Neurosurgical Forum
BROCA’S AREA
Catastrophic cardiovascular
complications from medical
malpractice stress syndrome
Joseph C. Maroon, MD
Department of Neurological Surgery, University of Pittsburgh Medical
M
Center, Pittsburgh, Pennsylvania
ore than 50% of physicians have been sued for
malpractice. An estimated 99% of those in high-
risk specialties such as neurosurgery will have
been sued by age 65.7 More than 95% of physicians sued
report that the litigation had a major psychological and/or
physical effect on them.18 Although most lawsuits do not
lead to payments to plaintiffs, approximately a quarter of
those sued report that it was the most stressful occurrence
of their lives.3
Most physicians enter medicine with a deep commit-
ment to helping their patients. Their identity and self-
esteem become integral and tightly bound to the quality
of their work. Thus, any legal allegation questioning their
competence threatens their very identity and may have an
enormous emotional impact. Furthermore, many physi-
cians share specific personality characteristics and life-
styles that make them uniquely susceptible to experiencing
adverse health consequences when confronted with charg-
es of malpractice. The traits that make good physicians and
neurosurgeons make them poor litigants.2,6 Physicians gen-
erally are in control, can detach themselves from emotions,
and are diligently obsessive when challenged. These same
traits can impede healthy coping when personally sued and
may have dire physical consequences.
A medical malpractice suit that alleges medical negli-
gence or wrongdoing is, therefore, not just a professional
concern or burden, but a very public existential threat to
the integrity and the very sense of self of the physician.
Existential threats are powerful life-changing events and
are associated with extreme stress and extreme physiologi-
cal stress responses.
The term medical malpractice stress syndrome (MMSS)
©AANS 2019, except where prohibited by US copyright law
characterizes the emotional reaction to being sued and
is akin to posttraumatic stress disorder.15 The stigma and
stress associated with a malpractice suit may result in anxi-
ety and depression, fatigue and emotional exhaustion, dif-
ficulty concentrating, irritability, changes in appetite and
libido, apathy, anger, and feelings of shame and guilt.
As devastating and permanently impactful as the so-
cial, professional, and health consequences of a medical
malpractice suit can be for physicians, there is a paucity
of research on the physical consequences of MMSS on
these individuals. A better understanding and awareness
of the mind/body risk factors and their consequences may
facilitate prevention of adverse health events when facing
litigation.
Presented and discussed are two cases of professional
athletic team physicians and spine surgeons who person-
ally experienced catastrophic cardiac and vascular conse-
quences associated with highly publicized claims of medi-
cal negligence and MMSS. I will highlight shared factors,
discuss underlying common mechanisms, and make pre-
liminary recommendations to prevent such occurrences.
Case 1
A 57-year-old male spine surgeon was sued for a failed
anterior cervical discectomy and fusion. After 5 years of
depositions, interrogatories, pretrial motions, and delays,
the trial was finally scheduled. The history, obtained from
his close colleagues and friends, revealed that anticipa-
tion of the trial “completely took over every waking mo-
ment.” After prolonged sitting for 5 days in court during
jury selection and preliminary motions, he developed mild
nonspecific chest discomfort, which he attributed to stress.
Approximately 36 hours before the trial was to begin, he
met with one of his closest friends.
At that time, he was visibly distressed, anxious, appre-
hensive, and depressed—more than he had ever been ob-
served to be before. He admitted to insomnia, lack of ap-
petite, and anger at the whole experience. The accusations
of professional negligence and incompetence were highly
publicized in the local media. He correctly believed that his
reputation as a nationally recognized premier sports medi-
J Neurosurg  March 29, 2019 1
Neurosurgical forum
cine surgeon was under attack. Because of pretrial stress
and the required time for trial preparation, beginning a few
weeks before the actual trial, he neglected his usual daily
1 hour or so of aerobic and resistance workout. He was on
no medications, had no history of cardiac or pulmonary
disease or risk factors for clotting disorders, and was in
general excellent health. He did not smoke or use alcohol.
Beyond his numerous publications and professional ac-
complishments, he was known to be dedicated to the high-
est medical ethics and was firmly committed to what was
in the best interest of his patients. He was known to have
boundless energy, a brilliant medical mind, and skilled
hands. The friend stated that throughout his career the
physician always “kept it together” and was “as cool as ice”
under pressure. So, his behavior and mood then were very
atypical.
On the morning of the first day of trial he walked to
his car, and suddenly fell to the ground and died. The au-
topsy revealed multiple pulmonary thromboemboli, well
organized and adherent, occluding the bilateral lower lobar
pulmonary arteries, which probably caused the nonspecific
chest discomfort prior to the trial. Also, there was a large
nonadherent saddle embolus occluding the main pulmo-
nary arteries that resulted in sudden death.
Case 2
In 2012 a complaint was filed against a 72-year-old
male neurosurgeon for a failed anterior cervical fusion
performed in 2009. There were 27 allegations of negli-
gence. In addition, punitive damages were sought because
of “wanton disregard and or reckless intentional conduct.”
Typically, punitive damages are not covered by malpractice
insurance and can amount to 2–3 times any award to the
plaintiff, and would come from the defendant’s personal
finances. From the date of filing until 2018 there were nu-
merous depositions, changes in the court date, and many
motions filed for dismissal after failed attempts at settle-
ment. With the final court date selected for May 2018, in-
tense preparation was undertaken by the physician begin-
ning 1 month prior. Thorough review of medical records,
depositions, complaints, and expert witness testimony be-
came all-consuming. Pretrial and posttrial meetings plus
court time averaged 12–14 hours per day with prolonged
sitting throughout it all. Despite the physician’s status as a
still-competitive Ironman triathlete, all meaningful physi-
cal activity came to a halt beginning 4 weeks before trial
commencement.
During the trial the physician was cross-examined for
2 days, and then there was a third day of direct and cross-
examination. The stress and total obsession with the details
of the case and the inactivity and anorexia resulted in a
weight loss of 12 pounds, insomnia, anxiety, depression,
and barely suppressed anger by the confinement in court,
missing a month of practice, and having to cancel needed
surgery for many patients. After 3 weeks of prolonged sit-
ting in court and no regular physical activity, closing argu-
ments were delivered and jury deliberation began. On the
morning of the verdict announcement, the physician expe-
rienced discomfort in the lower sternum and xiphoid area
and had tachycardia. He was extremely apprehensive of the
reputational damage and fallout, after 40 years of medical
2 J Neurosurg  March 29, 2019
practice, of a potential positive verdict for the plaintiff de-
spite the facts of the case mitigating against that.
Ironically, he was an expert witness who had been called
on to defend the actions of the patient in case 1, and was
aware of the tragic circumstances and the fatal pulmonary
thromboembolism. He was fearful of a similar catastroph-
ic event himself if there were a verdict for the plaintiff, and
realized he should not go to court to hear the verdict. In-
stead, he presented to the emergency room at a local hos-
pital, had an electrocardiogram, and subsequently a stress
test and cardiac catheterization via the radial artery. This
demonstrated a high-grade occlusion of the circumflex ar-
tery (Fig. 1), which was successfully stented. While on the
catheterization table he was told of the unanimous verdict
for the defense.
Cleared to resume his workouts, 12 days later while
walking up a hill with a 6% grade he experienced excruci-
ating pain in the left gluteal muscle that felt like a muscle
strain/sprain but without antecedent trauma. After resting
briefly, he was able to walk another 20–30 yards when the
pain recurred in the same location. The walk was aborted
and at home he subsequently listened over his left femoral
artery with a stethoscope. A loud bruit was heard. He or-
dered an MR angiography study the next day for himself,
which demonstrated a large thrombus in the iliac artery,
which was subsequently stented (Fig. 2). He was later able
to resume his vigorous daily exercise routine and neurosur-
gical practice.
Significant past medical history included a coronary
artery bypass graft to the anterior descending artery ap-
proximately 8 years prior for angina. Subsequently, he was
able to complete 2 Ironman distance triathlons—the last in
2017. There was no history of smoking, blood clots, hyper-
tension, or other medical problems.
Discussion
In both of the cases presented here, catastrophic vas-
cular complications occurred in otherwise healthy phy-
sicians immediately prior to or during the trial phase of
multiyear medical malpractice litigations. Both physicians
were exceptionally fit, enjoyed a very health-conscious ac-
tive lifestyle, and had no significant known health issues.
Both enjoyed reputations for excellent care and deep com-
mitment to patients. Both were overwhelmed with acute
and severe mental stress characterized by anxiety, depres-
sion, suppressed anger, insomnia, and fear of reputational
fallout. The most potent biological stress response is when
a stressor is uncontrollable and involves potential social or
reputational consequences—as in both of these cases.20 For
surgeons accustomed to being in control of their environ-
ment, abdication of virtually all decisions to lawyers can
be overwhelming.
The publicized allegations of malpractice represented
to both physicians an assault on their integrity and a true
existential threat. The Canadian physiologist Hans Selye
described “stress as the failure to respond appropriately to
emotional or physical threats to the organism, whether ac-
tual or imagined.”17 Despite their background of resilience,
both failed to adapt appropriately and suffered thereby.
What is the common link between pulmonary throm-
boemboli in case 1 and acute coronary artery syndrome