Those who will be sued in the future

Short White Coat is a blog about learning to be a doctor. Posts appear here as part of White Coat Notes. Joshua U. Klein, MD, is a third-year obstetrics and gynecology resident at Brigham and Women's and Massachusetts General hospitals.

The threat of medical malpractice litigation looms large over much of the medical profession these days, especially in high-risk specialties such as obstetrics. Disturbing as this may be for attending (i.e. full-fledged) physicians, doctors-in-training (i.e. residents) can be in a particularly precarious position. Their professional standing entails a peculiar combination of limited experience with abundant front-line responsibility, which certainly can put them at risk of litigation if things don’t go well.

Residents have earned their medical degrees, and thus are considered doctors, not students (as far as I know, a medical student has never been, and cannot be, sued; this is best supported by the fact that medical students are not required to carry medical malpractice insurance). Because of the way medical training has evolved, in an academic medical center, residents are almost always the first physicians responding to an urgent or emergent situation. Whether the issue is chest pain, shortness of breath, bleeding, or a Code Blue, the first doctor called is almost always an intern or resident. This is no coincidence, of course; for one thing, residents (as the name implies) are the ones spending the most time in the hospital, consistently working overnight, weekend, and holiday shifts when most of the senior doctors are at home.

More importantly, however, this arrangement is intentionally built into the trial-by-fire nature of medical training. The reigning logic dictates: you can only learn so much by watching someone else handle an emergency; at some point you have to jump in and be the one in charge yourself. There is always, of course, some system of backup provided by a more senior clinician, but initially, the system calls for trainees to stay calm and make good decisions under pressure, calling for help only if/when they feel truly overwhelmed.

It does not seem to be the case that residents get sued often, but it does happen. In one recent and highly publicized case, two Ob/Gyns were sued (and found liable for a huge award) regarding a case in which they were involved during their residency training, almost a decade before. While the system clearly dictates that residents are trainees acting under the auspices of an attending physician, this does not afford protection when it comes to malpractice litigation. Hospitals do routinely include medical malpractice insurance coverage as part of the compensation package for their residents, but the shield of the institution does not deflect lawsuits altogether.

Recognizing the psychological and emotional trauma that a malpractice lawsuit can inflict, one of the hospitals where I work has recently created a “physician support group” to help minimize the stigma, and support those physicians involved in litigation. At one preliminary meeting I observed, there were only a few hands in the room that didn’t shoot up when the speaker asked for those who have been or are currently involved in a malpractice lawsuit. The camaraderie seemed to be extremely cathartic, especially having division chiefs and other very prominent and well-respected academic clinicians openly participate in this group. While residents were not the primary target audience for the meeting, for better or worse, we were made to feel we belonged when one speaker addressed his comments to “those who have been sued, those who are being sued, and of course, those who will be sued in the future.”