“Trauma creates change you don’t choose. Healing is about creating change you do choose.”
One of my oldest and dearest friends, an ED doc/director, missed a diagnosis on a toddler with early meningitis. The child lived, but had permanent neurologic sequela. The parents were, of course, devastated. And angry. And as one would expect, hired an attorney.
But as the title of this piece suggests, I’m penning this to talk about the doctors rather than the patients. My heart aches for the patients when bad outcomes happen, and for their families and others who care about them. But after many years in medicine, my heart also aches for the physician. My heart ached for my friend, one of the kindest, most caring, most competent ED docs I’ve known.
I’m not talking here about “bad doctors.” I might have a modicum of compassion even for them, in that I don’t think physicians rendering substandard care as a matter of course ever aspired to be incompetent. But we’ve all heard horror stories about doctors who just kept harming patients and somehow escaped consequences, until they couldn’t any longer. There is no excuse for it, and there is responsibility in multiple pieces of the medical puzzle when this occurs.
No, I’m talking about good doctors, doctors who know their stuff, who care deeply about providing expert, compassionate medical care for their patients, who work long and hard to keep up with the latest information. Even good doctors can have bad outcomes, either from an honest mistake, or often, even when things seemingly go completely well from a technical standpoint, and yet the end result is suboptimal, sometimes tragically so.
Few think about the devastating effect this has on the physician who’s patient has not done well. And maybe that’s part of the distinction between “bad doctors” vs. “good doctors who have had a bad outcome.” Maybe the habitually inferior physician doesn’t care so much, or is able to rationalize, justify, tries to make excuses. I once fired one of my ED docs, not for the mistake he made but for his hubris in telling me it was no big deal, that it could have happened to anyone. (Fortunately the patient returned to the ED shortly after this doctor’s shift ended, was admitted, and ultimately did well, but could have had a devastating outcome.) I wanted my colleague to feel something about that, to acknowledge it. When he couldn’t, I lost faith in him. Admittedly, this occasion was the final straw regarding a series of situations where reasonable humility was lacking, and it became more and more difficult to expect improvement. Good doctors, on the other hand, suffer when their patients suffer. And they suffer in spades when there is a bad outcome, and in quadruple spades when it was due to a mistake they made.
How can we help them as coaches? We certainly don’t want good doctors to crumble under the weight of their grief and remorse and leave medicine. How can we help them recover and ultimately stay in the game?
For some years now I have been a physician peer coach. I work with other physicians who are in various sorts of difficulty. This could be anything from doctors who aren’t playing well with others, or exhausted ones struggling with burnout and disillusionment, to physicians who have been placed in leadership roles for which they are either ill suited or perhaps just need some onboarding/development coaching to help them rise to the role. But not uncommonly I’ve worked with docs who are dealing with the huge emotional impact of a patient who has died or otherwise had an unexpected bad outcome. It would be hard to describe the degree to which these poor souls beat themselves up, the sleepless nights, the shame that they heap upon their own heads and hearts, the self-doubt, the “if only’s…”
There are few professional fields where the cost of something not going as planned has such importance as in medicine. A wrong diagnosis re. the noise your car is making might leave you stranded on the roadside. It might also leave you mad as a hatter at your mechanic, deserved or not. But either way we expect that the mechanic will likely sleep well that night, and likely won’t be worrying about his professional future, etc. It is unlikely that the mechanic will need a peer coach.
So back to the question: How can we as coaches help?
First and foremost, as coaches we are trained to be expert listeners. We are able to be a vessel that can receive and hold the story, ask appropriate questions, sit in silence with our client when needed. We are also trained not to offer glib answers or nostrums. This is key, because the physician suffering after a bad outcome will see right through glib answers and nostrums.
Physicians need to hear that a bad outcome doesn’t make them a bad physician or a bad human being. The bad outcome is a “what,” not a “who.” If things came about due to a medical error, this is particularly crucial. Taking appropriate responsibility can be an important step towards healing. Being mired in shame is not.
We may need to act as a sounding board to help the client come to his own personal truth regarding whether this bad outcome was due to medical error or simply a bad outcome which can happen despite best efforts. This can be complicated. And it’s not a question that we as coaches can answer for the client, either emotionally or legally. Why is this important? Because a good doctor who has had a bad outcome will ask herself and others these questions over and over: “Could/should I have done something different? Did I make a mistake or was this simply one of those statistically unexpected things that happens “x%” of the time?” In due course lawyers, judges, and juries may have occasion to weigh in on these questions in their own contexts, but none of those answers will be emotionally more important than the ones the doctor works through herself. As coaches we can provide a safe place for this exploration.
Lastly, I’ve been asked how I decide when a doctor in these sorts of difficulties should have a therapist vs. a coach. It’s an important question, and of course a sometimes complex one.
First, as we all know, it’s not an either/or thing. I recently worked with a physician in these sorts of circumstances that had a therapist and also worked with me. I think the therapist and I brought different skillsets to the equation. He clearly had some situational depression and anxiety, wasn’t sleeping well, was concerned about the impact of all this on his family. He was also concerned about his professional reputation, how the organization was dealing with his practice privileges, whether he would end up on the national databank, keep his job or not, how to interact with his colleagues and the hospital administrators, whether he should retain his own legal counsel, etc., etc. I think the therapist and I each played our parts, interacting with him in sort of a Venn diagram way, each with our own sets of expertise, but with a lot of overlap in the middle.
But back to the original question: I think whether a therapist is needed involves thinking about several things. Some of them are matters of degree. Sadness and anxiety are normal after a bad outcome. Worry about the future, wondering how it will all turn out – all normal. But if the client is withdrawing, not talking to family, friends, colleagues, if the client is turning to alcohol or other substances to dull the feelings, expressing undue remorse beyond what we might expect, or perhaps most importantly, your gut seems to be bringing this question up for you, get that help from someone else who is also trained to help! In practicing medicine I always welcome second opinions when I’m unsure about something. We want to help the client as well as prevent a bad outcome, so pulling another trained person into the equation is sometimes needed and reasonable.
I love this work. I think I love it because it’s an area where I sense I can have a lot of impact. I know the sinking feeling of vulnerability in the pit of the stomach that a doctor feels when something has gone wrong. I understand the total preoccupation and ruminations that follow. As a physician peer coach, as a medical director for three ED’s, and as a partner in a busy private practice later in my career, I’ve sat with multiple physicians going through this emotional process. If I can help a doctor or other healthcare provider work through this, putting the pieces back to together the best that we can, helping a good doctor get back to the work she loves, well, that makes me a happy camper.
I’d like to encourage coaches to think about whether this is something you might feel called to do. Although it may help a wee bit to have some knowledge of healthcare, it certainly isn’t necessary. As coaches we typically come to this work with a built-in capacity for empathy and a desire to help. Add proper evidence based training to that, plus a pinch of good humor, and that’s a great start!
Coming soon: When Good Doctors Have Bad Outcomes Part II
In the next installment I will discuss how to help the physician client make good, non-emotionally driven decisions regarding how to deal with their healthcare organization, decide when and how to choose appropriate legal counsel and how to guide that process, etc. (Hint: Relying solely on the attorneys assigned by your malpractice carrier may not always serve you well.)