A major challenge for physicians facing malpractice litigation is how foreign the legal process feels. Our vocabulary is not the lawyers' vocabulary, and our ways of thinking about things are not their ways! That gap often heightens the feeling of incompetence just when we’re most vulnerable.
The phrase “standard of care” is one that's used in both worlds. The meanings attributed to the words “standard of care” on either side may differ, creating confusion. Understanding how the legal system employs terms such as “standard of care” will help us physicians to navigate the foreign territory of medical malpractice litigation. So, today let's talk about a very basic concept: How does the legal system define the term, “the standard of care”?
What does “standard of care” mean in medicine?
After a patient’s unexpected adverse outcome, physicians often revisit the events which occurred before that outcome became a foregone conclusion. Our training leads us to reexamine how things unfolded and our thought process. We engage colleagues in conversation and revisit the medical literature. We often long to understand whether and how the decisions we made and the actions we took were flawed in any way.
Sometimes this process results in unhealthy, self-degrading rumination. Ideally, though, we learn from the experience for the benefit of patients yet to come by exploring whether this patient’s adverse outcome might have been prevented. Essentially, this is an attempt to ensure that our on-going work mirrors “the standard of care.”
We use this phrase commonly in reference to particular clinical scenarios (eg - the standard of care for bronchiolitis or facial numbness). Nonetheless, I’ll bet that many of us would be hard-pressed to provide a clear, concise, and universal definition, equally applicable in each and every clinical situation, of “the standard of care.”
So, how would you define “standard of care”?
Care as delineated in algorithms derived from evidence-based medicine?
Doing as you were taught by mentors?
Carefully considering the patient’s unique circumstance and symptoms and engaging your training, clinical experience, and intuition to choose the best course of action?
Care that results in the desired outcome?
This is not just semantics. How we interpret this phrase will impact on our outlook in Morbidity and Mortality Conference, Root Cause Analyses, and most importantly, our inner, frequently destructive judgments of colleagues and ourselves.
Interestingly, the legal definition of “the standard of care” might be useful here.
How does the law define “the standard of care”?
As a physician-defendant, I worried about how the legal system could ever assess the standard of care for the downright rare clinical situation with which I had been confronted. As it turns out, the law defines “standard of care” helpfully, succinctly, and effectively.
According to the law, the standard of care is simply “what a reasonable practitioner would do under the same or similar circumstances.”
Read that again. Even memorize it.
The standard of care is what a reasonable practitioner would do under the same or similar circumstances.
Note: there is no mention of perfection. Further, the notion of “what a reasonable practitioner would do under the same or similar circumstances” allows that reasonable practitioners under similar circumstances may do things differently and still be right. And while the law’s standard of care is a national one, the definition leaves room for the realities of practice in assorted specialties in diverse practice settings (rural clinic -vs- urban tertiary hospital) with various resources available.
How is this definition useful to us?
In a future post, we’ll further explore how the definition of “standard of care” is interwoven into the legal definition of “medical malpractice.” For today, though, consider letting the notion that the “standard of care” is “what a reasonable practitioner would do under the same or similar circumstances” become part of the lens through which you view your co-workers and your own work.
All too often, we physicians hastily pass judgment on physician and nurse colleagues or ourselves after a patient’s adverse outcome or in the aftermath of a medical error. I know because I’ve done it myself.
Let’s agree to stop that. Today.
Let’s remember that “same or similar circumstances” might mean calm, cool, and collected, or it might mean a nurse attempting to operate two new-fangled pumps while simultaneously mixing a pressor with a label too similar to an antiarrhythmic’s in the midst of a code in the middle of the night after two nurses have called off on that unit. It can mean caring in a crisis for a patient with a previously undiagnosed major underlying condition, all the while aware that this patient attends your child’s school or just after giving terrible news to the patient and family two rooms over. It can mean being confronted with the patient with the rare presentation of the rare condition smack-dab in the midst of a busy clinic on the very day after a close friend has died or your 17-year-old wrecked the car while driving intoxicated.
Granted, the legal system doesn’t, can’t, and probably shouldn’t focus on many of those seemingly extraneous details. That is no reason why we can’t. Who will know better what it is like to be in those “same or similar circumstances” than we do? No one, that’s who.
We owe one another education after a bad event, but don’t we also owe one another generosity and support? Let’s make that our communal “standard of care” for each other. Perhaps love and support can be what every reasonable practitioner provides to a colleague who finds themselves somewhere in the middle of trying to figure out whether they should or should not have done whatever they did or didn’t do, big or small, under their particular “same or similar circumstances.”
Scroll down to share your thoughts in the comments below, and if you are looking to find your way after an adverse outcome or in litigation, reach out here or here. I’d be glad to talk about how coaching might support you as you do.