179 CLINICAL FOCUS: SUPPORT FOR CLINICAL STAFF zy Editorial: Needs of staff after serious -1 1 1 zyxw 0 zyxwvuts 1- 0 incidents and dunng litigation Charles Vincent Senior Lecturer in Psychology, University College London THE PRACTICE OF MEDICINE is a notoriously stressful occupation. Beginning in medical school there is an emphasis on high standards, not making mistakes and, above all, being able to cope with whatever is thrown at you. Once qualified the junior doctor faces long hours and daily encounters with sick and dying people in the difficult and sometimes chaotic environment of the National Health Service. To make matters worse, in many specialties the stress inherent in the job is compounded by a work ethic that is incompatible with a satisfying life outside medicine. The same stresses exist, to a varying degree, in nursing and other health professions. None of this is to deny that the work and relationships with both patients and col- leagues can be immensely rewarding. However, if one is to comprehend the reactions of clinical staff to errors and to litigation, the personal comitment and the demands of the work must also be understood. The nature of the job, and the high standards expected, combine to produce high levels of stress in many members of the health professions. Although most research has concentrated on junior doctors, who are arguably more at risk, it is clear that doctors in general suffer higher than average levels of depression and alcohol abuse than the general population and, in particular, than members of comparable professions. The main sources of stress vary from person to person, but making mistakes is a major concern for many. Mizrahi’ asked young interns ‘What were your most memorable experiences during training?’; 21% of the replies concerned actual or potential mistakes. In addi- tion he found that serious and even fatal mistakes were made by half of the new interns he interviewed in the first 2 months of their jobs. When asked to describe a recent stressful event British junior doctors singled out zyxwvu Charles Vincent MPhil PhD, Senior Lecturer in Psychology, Department of Psychology, University College London, Gower Street, London WCIE 6BT, UK. making mistakes, together with dealing with death and dying, relationships with senior doctors and over- work.2 The mistakes reported were all potentially serious and clearly had a major personal impact. For instance: ‘I missed the diagnosis of pulmonary embolism and treated the patient as a case of severe pneumonia until the day after. The patient’s condition deteriorated and only then was the diagnosis put right. I felt guilty and lost confidence.’ ‘Missing a diagnosis of perforated peptic ulcer in a patient zyxwv - at least she is now well and survived. It made me feel useless at my job though.’ If a departure from accepted standards of care is fol- lowed by a complaint or litigation, the stress may increase. Personal accounts and surveys of doctors involved in litigation attest to the strong and enduring reactions that can occur. Feelings of anger and betrayal are common. Doctors tell of feeling ‘utterly alone’ and ‘isolated from colleagues and patients’.”.“These reac- tions are by no means inevitable; trivial and unfounded complaints may provoke only irritation. As yet litigation is of less concern to nurses, but any member of staff may be involved in a complaint. The reactions of staff involved in a complaint or in litigation are, from one perspective, quite understand- able. Most people react in the same way when their abilities are questioned, with anger and defensiveness at the implied attack on their competence and per- sonal integrity. However, litigation is essentially a mechanism for patients to claim compensation and need not be interpreted as an attack on the personal competence of the staff involved. In addition, it is sel- dom that serious incidents are wholly caused by the actions of one individual. Recent developments in the analysis of accidents in both medicine and other high risk areas have shown that the primary causes may be more general organisational factors.”‘ Thus in a hos- pital where there are problems with supervision, train- ing and the communication of information, junior doctors may find themselves forced to deal with