anxiety disorder characterized by 3 clusters of symptoms:

• Recurrent, intrusive recollection of the events; recurrent flashbacks and dreams.
  
• Persistent avoidance of stimuli associated with the event; numbness, detachment, avoidance of patients.
  
• Persistent symptoms of increased arousal; insomnia, hypervigilance, irritability, difficulty with concentration.
  

I suggested that some level of posttraumatic stress disorder was the explanation for many of his symptoms.

“I am a rock” mentality may predispose to PTSD

Litigation, because of its protracted nature, is particularly retraumatizing. David concurred: “This explains why just opening a lawyer’s letter now causes my heart to pound.”

Unlike the military, physicians do not enter a stressful environment organized into teams. Should trauma and acute stress reaction occur, most physicians continue working despite their intense physical responses. There is little community support, so withdrawal and isolation is the norm, and this “norm” may predispose to posttraumatic stress disorder.

As a result, some physicians manifest behavioral problems such as being hyperreactive, aloof, or disruptive, or they abuse alcohol and drugs. Ironically, these behaviors probably lay groundwork for additional lawsuits.⁷

Counting up the losses

David asked what I meant by “losses.” I explained that the nature of trauma is to create loss.

• Together we listed his loss of:
  trust
  safety
  peace of mind
  sense of justice
  integrity of personal boundaries
  control
  self-esteem
  self-confidence
  passion
  idealism
  

Mourning these losses and releasing pent-up emotions of anger, grief, disappointment, frustration, shame, and guilt was essential.

The power to choose how to respond

While he could not stop the lawsuit, he did have the power to choose how to respond to it. It was his choice whether to be demolished by this lawsuit or to use it to grow personally and professionally. If he agreed, I would partner him in transforming his suffering into growth. On the other hand, should his symptoms not recede, he would need to see a psychiatrist.

By now I had:

• validated his trauma, losses, and suffering
  
• provided him a cognitive framework
  
• interrupted his lament
  
• created safety for him to express his emotions
  
• emphasized he was not helpless, and that he had choices
  
• offered to partner with him, thereby relieving his isolation
  
• role-modeled listening
  
• offered him hope and a sense of some control.
  

 

A set-up for litigation stress

Surveys reveal that many medical students are exposed to serious trauma such as sexual abuse or domestic violence prior to entering medical school.⁸ They then enter medical training, which has been described as a “neglectful abusive family system,”⁹ and which adds trauma and toxic shame—this continues into a career punctuated with acute episodes of severe trauma such as medical errors, unexpected death of patients, and litigation stress.

Breast cancer, traumatic birth cause acute stress

David read books on trauma¹⁰ and suffering,^11,12 and began to explore ways to apply his new insight. He read journal articles that described acute stress reaction in patients diagnosed with breast cancer,¹³ traumatic birth,¹⁴ and spontaneous abortion.¹⁵ Now he understood why patients sometimes left his office bewildered and disoriented, unable to retain any information, and why patients with chronic trauma experience functional somatic symptoms. He also learned how to respond more effectively.

The outcome: Self-empowerment

Together we studied his written narratives of patient encounters and did role plays of these encounters. He was a good student, and his ability to communicate empathy and support eventually matched his technical proficiency. Increasingly, not only patients, but also employees and colleagues turned to him for listening in times of stress. Their positive feedback enhanced his sense of well-being. His newly acquired empowerment and sense of control was key to his success.

Over the course of 8 months, he traveled full circle from trauma victim to healer.

Litigation stress: Take it seriously

When taken seriously, much can be done to transform litigation stress into physician empowerment. Studies need to be done on stress disorders in physicians, so as to refute the culture of denial that exists around the trauma inflicted by malpractice litigation. Innovative programs need to be developed to minimize the harmful effect of litigation and to support physicians suffering litigation stress.