Two envelopes, two different kinds of bad week.
The first is the one everybody knows about: a malpractice summons. It is common, it is discussed, at least a little, and if you are lucky enough to hold the right insurance policy there may be a program.
The second envelope is worse, and almost nobody writes about it.
It is a letter from the state medical board. Or it is your chief medical officer opening a focused professional practice evaluation. Or it is notice that a privileges action will be reported to the National Practitioner Data Bank.
Here is why it is worse. Counsel says say nothing. The hospital says nothing. Your colleagues are potential witnesses in the proceeding, which means the people you would normally talk to are precisely the people you cannot. There is usually no insurer program, because your malpractice carrier does not cover this. And unlike a lawsuit, where the worst realistic outcome is a payment made by an insurer, the worst outcome here is that you are no longer a doctor.
The physician receiving that letter wants to find one person: someone in their specialty who went through a comparable investigation, survived it, and can say what actually happens next, how long it takes, and how to stay sane.
They will almost certainly not find that person. Because nobody admits to this, and there is nowhere to look.
The numbers, for two overlapping populations
Two groups of physicians need essentially the same thing and are served by essentially nothing. It is worth taking them in turn, because the evidence differs.
Physicians under investigation
The most rigorous data comes from the UK. Bourne and colleagues surveyed 7,926 doctors and published in BMJ Open. Comparing those with current or recent complaints against those without:
- Moderate to severe depression: 16.9 percent versus 9.5 percent.
- Anxiety: 15 percent versus 7.3 percent.
- Suicidal ideation: 2.08 times higher.
- Almost four in ten reported feeling bullied by the process.
- More than 80 percent reported practising defensively afterward.
A separate GMC-commissioned review examined 28 suicides or suspected suicides of doctors who were under fitness-to-practise investigation between 2005 and 2013.
In the United States, the scale is substantial. Public Citizen reported 1,196 serious disciplinary actions across 64 boards in 2023 (1,289 in 2021, 1,250 in 2022). Complaints run many times higher than actions, and most are dismissed, which is important: the great majority of physicians who endure this process are ultimately found to have done nothing warranting serious action, after months or years of fear.
One more finding worth sitting with. Public Citizen documented an 11-fold variation in serious-action rates between states, from Ohio at 1.82 per 1,000 physicians to Indiana at 0.17. From inside the process, that variation reads as arbitrariness, and arbitrariness is corrosive in a way that consequence alone is not.
Physicians after an adverse patient event
The second population is far larger. Second victim research finds career prevalence of 53 to 59 percent in physician cohorts, with several authors concluding that essentially every physician experiences it over a full career.
The consequences are well characterized: second victims show roughly twice the rate of burnout and intent to leave; a recent self-perceived major error is associated with 3.4 times the rate of suicidal ideation; and events involving permanent patient harm are nine times more likely to leave symptoms persisting beyond six months.
And the institutional response, historically: in Waterman's study of 3,171 physicians, only 10 percent felt their organization supported them.
The finding that explains why programs underperform
Here is the single most important piece of evidence in this whole area, and it comes from a 2025 University of Toronto survey of surgeons.
- 82.3 percent want "a respected peer to discuss the details of what happened."
- 56.9 percent think an institutional peer support program would be valuable.
- Only 43.1 percent would actually use their own institution's program.
Look at the gap. Eighty-two percent want the thing. Forty-three percent would use the version their employer offers.
That is not a stigma problem, though stigma is real and the authors note it. That is a trust boundary problem.
Consider what an institutional peer supporter is, structurally. They are a colleague. They may sit on the peer review committee examining this same event. They are employed by the organization whose risk management department has already been notified. They are, however well-intentioned and well-trained, inside the system that is also assessing you.
Declining that support is not irrational. It is an accurate reading of the situation.
You can see the same pattern in utilization data. Kaiser's POST program, a serious and well-designed effort, reported 530 attending physicians, 59 trained supporters, and 306 interactions over three years. That is roughly one interaction per two physicians across three years, in a population where career second-victim prevalence exceeds 50 percent.
High awareness. Low use. Every institutional program reports some version of this, and it is usually attributed to stigma or physician reluctance.
A 2025 scoping review in the Joint Commission Journal on Quality and Patient Safety examined 25 peer support programs and found something worth stating plainly: all of them were institution-based.
Every single one. The entire field has built one architecture, and the utilization data suggests the architecture is the constraint.
The parties-of-interest problem, again
This is the same structural pattern that appears throughout healthcare's support infrastructure, and it is worth naming precisely because it explains so much.
Healthcare has systematically assigned the job of supporting clinicians in crisis to organizations that are also parties to the clinician's risk.
- The employer runs the wellbeing program, and also runs peer review, and also employs you at will.
- The malpractice carrier runs the peer program, and also controls your defense.
- The licensing board oversees the physician health program, and also holds your license.
- The hospital runs the second victim program, and also investigates the event.
When a physician declines these programs, the standard interpretation is that physicians are stoic, stigma-averse, or too busy. The more parsimonious explanation is that they have correctly identified who they are talking to.
The corroborating evidence is consistent. Physicians report preferring peer support from other physicians at roughly 88 percent, against 48 percent for a mental health professional and 29 percent for an employee assistance program. Roughly 40 percent report reluctance to seek formal mental health care because of licensure concerns, and most states have historically asked about mental health history on licensing applications.
The profession has been giving the same answer for thirty years. It wants a peer, and it wants that peer to be genuinely outside the machinery.
The population nobody covers at all
Even if institutional programs worked perfectly for the people inside institutions, a large and growing share of physicians are not inside one in any meaningful sense.
- 11.9 percent of physicians are in solo practice, and 47 percent are in practices of 10 or fewer (AMA, 2024). There is no peer support program in a three-person practice.
- Roughly 57,000 physicians currently work locum tenens, about 8 percent of the workforce, and 41 percent of physicians have worked locums at some point. A locums physician on week two of a contract has no institutional home, no colleagues who know them, and frequently leaves the site before any debrief happens.
- Rural physicians in the 92 percent of rural counties designated as primary care health professional shortage areas may be the only person in their specialty for a considerable distance.
- Ambulatory surgery center proceduralists, whose numbers keep growing as volume shifts out of hospitals.
For all of these physicians, the institutional model does not fail. It never existed.
And notice the interaction between the two problems. The clinicians with the least institutional cover are frequently those practising with the least backup, in the highest-uncertainty settings, which is where adverse events and subsequent scrutiny are most likely.
Support infrastructure in medicine is distributed almost exactly inversely to need.
Five states
There is a specific, tractable policy fact that most physicians have never heard, and it explains a great deal about why cross-institution peer support has not developed.
Arizona passed legislation (HB2429) shielding peer support communications for physicians from board reporting and legal discovery. Delaware, Virginia, South Dakota, and Indiana have comparable protections.
Five states.
In the other forty-five, a peer support conversation about a serious adverse event or an investigation carries genuine legal uncertainty. Not certain exposure, but enough uncertainty that any well-advised program must be cautious, and any well-advised physician must wonder.
This is one of the most tractable pieces of health policy in the entire field. The template exists. The precedent exists. It costs essentially nothing. And it is absent in most of the country, which means the legal foundation for the thing physicians say they want most does not exist where most physicians practise.
What would actually work
The design follows directly from the evidence, and the evidence is unusually specific about what physicians want.
Outside the employer, the carrier, and the board. This is the non-negotiable property. The 43.1 percent figure is the entire argument. Any program run by a party to the physician's risk will underperform regardless of how well it is designed.
Matched on experience, not availability. Same specialty. Same investigation type or event type. Similar career stage. The whole value is "I have been exactly here," and generic support fails to deliver it. This requires a population large enough to contain the match, which is precisely why single institutions cannot solve it.
Portable. Physicians change employers, states, and carriers. Their need does not respect those boundaries and neither should the support.
Protocol-driven, with the boundary in writing. Process and emotional experience, explicitly not case facts, documents, or timelines. Written down, so the physician can hand it to their attorney and get approval rather than a shrug. This is what makes it usable during an active proceeding rather than only afterward.
Statute-aware. Given that protection exists in only five states, any serious program must know the position in each jurisdiction and design accordingly rather than assume.
Available before the crisis. Nobody builds trust with an institution while in acute distress. The relationship has to predate the letter.
And staffed by people who have been through it. Here the supply picture is unexpectedly favorable. The physicians most likely to have survived investigation or a serious adverse event are the most senior. That same cohort consistently reports wanting to contribute and lacking flexible ways to do it. Retired physicians have a particular advantage that is worth stating explicitly: they sit outside every peer review chain, which makes them the safest possible listeners and, currently, the least used.
What you can do
If a letter just arrived
Understand the base rates. Complaints vastly outnumber serious actions, and most are dismissed. The 11-fold variation between states means the process feels arbitrary because in some measurable respects it is, not because you have been singled out.
Ask your attorney what you may discuss, explicitly. This conversation is available to everyone and almost nobody has it. The answer is usually that your emotional experience and the general process are fine while case specifics are not. Getting that stated out loud converts a total prohibition into a workable one.
Find someone who has been through it, for the process not the case. What a deposition feels like, how long the silence lasts, how to keep working. None of that requires discussing your matter.
Watch for the documented risks. Depression at 16.9 percent, anxiety at 15 percent, and more than double the rate of suicidal ideation are findings about a population, not judgments about you. In the US, the 988 Suicide and Crisis Lifeline is available at any hour, and the Physician Support Line has offered free confidential support staffed by volunteer psychiatrists.
If you lead an institution
Read the 43.1 percent finding honestly. Your program's low utilization is probably not a marketing problem. Consider funding access to external support your organization does not run, which is counterintuitive and is what the evidence supports.
Cover the uncovered. Your locums physicians, your ASC proceduralists, and your affiliated small practices have nothing. They are also frequently practising with the least backup.
Separate support from review, visibly. If the same department that runs peer review also runs peer support, physicians will assume, reasonably, that information flows between them.
If you are senior or retired
You are the supply. You have survived things that younger colleagues are facing alone right now, and if you are outside the peer review chain you are the safest listener available to them.
Say so out loud. The single most useful sentence available here is telling colleagues that you have been through an investigation or a serious adverse event and are willing to talk about it. It breaks the silence that makes a common experience feel unique, and almost nobody says it.
If you make policy
Pass the statute. Five states have peer support confidentiality protection. The template exists, the cost is negligible, and the absence of it is the legal reason the thing physicians most want cannot be safely built in most of the country.
Fix the licensing questions. Roughly 40 percent of physicians avoid mental health care over licensure concerns. Asking about history rather than current impairment produces the untreated illness it is meant to detect.
Frequently asked questions
How common are medical board investigations? Serious disciplinary actions numbered 1,196 across 64 US boards in 2023, with complaints running many times higher and most being dismissed. Rates vary enormously by state, from 1.82 per 1,000 physicians in Ohio to 0.17 in Indiana, an 11-fold difference.
What is the psychological impact of being under investigation? Substantial and measurable. Research in BMJ Open surveying 7,926 doctors found those with current or recent complaints reported moderate to severe depression at 16.9 percent versus 9.5 percent, anxiety at 15 percent versus 7.3 percent, and 2.08 times the rate of suicidal ideation, with almost four in ten reporting feeling bullied by the process.
Do physicians use institutional peer support programs? Much less than they want the service. A 2025 University of Toronto survey found 82.3 percent of surgeons wanted a respected peer to discuss an adverse event with, but only 43.1 percent would use their own institution's program. Utilization data from established programs shows the same pattern of high awareness and low use.
Why don't physicians trust employer-run support programs? Because the employer is frequently also a party to the physician's risk. The institution offering support may also be running peer review on the same event, and the peer supporter may be a colleague involved in that process. Declining is a rational assessment of the situation rather than simple stigma.
How common is second victim experience? Career prevalence in physician cohorts runs 53 to 59 percent, with several researchers concluding nearly all physicians experience it over a full career. Consequences include roughly twice the rate of burnout and intent to leave, and permanent-harm events are nine times more likely to leave symptoms persisting beyond six months.
Are peer support conversations legally protected? Only in a minority of US states. Arizona, Delaware, Virginia, South Dakota, and Indiana have enacted protections shielding physician peer support communications from board reporting and discovery. In most states the legal position is uncertain, which constrains what any program can safely offer.
Who supports locum tenens and solo physicians? Structurally, nobody. Roughly 57,000 physicians currently work locum tenens and 41 percent have at some point, while 11.9 percent of physicians are solo and 47 percent are in practices of ten or fewer. Institutional peer support programs, all 25 examined in a 2025 scoping review, are institution-based by design.
The bottom line
Eighty-two percent of surgeons want a respected peer to talk to after something goes wrong. Forty-three percent would use the program their employer built for exactly that purpose.
Every peer support program in a recent review of the field is institution-based. Every one of them is offered by an organization that is also, in some capacity, assessing the physician it is offering to support.
Meanwhile the people who most need this are frequently the ones furthest from any institution: the solo practitioner, the locums hospitalist on week two, the rural surgeon ninety miles from the next one, and the physician whose license is under review by a board whose action rate is eleven times higher than the state next door.
The support they want exists in enormous quantity. It is sitting in the memories of colleagues who have been through the same thing and have never said so out loud, because the silence around these experiences is nearly total and everyone assumes they are the only one.
The most common professional catastrophes in medicine are experienced by almost everyone and discussed by almost no one. That is not a psychological finding. It is an infrastructure finding.
If you are in crisis, the 988 Suicide and Crisis Lifeline is available in the United States at any time. The Physician Support Line has offered free, confidential telephone support staffed by volunteer psychiatrists. Nothing in this article is legal advice.
Part of a series on the missing professional infrastructure of healthcare. Previously: "Have You Managed This?"
Evidence note: sources include Bourne et al. in BMJ Open (2015) surveying 7,926 doctors; a GMC-commissioned review of doctor suicides during fitness-to-practise proceedings; Public Citizen's ranking of state medical board disciplinary actions (2025); the University of Toronto surgeon peer support survey (2025); the Joint Commission Journal on Quality and Patient Safety scoping review of 25 peer support programs (2025); SeViD second victim prevalence studies; Waterman et al. (2007); AMA Policy Research Perspectives on practice arrangements (2024); and CHG and Weatherby locum tenens workforce data. NPDB report volumes are summarized from public data tools and should be verified directly before republication.
