Establishing our place in obstetrical health care can come with a steep price, not the least of which is basic recognition. At times, you can only hope for gratification or peace-of-mind. As midwives, it can be a struggle. Burnout in healthcare has been recognized and documented for years. Signs and symptoms include: exhaustion, depression, work-life conflict, diminished joy, physical and mental stress, to name just a few. We do not necessarily experience it to the extent of debilitation, but we all know what it is. And where it comes from.
Burnout is specific to our coping mechanisms, home life, and workplace culture. In the next articles on burnout, I will discuss only three specific stressors and potential coping mechanisms to consider. In no particular order of significance, these stressors are: 1) Fear of Liability, along with associated legal interference. 2) Collegial Sabotage, featuring the predictable perpetrators. 3) Hospital Corporation Apathy and Disrespect; no easy solutions.
How each of us experiences career burnout varies depending on our personalities and employment situations. Prevailing, ugly cultures of care are the most productive for creating high-acuity provider burnout. Career burnout means many things to different providers. It may depend upon several factors:
- practice setting/culture, attitudes, and management of the corporate entity.
- specific emotional triggers
- family relationships and responsibilities
- money
- respect
- self-worth and status
Occasionally, prior to a raging house fire burnout, soon-to-be-burned-beyond-recognition providers may smolder for varying periods. Smoldering situations can resemble the following:
- You're informed by Human Resources that your salary is going to be capped at an unsatisfactory level and, because of your age, and for the remainder of your employment, you will never be paid more (yes, an age and employment discrimination lawsuit that never happened, but should have).
- As a hospitalist CNM, you are asked to deliver a private attending OB's patient. Because this doctor just woke up at home, she will not make it to the hospital in time. You and the patient deliver a perfect baby, but when the attending finally arrives, instead of saying thank you, she berates you at the crowded nurses' station for not getting cord gases. ("I always get cord gases! Why don't you know that?")
- In a money-saving outburst of brilliance, the hospital decided that OB Triage responsibilities should be shared by RNs and CNMs. One role. Two differing levels of provider capability. Only one level (CNM) is legally certified/hospital-approved to perform a screening evaluation under EMTALA. Also, one designated salary for two disparate levels of education and scope of practice.
- First year OB residents assigned to "strip rounds"; responsible for monitoring all the EFM tracings on the labor deck. They are beyond clueless, and also documenting their faulty interpretations in the medical record, where your name is found, as well.
- You only feel comfortable talking to the newborn that you just delivered.
- Corporate blackmail (more on that, later).
- Ageism and unkind gossip directed toward older midwives.
- L&D nurses are entitled to degrade your management plan for a patient's labor and delivery. In front of the patient.
- You have no idea what day it is.
Fear of Liability
As health care professionals, we have all experienced stressful care situations where a patient (or two) is at high risk of permanent injury or death. For certain areas of practice, these stressful situations are relatively infrequent. In some provider specialties, such as OB hospital midwifery, high-stress situations may occur every day. Fear of malpractice may hover over midwives' heads each hour that they are engaged with patients.
Over several decades, obstetrical malpractice litigation has increased significantly. It has been reported that malpractice claims actually peaked sometime in the 1980's; however, the number of claims filed, even today, is described as "epidemic". Fear of litigation can trigger intense, but often unrealistic, fear in providers of healthcare .1
Unfortunately, in litigious medical environments, malpractice lawsuits receive greater visibility, especially when millions of dollars are awarded to injured plaintiffs. Permanently brain-injured baby cases, along with shoulder dystocia litigation, are associated with exceptionally high monetary damages and awards. The only reassuring fact, offsetting the reality of these verdicts and the disrupted careers they entail, is that plaintiffs' awards at trial are relatively few.
Cases litigated through the court system reveal that jurors find for defendant care providers far more often than for plaintiffs. Understanding this, however, does not diminish the anxiety and stress that malpractice litigation can inflict on the professionals experiencing it.
Fear of liability is a rational response to work/life stress. Some plaintiffs' trial attorneys are attempting to take advantage of medical providers' anxiety and burnout. Random law firms are manipulating consumers through media advertising to believe that medical care providers are anxious, burned out, and unable to function at expected professional levels. Although it's hard enough to live with the potential for being sued, attorneys advertising about doctors' and midwives' incapacitating fears and exhaustion in practice are especially aggravating. In addition, these ads encourage consumers to be on high alert for any indication that their providers are burned out or otherwise diminished in their capabilities to provide competent medical care.
“Good morning, Dr. Smith. You look like hell. Are you feeling burned out today?”
Law Firm Advertising
One medical injury law firm blog post argues that the medical industry may be causing malpractice incidents, suggesting that medical professionals are under intense pressure, especially those working in hospitals. One of these law firm advertisements was written during the COVID-19 crisis, and on its face, it is not wrong. What may have been exaggerated was an assertion that providers are currently "more burned out than ever, and this has been a problem in America "for a long time. This statement reveals the real intent behind the ad: "Burnout can cause doctors to make critical mistakes.".2
A paragraph follows describing a wrong-medication incident that debilitated and caused the death of an elderly patient. It ends with: "You deserve medical staff that is prepared to give you high-quality care. If you received substandard treatment at the hospital because of burnout, it was your life at risk. You may be left with worse, not better, health as a result. This is unacceptable. 3
Free legal consultation is offered. "You Pay No Fees Unless We Win!’ 4
Irresponsible, fear-inducing advertisements about professional burnout in hospitals may be productive for firms that are actively "ambulance-chasing." They erode public confidence in medical care and add further stress to providers who are working "harder than ever." Law firms with integrity do not stoop to these tactics; they rely instead on well-earned reputations for fairness and reason.
Legal Consciousness
A 2022 study explored the association between fear of malpractice and burnout among Chinese doctors. A finding from this study suggested that "Legal Consciousness (LC)" may buffer the effect of fear of malpractice in doctors experiencing burnout. Legal Consciousness is a personal, psychological resource that helps an individual deal with the fear of malpractice, referring to providers’ willingness to study and apply legal knowledge in medical practice. Understanding aspects of legal proceedings appeared to alleviate malpractice anxiety. Most Chinese medical workers were willing to broaden their legal knowledge and apply it to their medical practice. 5
Practical legal knowledge should be considered for alleviating some fears of malpractice. This does not require earning a JD. Limited knowledge regarding the realities of litigation may be helpful, along with assessing your level of diligence and continually finding ways to improve your practice.
If you are a care provider suffering burnout, you must seek immediate help. I do not anticipate that all health care entities will be sympathetic or helpful, but they should be informed. Trying to alleviate burnout on your own is not recommended by anyone. There are numerous articles that show burnout is linked to provider error and the potential for patient harm. 6
1. FEAR OF MALPRACTICE LIABILITY AND ITS ROLE IN CLINICAL DECISION MAKING. Hauser MJ et.al. Mark J. Hauser, M.D.
2. How burnout in the medical industry may be causing malpractice incidents. TLF. The Medical Injury Law Firm. p.2
3. TLF. pg 3
4. TLF . pg 4
5. The association between fear of malpractice and burnout among Chinese medical workers: The mediating role of legal consciousness. Fei Liang, Shu Hu, Youqi Guo. BMC Psychiatry. 2022 May 25;22:358. doi: 10.1186/s12888-022-04009-8.
6. Burnout and Malpractice Litigation. The Sara Charles, MD, Physician Litigation Stress Resource Center
http://www.midwivesontrial.com