Your malpractice insurer wants to feel your pain. It may even provide a cash incentive if you'll just open up about your deepest fears and desires.

No, Oprah Winfrey isn't running the risk-management department. Bottom-line insurance executives aren't beating drums and hugging trees in the forest, and only a few actuaries have joined the bean sprouts and tofu crowd. Insurers have simply recognized an indisputable fact: Burned-out physicians are more likely to make mistakes than their mellower colleagues.

In other words, a happy doctor is a better business risk. And a stressed-out physician is a lawsuit waiting to happen. (Exhausted doctors are big risks, too: The grueling hours worked by residents have become a major issue in malpractice litigation.) As a result, learning to cope with burnout is now a liability-prevention strategy. And insurance carriers across the country are sponsoring stress-reduction seminars. In fact, some insurers provide a nominal discount on premiums if physicians attend the classes.

"We can joke about doctors getting in touch with their feelings, but that's not our primary motivation," says Theodore L. Passineau, senior health-care adviser for PICOM Insurance Co., a Michigan-based doctor-controlled carrier that covers about 5,500 physicians in the Midwest. "There's a link between stress and liability. Calmer, rested doctors are more careful, and therefore get sued less. We're in business to improve patient safety and reduce the number of lawsuits."

The deadly cycle of stress extracts a high price

Burnout is costly in more ways than one. Replacing a burned-out or impaired doctor can cost a large group practice upwards of $50,000 - counting a month's lost productivity as well as the expense of recruiting his replacement. When it comes to malpractice, try to calculate the cost of missing a cancer diagnosis because the physician was too stressed to follow up on a finding, or too distracted to ask a lab to redo a test with equivocal results. The misstep could cost the patient his life, and it could cost the physician's insurer millions.

Burnout and malpractice create a cycle of continuing stress and business losses. "Once a malpractice claim is filed against a physician, the chance of that doctor's being involved in a subsequent incident that will result in another lawsuit increases significantly during the following year," says Passineau.

"Few things in life are as stressful as being a defendant in litigation," he continues. "As doctors try to cope with that stress, they can be distracted and are at risk for making more mistakes." (See page 218 for ways to counteract the stress of a malpractice case.)

Stress affects patient care in subtle and insidious ways, says Edward E. Bartlett, a risk-management consultant in Rockville, Md., who conducts stress-reduction seminars for medical-malpractice carriers. "You can't always separate and quantify the stress to show a cause-and-effect relationship to a patient's injury. But we know it plays a big role."

While everyone has some stress, burnout occurs when your anxiety level interferes significantly with your ability to cope. A doctor who's feeling burned out is less likely to ask for a complete history, or order an extra diagnostic test to pin down a problem, says Bartlett. "Stressed-out doctors are emotionally exhausted and may just be going through the motions, not completely attuned to their patients' physical or emotional needs."

Stress also is expressed by a lack of compassion - "empathy fatigue." A GP at one of Bartlett's seminars related this incident: The patient was a truck driver in his late 30s, a heavy smoker who'd complained of a cough and some chest discomfort. The physician diagnosed bronchitis. A few days later, the man was found unconscious in his bedroom. He was rushed to the hospital, where he died. The diagnosis was a silent myocardial infarction.

The man's wife sought out the physician to vent her grief. She wasn't blaming anyone but just wanted someone to listen to her. The doctor's response: "You're crying on my shoulder now, but you'll probably be suing me a month from now."

"The GP who made this cavalier and insensitive remark isn't a horrible person," says Bartlett. "He truly didn't realize at the time what an awful thing he'd said. Stress can do that. Take a physician who hasn't had a vacation in two years, and practices in an area with high managed-care penetration. Maybe he's seen his income dip significantly. None of that is an excuse. It's just a fact that stressed-out doctors display less empathy.

"This GP did end up being sued, and he may have instigated the process by his remark. It becomes a vicious cycle: The guilt and shame he feels over what he said to the widow reinforce his feeling of burnout."

Raise your hand if you're stressed out by managed care

Bartlett routinely asks that question at his seminars. Everyone laughs and raises his hand. In fact, a Seattle FP has defined what he calls "managed-care hypertension." He recorded his blood pressure before and after phone calls to managed-care plans to request authorizations for services needed by his patients. "Blood pressure following frustrating telephone calls exceeded values required for the diagnosis of hypertension and, if sustained, would indicate the need for treatment to avoid the associated morbidity and mortality," the doctor wrote in a letter to The Journal of the American Medical Association a few years ago.

"Changes in the health-care market are stressors, but we can't blame it all on managed care," explains Bartlett. "Stress isn't caused exclusively by external factors. Some physicians with many managed-care contracts are happy. Others with one or two contracts are miserable. Personality characteristics determine how an individual reacts."

"At the seminar, we tried to explain that while treatment authorizations are a hassle - for everyone - at least they allow the patient to receive necessary medical care. Actually, just knowing that other doctors at the seminar were similarly hassled by managed-care plans helped this physician realize that he wasn't so isolated."

Some medical psyches are prone to stress

At his seminars, Bartlett encourages physicians to share their experiences. He then attempts to provide methods for dealing with stress. While many techniques seem basic, it's clear that too few physicians practice them.

"Some of the advice may sound like Psychology 101," he says. "But in hectic everyday practice, physicians lose sight of these basics. Doctors can be their own worst enemies when it comes to lowering stress. The qualities that make them good doctors, such as striving for perfection, taking on more responsibility, and their willingness to sacrifice, can stand in their way when trying to overcome stress."

Consider how these personality types can suffer.

Perfectionists. "No one can be perfect all the time," says Bartlett. "To believe that you can be is the worst form of self-abuse. Yet many doctors fall into this trap. Then when something goes wrong, as it inevitably must, they beat themselves up and feel ashamed. Often, they'd rather cover up a mistake than admit failure. At our seminars, we urge doctors to strive for excellence rather than perfection."

Expectations of perfection are also imposed on others, creating enormous resentment. "I secretly resent it when my staff takes off for a long weekend," one doctor told Bartlett. "Don't they care about my business? If I can work six days a week until 10 each night, why can't they?" After discussions with Bartlett's group, this doctor decided to take off one weekend each month. "My business will survive if I'm not there to nursemaid every waking moment," he admitted.

High achievers. "I think, therefore I am," has now been changed to "I work, therefore I am," or "I earn, therefore I am," says Bartlett.

When medicine is no longer rewarding, the pursuit of wealth can become a consolation prize. Crank up the numbers and see more patients. But wealth is a trap: It seldom brings happiness. "Some physicians don't know when or how to stop," says Bartlett. "They feel guilty about taking time off and losing a few bucks. They become trapped in a gilded cage."(*)

Bartlett tells of one physician who normally worked an 80-hour week. Because of his grueling schedule, he made a mental error that led to a harmful outcome. The doctor went into a depression and feared a lawsuit would be filed. "This incident was a warning that I've been working too hard," he told the group. "And I've learned how important my family is, because they've helped me through this experience." The irony, Bartlett says, is that this doctor pats himself on the back because he now works "only" 70 hours a week.

Responsibility takers. "If the patient gets better, I'm a good doctor. If he doesn't, I'm a bad doctor." While most physicians can intellectually see the fallacy in that kind of thinking, too many act it out anyway, says Bartlett. Especially in the age of managed care, there just isn't enough time to fix every problem, or enough resources.

"Take a patient with diabetes," he says. "Most of the success in controlling this disease rests with the patient's willingness to modify his diet, check his blood glucose, and curtail certain activities." So this patient's outcome doesn't necessarily have' anything to do with how good his doctor is. One solution might be for physicians to distribute a patient brochure explaining the patient's responsibility for his own health.

Approval seekers. "We spend most of our time talking to patients and our staffs, and they tell us we're wonderful," one physician notes. "After a while, we begin to believe it, and we become a victim of our own success."

While many doctors love to be loved, the trap is that they may feel they can never say No, so they let others take advantage of them, says Bartlett. "Doctor, can you work in just one more patient? Can you help us out with this committee? I know it's after hours, but can you see me for just a few minutes?"

"These doctors are always running late," Bartlett adds, and they eventually become fatigued by doing so much for others. "They don't want to say No to case managers, and they don't want to say No to patients or their own staffs. Stress has to increase."

Self-sacrificers. Many physicians develop what Bartlett calls the "as soon as" syndrome. "As soon as I pay off my medical-school debts, I'll start taking some vacation time. As soon as I establish my referral base, I'll slow down a little. As soon as I get my kids through college, I'll stop working Saturdays."

"The problem is that the doctor keeps putting off meeting his own psychological, social, and spiritual needs," says Bartlett. "We try to get doctors to stop beating up on themselves so much."

Control freaks. "An FP complained that his scheduler consistently overbooked patients at the beginning of the day," says Bartlett. "He was angry and disgusted, and he felt a loss of control. He had responsibilities to his patients and felt he couldn't meet them if he was being triple-booked for 9 a.m.

"The obvious solution was to speak to the front-office staff about the problem," Bartlett continues. "But this physician was so angry that he worried about exploding if he confronted them. We worked on assertiveness training: how to express anger without going overboard."

Guilty ones. "Physicians at the seminars often tell of how guilty they feel about a mistake they made years ago," says Bartlett. "Even when no lawsuit resulted, these doctors have carried the burden of shame for years. They question their own abilities. That often leads to resentment of patients as potential adversaries in court. Just acknowledging these feelings and having them validated by other physicians in the room provides some relief."

* See "Why more money won't buy you happiness," Sept. 8, 1997.

RELATED ARTICLE: Reducing stress after you're sued

Being a defendant in a lawsuit is one of life's most stressful events, say malpractice insurers. "For an attorney, a lawsuit is just business. For a physician, his ego, reputation, and self-worth are on the line," says Theodore L. Passineau, senior health-care adviser to PICOM Insurance Co., a doctor-controlled carrier based in Michigan. "A doctor who's been sued is at much greater risk of having another incident that will result in a subsequent lawsuit." Passineau recommends these techniques to reduce stress.

Keep control of hours. "Once a physician is sued, he resolves to do better, to document more, to keep up with his reading," says Passineau. "But physicians already work 60-70 hours or more a week. If you add more work time to that, it becomes counterproductive and fatigue sets in, making you more susceptible to slip-ups."

Use consultations. Physicians facing a lawsuit naturally tend to second-guess themselves: Are they really as good as they thought? It's wise to discuss tough cases with a consultant you trust. That helps ensure that you aren't making a clinical error. And confirmations reinforce your confidence and self-worth as a physician.

Emphasize people skills. It's not uncommon to hear physicians say, "After I was sued, I saw every patient as a potential adversary." Patients pick up on that attitude, and their relationship with you can break down. It's more important than ever to take the time to sit down with patients. Make eye contact. Don't write while the patient is talking. Give the patient your full attention.

Work on relationships. Litigation is a family experience that affects spouses and children. Yet many physicians, especially men, bear the burden themselves. Some don't even tell their spouses that they've been sued. That lack of communication adds stress to a marriage, which is the last thing a doctor defendant needs.

Maintain balance. Don't let the litigation consume every aspect of your life. Worrying about a lawsuit 24 hours a day will just burn a hole in your stomach. There's a need to compartmentalize. Exercise is important, and, for many, so is worship. Litigation takes years. Act for the long haul.

Monitor alcohol and drug use. Some physicians tend to be compulsive, and extreme stress can make these individuals vulnerable to addiction. Don't self-prescribe, especially when under the stress of a lawsuit. And keep closer tabs on alcohol intake.