When things go wrong: Experienced physicians on what really drives medico-legal risk and how to minimize it

For physicians, especially those early in their careers, the fear of medico-legal complaints can feel like an undercurrent lingering in the background, like a steady hum of unease, even anxiety.While the fear may centre on big mistakes, experienced physicians say the reality is often less about catastrophic errors and more about everyday interactions that quietly go wrong.“In my experience, complaints are less about the complication itself and more about how the patient experiences the process around it,” said Dr. Duncan Rozario, a general surgeon at Oakville Trafalgar Memorial Hospital, west of Toronto.Unexpected outcomes where patients feel they were not adequately warned, communication breakdowns during followup and situations where patients feel abandoned after complications are among the most common triggers for medico-legal complaints, he said.Dr. Alan Kaplan, a family physician in Aurora, Ont., sees the same pattern.“Usually it’s communication issues,” he said. “Misunderstanding. Lack of communication of abnormal results. Unfortunate outcomes.”“Communication is really the number one issue to focus on,” said Dr. Rozario.That view is supported by research from the Canadian Medical Protective Association (CMPA), which examined real patient cases in a 2024 study to better understand what drives complaints. The analysis identified four key themes behind medico-legal issues: communication, quality of care, ethics and system-level factors such as wait times and access to care. Across those cases, patients frequently pointed to concerns such as lack of clarity, feeling unheard, insufficient involvement in decision-making and perceived gaps in empathy or transparency.The findings point to a clear path forward: Strengthening communication, patient involvement and transparency, while addressing system pressures (such as long wait times), can help reduce complaints. The CMPA recommends targeted training in these areas, which can support physicians in building stronger patient relationships and lowering medico-legal risk.Managing uncertaintyMedicine inevitably involves uncertainty, and both physicians say being open about that reality is the best option. Dr. Kaplan notes that courts generally judge care based on whether it met the standard of being reasonable and appropriate—not flawless.“You do not have to be perfect,” he said. “You have to be reasonable and appropriate.”Being honest about uncertainty can actually strengthen trust with patients, he adds. “It is OK not to know and get help to find out.”Dr. Rozario approaches uncertainty in a similar way. “Patients generally tolerate uncertainty well if they feel their physician is being honest and thoughtful,” he said.Rather than presenting definitive answers prematurely, he frames situations in terms of probabilities and next steps. “What builds trust is not pretending certainty—it’s demonstrating a clear plan and a willingness to reassess if the situation changes.”Listening—and documentingBoth physicians say delayed diagnoses can also become flashpoints, particularly when symptoms were initially attributed to something benign and later turn out to be something more serious. Dr. Rozario also points to transitions of care—handoffs between providers, postoperative coverage or emergency department referrals—as moments when misunderstandings can easily develop.Setting expectations early is critical.“I try to be very clear that surgery is about managing risk, not eliminating it,” Dr. Rozario said. “I explain the most common complications, the serious but rare ones, and what recovery typically looks like—including the possibility that recovery may not follow the ideal path.”Dr. Kaplan sums up his advice in a few simple steps. “Listen. Empathize. Do what you can. Chart!”Dr. Rozario agrees, stressing that documentation should clearly capture the physician’s thinking. “Document clearly and contemporaneously, especially clinical reasoning and discussions about risks or uncertainty,” he said.Communication is particularly important when things are not going according to plan.“Silence tends to create anxiety and mistrust,” Dr. Rozario said. “Call patients when things are not going well—do not try to hide from challenges.”Risk reductionAsked what habits can reduce risk, Dr. Kaplan advises physicians to remain open-minded in their diagnostic thinking. “Consider the worst and hope for the best, but do not get too comfortable with your first diagnosis.”Dr. Rozario emphasizes the importance of closing the loop on unresolved issues. “Tests, consultations and abnormal results should always have a clear plan and documented follow-through,” he said.The system factorNot surprisingly, system pressures can also contribute to risk.Dr. Kaplan points to wait times, limited access to tests and staffing shortages as ongoing challenges. While courts may not accept these issues as excuses, physicians should document the steps they take to manage them—such as contacting specialists, following up on test requests or using e-consult services.Dr. Rozario agrees that systemic barriers can create delays that patients may misunderstand.“From the patient’s perspective, those system limitations are often invisible,” he said. “They may interpret delays as inattention or poor judgment on the part of the surgeon or their office.”Relationships matterThe strength of the physician-patient relationship can also influence whether problems escalate into disputes, and the continuity of care in family medicine can offer some protection.“Frankly, you’re less likely to be sued by someone you have had a long-term relationship with and who likes you,” Dr. Kaplan said, although he cautions physicians not to rely on that goodwill alone.Dr. Rozario agrees. “In the long run, the physician-patient relationship is one of the most important factors in preventing disputes. When complications occur—which they inevitably will—being transparent and present with the patient is critical,” he said. “Medico-legal challenges are usually a problem with breakdown in communication, not bad outcomes,” so having a trusting relationship helps.An ED perspectiveNewmarket, Ont., emergency physician Dr. Raj Waghmare notes that his perspective on medico-legal risk is shaped by the realities of emergency medicine, one of which is that physicians are often seeing patients for the first, and sometimes only, time.ED physicians must make decisions quickly and often with limited background information. In that environment, Dr. Waghmare said clear communication becomes especially important.One of the most common risk points in the emergency department comes at discharge. Because patients may not have easy access to followup care, Dr. Waghmare says he tries to be extremely clear about what patients should expect and when they should return.He often gives specific timelines tied to symptoms and makes it clear that patients should come back if their condition does not improve, worsens or if they simply feel unsure.“Children are often those whose clinical state can change quickly and unexpectedly. They can recover from illness quickly and they can deteriorate quickly. I’m very clear with discharge instructions,” he said.Honesty in the face of uncertainty is key, he adds. When a diagnosis is not clear, Dr. Waghmare tells patients directly that it may take time for an illness to “declare itself.” In his experience, patients are generally receptive to that transparency.“If you’re completely honest with patients, I find that they will sense your honesty, and realize that just like them, you’re only human,” he said.Even in a busy emergency department, Dr. Waghmare emphasizes the importance of listening carefully to patients and allowing them to explain their concerns. Sometimes that means letting a patient talk longer than expected. “Speak in a relaxed, non-rushed manner and let the patient tell their story.”Psychiatric perspectiveFor Kingston, Ont., psychiatrist Dr. Joseph Burley, his specialty brings additional layers of medico-legal risk, particularly around consent, capacity and the therapeutic relationship—areas where communication must be especially clear.“In my specialty, inadequate assessment, inadequate record keeping, sexual misconduct, inadequate communication for consent and boundary violations are most common,” he said. “Effective, empathic, inclusive, humble communication is fundamental to preventing complaints.”Conversations about treatment can be particularly complex in psychiatry, where side-effects and outcomes are often uncertain. Dr. Burley says physicians can sometimes hesitate to fully outline risks out of concern patients may refuse care—but avoiding those discussions can undermine trust.“If we don’t tell patients about sexual dysfunction and weight gain (side-effects), they feel betrayed and refuse other efficacious treatments,” he said. “In general, I find patients appreciate and respect honesty as part of their care.”That same emphasis on transparency applies to uncertainty. Rather than overstating the likelihood of success, he encourages physicians to be upfront about the limits of treatment and to work collaboratively with patients on next steps.“Telling or inferring that our treatments will work when we know that they often don’t is somewhat dishonest,” he said. “It is best to warn patients about negative effects up front and collaborate with them about solutions.”Managing conflict is another key skill. When patients are frustrated or feel unheard, Dr. Burley encourages physicians to explore the source of that frustration—often within the relationship itself—and to remain aware of their own reactions.Self awareness“Self-awareness of our own defensiveness or fear of conflict or criticism is a key factor,” he said. “Coping with conflict effectively is part of building a closer therapeutic alliance.”He also highlights the importance of advocacy, particularly in a strained health system. Helping patients navigate delays or access issues—whether through followup, outreach or persistence—can reinforce trust and reduce dissatisfaction.Among the most underused tools, he adds, is apology. “Apologizing—asking forgiveness and correcting circumstances that have caused harm, anxiety, anger or relationship disruption—is known to decrease reports and lawsuits,” he said.Ultimately, many of the habits that reduce medico-legal risk come back to fundamentals: active listening, humility, clear boundaries and shared decision-making. And as Dr. Kaplan said, “Chart, chart, chart.”

When things go wrong: Experienced physicians on what really drives medico-legal risk and how to minimize it

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