Apologies Are Best Practice

We all make mistakes in medical practice. To err is human. Most physicians care for more than a thousand patients a year. Busy, office-based physicians have five thousand or more visits a year. If we make significant mistakes 2 percent of the time, more than 20 of our patients, and 100 visits annually, have some avoidable harm.

The Doctors Company surveyed about 500 physicians and found that only about one half feel that they should always apologize to patients when a medical error occurs in the practice. Of the half that does routinely apologize, most struggle with the decision. Liability risk hangs over our heads with every patient, and revealing a medical error may seem to intuitively send us down this path.

Mounting evidence shows that apologizing for medical errors lowers liability risk, while concealment of errors increases risk (1). There is a growing “Sorry Works” movement in the United States, and “I’m Sorry” legislation is passing in a growing number of states (2). While this legislation does not absolutely protect physicians from liability risk, it does make the physician’s apology to the patient and family inadmissible in court. California has such legislation.

The policy of the American Medical Association is that the physician is ethically required to inform the patient of all the facts necessary to ensure an understanding of what has occurred (3). Disclosure to the patient and family of all the facts is simply the right thing to do. We know this, but it is still hard. As physicians, we have this professional aura of being infallible. “First, do no harm” is at the core of our Hippocratic Oath. Admitting mistakes is uncomfortable, and it is human nature to look for alternatives. When medical students are given situations of making mistakes, but have an alternative to admitting them, many choose the alternative as the preferred approach (4). Getting us to do the right thing takes conscious effort and training.

There are clear and simple principles for apologizing to patients (5). Important features of an apology are:

• Make the apology promptly;
• Be sincere;
• Apologize in person;
• Keep it simple, such as, “I am very sorry for any suffering or inconvenience this event has caused you.”

Avoid blaming others or minimizing the event. While the root causes of the error may be known or revealed later, stick with the facts in a way that is easily understood by the patient. Avoid giving an involved explanation that may confuse the patient or arouse suspicion.

Patients usually find out when they are a victim of a medical error. If they feel that concealment has occurred, they rightfully become angry. If we are not forthcoming with what has occurred, they are more likely to seek an attorney to find out and get retribution. A sincere apology can diffuse the anger and help the patient along the path of acceptance. A plaintiff attorney may be less likely to take a case when they learn that the physician has apologized.

Every medical error is an opportunity for learning. After apologizing, reassure the patient that you will learn from this event in order to prevent similar harm to others. Most errors occur due to system failures that allow for the mistakes to occur. The root cause of the error should be analyzed and steps should be taken to avoid the same circumstances. Patients may get some satisfaction from knowing that their mishap may have helped improve care and prevent harm to others.

What to do about medical charges related to the medical error can be tricky. There is conflicting advice on whether all fees should be waived. A current recommendation is to waive your professional fee for the visit that led to the mishap; this may help build patient confidence and loyalty (5).

I heard a story recently about a wise physician who told a young colleague to have two drawers in her desk: one drawer for the letters of thanks and appreciation from grateful patients, and the other drawer for the nasty letters of criticism from angry patients. When the physician is having a bad day, open the draw of thank you letters and read some. When the physician if feeling overly confident, open the drawer of nasty letters and read them. Even though the drawer of thank-you letters will be fuller, the learning comes from the critical ones.

Good judgment comes from experience, and experience comes largely from bad judgment. Learn to live with mistakes — learn from them, share them, and apologize to those we inadvertently harm. This may be hard, but often the right thing to do is hard. We as physicians sleep better and find peace in doing right by our patients.

References:

1. Kraman SS, Ham G. Risk management: extreme honesty may be the best policy. Ann Int Med. 1999;131:963-967.
2. Sorry Works! Coalition. www.sorryworks.net
3. Troxel DB. Physician disclosure of adverse events. The Doctor’s Advocate. The Doctors Company. Second Quarter 2006. p1 and 6.
4. Lesnewski R. Mistakes. JAMA. 2006;296:1327-1328.
5. Malaty W, Crane S. How might acknowledging a medical error promote patient safety? J. Fam Pract. 2006;55:775-780.