This week, Friday Feedback takes a second look at when doctors say or don't say "sorry." As an alternative model of handling medical errors, apologizing has shown some effectiveness in reducing the number of malpractice lawsuits and is being adopted in various places around the country.
We reached out to a diverse group of physicans and healthcare professionals by email and asked them to respond to the following questions:
How do you admit when there's been an error and how do you say you're sorry?
From your perspective, how effective are new institutional approaches to medical errors?
The participants this week:
Richard C. Boothman, JD, adjunct assistant professor, risk management top executive, clinical affairs, University of Michigan
Neil Brooks, MD, family physician in Vernon, Conn., and former president of the American Academy of Family Physicians
Kevin R. Campbell, MD, cardiologist, UNC Health Care
Shirie Leng, MD, anesthesiologist, and former nurse who blogs at medicine for real and this week wrote, "This is why doctors practice cover your ass medicine"
Russell Libby, MD, founder and president of Virginia Pediatric Group, a primary care pediatric practice with three offices in northern Virginia, and president of the independent practice association HeathConnect IPA
Fred N. Pelzman, MD, an internist at New York Presbyterian-Weill Cornell Medical Center and MedPage Today columnist on patient-centered medical homes
Joan E. Shook, MD, chief safety officer, Texas Children's Hospital and professor of pediatrics, Baylor College of Medicine
Leana S. Wen, MD, MSc, director, patient-centered care research, department of emergency medicine, The George Washington University, blogger and author of When Doctors Don't Listen
Honesty Is the Best Policy
Shirie Leng, MD: "The one time I've informed a patient of a complication I was the cause of, it was a fairly common complication during an epidural procedure; the dura was punctured with the large Tuohy needle. When it happened, I repeated the procedure successfully at a different level and waited until the patient was comfortable with the epidural before I spoke to her about the wet tap."
"I sat down by her bed and explained what had happened, drawing a picture of the epidural space. I then told her what to expect and the steps we could take to ameliorate the headache she would most probably get. I then followed up with her for the next few days and made sure that the OB anesthesia team knew about her every day. I don't actually remember ever saying 'I'm sorry.' I certainly should have."
Richard C. Boothman, JD: Thoroughly understanding what happened and how we can avoid the same outcome for future patients is critical. Disclosures to patients, therefore, are rarely one conversation; instead patients understand it is a process and we work hard to manage their expectations. A poorly-handled disclosure is worse than a delayed, but knowledgeable and sensitive, one. Admissions must be placed in context so patients can process properly the information we are giving them. And we've found that having given patients an opportunity to understand, they are incredibly more understanding and forgiving than anyone ever believed before.
Leana S. Wen, MD, MSc: "We know that patients want transparency, and doctors must be trained to apologize and be open with our patients. The key is to be open, honest, and compassionate, to address the mistake, and to discuss remediation. Defensiveness has no role in this process."
Kevin R. Campbell, MD: "Patients and families respect and appreciate an honest and straightforward approach. It is essential to describe exactly what has happened, why you think it may have occurred, and exactly what you intend to do to rectify the situation and (in some cases ) stabilize and treat the patient."
Relationships Are Key
Fred N. Pelzman, MD: "Having an existing, long-term, strong relationship with patients helps involve them in medical decision-making and plans, and close coordination and follow-up are the best ways to ensure high-quality patient care and avoid errors and bad outcomes."
Leng: "I think prevention of lawsuits happens as soon as the doctor encounters the patient and starts to develop a relationship, way before anything unfortunate occurs. A patient who knows and trusts their doctor is far more likely to understand when a mistake is made. Bedside manner is vastly under-rated. Patients sue because they don't know the doctor, don't trust the doctor, don't like the doctor, or feel that they are not being heard by the doctor.
"Emergency medicine physicians are particularly affected by this, since by the nature of their work they don't have a lot of pre-existing relationships with patients. The same is true of anesthesiologists and radiologists, but the problem really applies to any doctor who encounters a new patient. Maybe that is part of the reason peripartum lawsuits are common."
Russell C. Libby, MD: "Certainly, professional expertise and conduct are usually going to gain the confidence of a patient, but being open to their input, making sure they understand a diagnosis and treatment plan along with its potential for desired as well as undesirable outcomes, and engaging them in making a choice in their care can create a positive relationship."
Joan E. Shook, MD: "At Texas Children's Hospital we believe in full transparency with our patients. We feel that the more transparent an organization is the better outcomes the organization can achieve. But, we know that we are not perfect. When we make a mistake, we are open and transparent with the family, bringing the mistake to their attention as soon as we know about it and discussing what went wrong along the way. We do everything we can to rectify the situation and then keep the family updated each step of the way. We allow the family to ask questions and make sure they have an open forum to be heard. The more engaged you are with a family the more open the family is to working with you toward a solution."
The System Is Broken
Leng: "The current system of American medicine does not promote physician-patient trust. There is plenty of evidence in any number of media outlets that patient trust in physicians is at a very low point. Any condition beyond basic primary care is referred to specialists, who often don't have an established relationship with the patient they are being asked to treat."
Pelzman: "Whatever changes come about, whatever systems we create, be they 'safe harbors,' or tort reform, or medical courts, unless we improve what is leading to these errors doctors will remain loathe to plunge ahead with apologies."
A System for Sorry?
Boothman: "The Michigan Model appeals to universal aspects of human nature -- like the need for respect and patients' deep need to understand what happened to them and why -- that transcend cultural and geographical boundaries. Our approach should be effective literally anywhere. But its efficacy depends first on an institution's willingness to be accountable for mistakes, on its commitment toward improvement, and, overall, on its determination to overcome decades of exaggerated fears about being honest."
Neil Brooks, MD: "Rather than focus on an institutional model, the real focus needs to be on the personal relationship between the primary provider and the patient."
Leng: "Protocols and standards of care don't prevent lawsuits, they only produce cookbook doctors. Empathy and honesty right from the beginning won't prevent lawsuits either, but as some institutions are discovering, they help. Institutional models are all well and good, but bedside manner is a tough thing to teach. A hospital-wide initiative has the positive effect of making people more comfortable with difficult conversations, or at least less afraid of admitting a mistake.
Wen: "Institutional models need to exist to support doctors in mistake disclosure. There also needs to be some degree of protection against malpractice as well; open disclosure can only work if doctors are incentivized to disclose."
Campbell: "Models of early intervention can be effective but must include both hospital administration and physicians together. It is essential that patients see the work that is being done represents the work of an entire 'team.' It must be made clear that all parties are invested in making sure that errors are identified, corrected and prevented in the future -- physicians, nurses, and hospital administrators."
Boothman: "There are several groups studying the Michigan Model in other care environments. Most of those with whom I've worked almost immediately experience the same benefits we've seen. Our experience has graphically taught us this important lesson: that the best healthcare occurs only when we are all in this together."
Shook: "Texas Children's is working to align with the strategies behind the U. of Michigan model. Over the past several years, the hospital has put a big focus on reporting, organizational safety briefings calls, addressing safety issues in real time, measuring safety incidents, putting processes in place to adhere to safety practices, and being transparent in communicating outcomes."
Libby: "Many states have enacted 'I'm Sorry' legislation that allows for empathetic expressions in these difficult situations without implying that they are expressions of guilt. I do believe the concept is integral to the evolving patient-centered medical care approach, representing a new level of mutual responsibility between the patient and their physician.
"I've worked extensively on tort reform in Virginia where we have a unique total cap that we worked out with our trial bar. I have been aware of the 'I'm Sorry' approach to reducing malpractice lawsuits, which comes from a person who lost a sibling (I think) to a medical error. Although there was a reasonable cause, the physician was so reluctant to interact or show empathy. This person did some research, wrote a book, and now runs Sorry Works to reduce malpractice lawsuits."
Barriers
Libby: "The hardest thing to do when something goes wrong is acknowledging it even though you know there may be anger and even threats leveled at you. However, you have been there to help the patient (and their family) and it should not stop when there is an error. I believe it is a form of abandonment when a physician abruptly withdraws and shows no interest or empathy, and it will raise the level of anger and the potential for a lawsuit."
Wen: "It's not easy for doctors to admit that we're wrong, and even harder for us to say that we caused an error."
Pelzman: "We've all made errors, big and small, some of which led to absolutely no harm, some of which likely caused great harm. Apologizing is one of the hardest things we have to do, and there is no better or easier way than to just come right out with it. People are more willing to accept and understand your mistakes if they feel like you were doing your best and looking out for them all along."
Shook: "Even though it can be scary to open up and shine a light on your issues, there is so much that can be learned from doing the exercise especially when it comes to the lives of our patients."
Boothman: "Those who lack the courage to try and the determination to improve have been unable to break from decades of 'deny and defend. They have not seen the benefits we have experienced, not only in medical malpractice numbers, but more importantly in cultural shifts toward transparency that opens to the doors to meaningful peer review, continuous commitment to clinical safety and quality -- and ultimately, a patient-provider relationship of a quality previously unknown in most institutions."
Brooks: "Personal relationships are deteriorating. The reasons are multiple but I'll cite a few:
1. The misuse of the EHR. Too often this has become a barrier between the physician and the patient. Think of your last encounter in which the computer became the focus of the provider's attention. This is not only with the physician, it starts with the front office staff or admitting personnel and extends through virtually every encounter, technicians, nurses, therapists, et al. The patient is too often treated as a biological node that generates data with little concern for their humanity.
2. Failure of physicians to touch the patient. I was recently a patient in an ER in which the physician hardly touched me. Several others have related to me that the same thing happened to them. This lack of contact further denies any real interaction with the patient. Empathy will only be established when it begins at the start of a relationship and not after there is an adverse consequence.
3. Promising too much either explicitly or implicitly. Look at the ads from hospitals and other treatment centers. 'We are the best.' 'No one is as good as we are!' Even doctors use hyperbole in their statements. 'Ten best in the country ... I can do something no one else can.'"
You may also be interested in recent Friday Feedbacks:
How to Stop Overstated Findings
Time to Trash the Medical Home?
Mammograms Useless or Useful?
Friday Feedback is a feature that presents a sampling of opinions solicited by MedPage Today in response to a healthcare issue, clinical controversy, or new finding reported that week. We always welcome new, thoughtful voices. If you'd like to participate in a Friday Feedback issue, reach out to e.chu@medpagetoday.com or @elbertchu.
Elbert Chu, a science and education journalist, has written for The New York Times, Popular Science, Fast Company, and ESPN. Most recently, he produced a multimedia project that investigated abuse of antipsychotics in New York City nursing homes for the Gotham Gazette. In his education mode, Elbert is co-founder of edradar.com, which helps people navigate online education. His documentary photography projects have included Haiti's earthquake, and the aftermath of a school shooting. MOST READ IN Practice ManagementTOP CME IN Practice Management
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