Tony (not his real name) was one of those patients who came to be a friend. I was his doctor for 11 years, guiding him through some very difficult times with a chronic autoimmune disease. He was a handyman, a fly fisherman, a husband, a father and a man of deep faith.

His condition was difficult to control, but he always offered a smile as he patiently and hopefully waded through a series of treatments through the years. I’m a terrible fisherman, and neither of the two necessary traits (patience and reading the water) comes naturally to me. But it didn’t keep him from giving me flies that he had tied himself, even giving me a handmade bamboo fly rod that to this day sits in my study unused but treasured.

One afternoon, my receptionist urgently pulled me out of an exam room, concerned. “There’s a man in the waiting room, a deputy or something, and he wants to see you … he has some papers.” To this day, I’m not sure who or what he was other than a messenger of misery. I suppose he was a constable. He handed me the papers, and I vaguely remember a badge, a gun that seemed entirely unnecessary and a decidedly unsympathetic look, a preview of the stress and self-doubt that the coming months would bring.

I hadn’t seen Tony for quite a while, and it turned out that he had been diagnosed and quickly passed away with an aggressive malignancy that a plaintiff’s attorney seemed pretty sure several of my colleagues and I should have divined, even in the absence of any signs of it when last seen. This was some years back, in the era before tort reform in Texas, an era where hardly anyone knew a physician who had not been sued at least once. Now it was my turn.

If you haven’t been through it, it’s hard to understand the emotions you go through during malpractice litigation.

In some ways, it attacks the very core of who you are as a physician — an accusation that you are doing exactly the opposite of what you swore an oath to do and spent all those years training to do well. There was a strong sense of injustice, as I knew I had really done nothing wrong. I was forbidden by counsel to discuss it with friends or colleagues, adding an unhealthy serving of isolation to a plate full of shame and anger. To complicate matters, even more, I was simultaneously grieving a man who I considered a generous friend. After a year of silent anguish, second-guessing myself and being suspicious of patients I once felt at ease with, I was as unceremoniously dropped from the suit as I had frivolously been added in the first place. There was a tremendous but profoundly incomplete sense of relief. Now even two decades later, I still recall those emotions clearly, even as I ironically still treasure the fly rod Tony gave me.

As physicians, we are called on to be many things by patients and by ourselves.

Compassionate, competent, vigilant, intelligent, patient, available, and when lives are in the balance, perhaps even perfect.

Litigation, deserved and undeserved, remains a constant threat lurking behind any mistake or just bad luck, but fortunately not as much as some years back. This extreme kind of judgment against us has to some extent, been replaced by 100 smaller cuts that we face from criticism from patients or their families, online reviews, peer review, insurance authorization denials, peer to peer reviews, colleagues, employers, practice managers and at times, most damaging of all, from ourselves.

Some of these criticisms are well-deserved, even constructive, and are to be carefully considered as teaching moments, while others are simply based on bureaucracy, greed, frustration, or just nastiness. All of them challenge our deep and ultimate calling to bring compassion and love, along with our talents, to each and every interaction with our patients. We have to be careful, through self-reflection and support from colleagues and loved ones, that this type of criticism does not harden us over time in a way that causes us to lose the compassionate calling that a younger version of ourselves set out to pursue all those years ago.

Brian Sayers is a rheumatologist.

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