Practicing in a climate of fear

I saw a patient this week. They were over 60, their gender doesn’t matter, but they came in with a simple history.

“I hadn’t been to the loo for 4 days, then I did, and I bled”

Straightforward really. Easy peasy. I went through the history, asking about all the red flags, checking for other symptoms. The examination was boringly normal so I sat down while the patient got dressed to talk through what we were going to do.

Then I thought about being sued and I stopped.

My diagnosis and management plan were sensible. Common things are common and I knew this didn’t need an urgent referral. In fact, it didn’t even fit the criteria for a 2 week wait. I knew what had caused the bleeding, there were no red flags. Why should I be thinking about being sued?

“I hate that I sat at my desk and doubted myself because of the climate we now practice in.“

Reflecting on your diagnosis and treatment is part of being a GP. Having a differential in your brain because yes, while common things are common, one of the things we do best is put together disparate pieces of a puzzle and sometimes – suddenly – the dots are connected. I know the areas I’m good at. I know the areas I’m not, and I am more than happy to ask a colleague for advice if they have more experience than me. I’m happy to admit to a patient I need to double check a guideline or the BNF because I’m not so arrogant as to assume I know everything.

But this feels different – this feels as though someone is out there, just waiting for me to make a mistake. Not to be clinically negligent and dangerous, but to be simply human. The phrase “practicing in a climate of fear” has been used, and it’s true. I’ve been lucky not to have a major complaint in my career so far that has gone the full distance to lawyers and courts, but I know it’s only a matter of time. Whenever I speak to colleagues who have, or I read the postings on social media, or the magazines from the defence organisations, the cases are always ones I can easily identify with. After all, that’s what our significant events are that we present at appraisal every year. When something almost went wrong but didn’t, or it did go wrong and what we can learn.

I met a colleague once who had one such complaint – it had gone all the way down the legal system, and his MDO had settled. Not – they were clear – because he had done anything wrong, but because the chances of them winning and the costs of a court case, meant it was cheaper to settle. Ever since then, he refers everything. He knows it isn’t cost effective. He knows it isn’t good medicine. He knows it’s not in his patients interests all the time. But how I feel today, sat in front of my computer, is a tiny fragment of how he must feel in every single appointment.

When the patient sits down, I’m still undecided. I opt for the strategy that has worked so far, and I talk to them. Together, we make a decision. It’s not foolproof, but I feel a lot happier practising as part of a team with my patients, than I do catastrophising every 10 minutes.

I’m sure I’ll come a cropper at some point, but I refuse to spend my career making decisions based on how scared I feel that day, rather than what is right.


Dr Zoe Norris is a portfolio GP in Hull. Having worked as a salaried GP and partner, she became a well known name by writing for the Huffington post and blogging about the challenges GPs were facing across the country.

Zoe took on the role of media lead for the online group GP Survival, while working in roles as a locum GP, GP appraiser, and lecturer for the NB Medical Hot Topics courses.

She is a sessional member of Humberside LMC, Yorkshire sessional representative, and was elected as Chair of the GPC UK sessional subcommittee in July last year.

She continues to support the online groups of GP Survival and Resilient GP, and is a columnist for Pulse.


  • Marion Brown
    Posted at 15:30h, 30 January Reply

    This is a really relevant article and, as someone who has the luxury of time within my own role, to ‘listen’ to patients, as well as talking with them (not just ‘to’ them!), I can empathise fully with the dilemma’s facing GPs – potentially with every single time-pressured GP consultation.

    The climate of fear – of complaint and litigation etc. – has become endemic and all-pervading and is seriously affecting the ability of GPs to have confidence to trust their own intuition, experience and common sense. Importantly, it is also compromising the flow of valuable patient and doctor experience feedback which is necessary for any system to pick up systemic problems at an early stage and to take necessary corrective action..

    The GP and NHS complaints procedures are cumbersome and tend to be seen and felt as threatening to doctors and thus inevitably to result in defensive reactions rather than true systemic ‘learning’ outcomes.

    The MDO advice prefers to encourage adherence to caution and ‘guidelines’ which (guidelines) may actually be misleading, as described in my own GP View ‘Outsider’s View’ article, due to the complexity and lack of responsiveness inherent within the system.

    The ‘Bolam’ test (or in Scotland the ‘Hunter v Hanley’ test) necessitates doctors to keep on doing ‘what any other reasonable doctor would have done given the same circumstances’.

    Fear is not a healthy climate for anyone to work in.

  • Polly Dee
    Posted at 22:13h, 22 March Reply

    I agree very much with the original article and what Marion Brown has written. From a patient’s perspective I can tell that this climate of fear is affecting my relationships with medical professionals. I made a complaint – a very justified one – some years ago now. Since then my file has become a container for medical defence statements and protective diagnoses, punctuated by key omissions. I would never have sued – I just wanted help, the truth and somebody to look into the issues which were affecting my care, but the medical defence unions leapt in and an aggressive stance backed by other doctors was mounted.

    A bit of introspection here is needed and a little less panic. Most patients want help not the legal system when they complain. Truth, transparency, kindness and responses which acknowledge that “we all make mistakes” goes a long, long way.

    Please drop the defensiveness. We’ll respect you more for it and there’ll be a lot less paperwork!.

  • Fiona French
    Posted at 12:30h, 24 March Reply

    A climate of fear is detrimental to both doctors and patients alike. I have been seriously harmed after withdrawing from a benzodiazepine. I had consumed it for 40 years thinking it was necessary for myoclonic epilepsy. The drug blighted my entire adult life. I have spent 3.5 years mostly in bed and suffered the most horrendous ordeal. My brain is damaged. I am physically and cognitively disabled. I doubt that I will recover. My retirement is ruined.

    What would have helped me most? A clear and unambiguous acknowledgement that I have been harmed by benzodiazepine withdrawal. Instead I have been given several spurious diagnoses. Letters from GP to consultant and back again simply state that I (the patient) believe my symptoms are due to benzodiazepine withdrawal. How strange that doctors with extensive medical education and training are unable to offer an educated opinion on this matter. The reasons for this are clear. Some deny categorically that my symptoms are not due to drug withdrawal. However, no further scientific explanation is given to support this assertion. Perhaps they think I am a complete fool.

    There is of course no treatment which will restore my brain to normal functioning. I would have come to terms with most of this but I cannot come to terms with the blatant dishonesty and I now have no desire to consult with any medical professional unless it is absolutely necessary. I will attend for routine blood tests and appropriate scans but otherwise I have no confidence in any medical opinion. How tragic this is. None of this is good medical practice and it most certainly is not good patient care. How is it possible to have a meaningful doctor-patient relationship where dishonesty is so blatantly obvious. And so we have diagnostic labels such as “neurological functional impairment” and more recently “medically unexplained symptoms” or MUS. Now convenient this is to mask the damage done to patients by prescription drugs and drug withdrawal. These trends only serve to discredit the medical profession even further.

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