Hospital disclosure and apology programs healing for both physicians and patients
Admitting fault and apologizing are skills that don't come naturally to many physicians, not because they are physicians, but because they are human, says Daniel O'Connell, PhD, master trainer and course manager at the Institute for Healthcare Communication in New Haven, Conn.
Although more organizations are moving toward apology and disclosure programs and healthcare attorneys are no longer advising physicians to stay mum, physicians are still having a hard time saying "I'm sorry."
MSB sat down with O'Connell, who has led apology and disclosure programs at Bay State Medical Center in Springfield, Mass. and Yale School of Medicine, among others, to find out why apologizing is so difficult and what physicians and medical staff leaders can do to reach a successful resolution to a poor clinical outcome.
MSB: Why have physicians found admitting errors to patients so difficult?
DO: Ultimately, physicians think like everyone else: If I tell the truth, I could get myself in trouble, and since I've done something that the other person doesn't approve of, one option is to tell lies of omission or commission and hope they are never uncovered.
Disclosing the truth is also hard to do because it is difficult to say that X actually caused Y. Medicine is complicated enough that people of good will could disagree on what caused Y. Therefore, even if I wanted to tell you the truth about everything, the truth is sometimes quite complicated.
But it is not just psychological; there is a business perspective. Physicians pay damages in liability claims through insurance companies, so they are beholden to the preferences of the insurance companies, which have traditionally concluded that they can do better by waiting for claims and lawsuits to be filed than by encouraging their insured physician to deal with the adverse medical outcomes in a straightforward manner.
MSB: How do patients benefit from physician apologies and disclosures?
DO: If, after an adverse outcome, the physician doesn't answer a patient's questions about causation, fails to express sympathy, or behaves defensively or with condescension, then no one would see that as psychologically healing. And in America, how do you get someone's attention who seems to be ignoring your legitimate concerns? You sue them.
But if a physician deals with a medical mistake straightforwardly, apologizes, explains the truth, and gets his or her insurer involved, maybe the patient or family wouldn't be so infuriated that they and a jury agree that they need millions of dollars in compensation.
MSB: So, organizations benefit from apology and disclosure programs because it saves them money.
DO: The research is starting to show that by dealing with adverse outcomes proactively, organizations can save money. First, they won't spend a quarter of a million dollars on legal fees defending the claim all the way through a trial only to settle on the courthouse steps.
Second, the organization will be dealing with a patient or family member who has no extra source of bitterness, meaning they are less likely to sue for tens of millions of dollars. The patient might have a sad situation, but if they are dealing with a thoughtful organization that is genuinely apologetic and humble, that will help the patient solve the problem, the patient is more likely to accept a more reasonable amount of money.
In states with no cap on noneconomic damages, juries award many millions of dollars for pain and suffering.
MSB: How can practitioners successfully resolve adverse outcomes?
DO: We teach that there are four elements to a successful resolution to an adverse outcome, and the first is ethical. Every practitioner has an obligation to first do no harm. If a practitioner deceives a patient, he or she has probably harmed the patient.
For example, a practitioner doesn't give a patient an accurate understanding of what happened during the course of care, the patient may go forward giving every other physician an inaccurate history.
Other physicians may misunderstand what is going on with the patient and be slow to recognize the symptoms of the real health problem. It might also leave the patient incredibly anxious with a misunderstanding of his or her vulnerability.
For example, imagine that a physician accidentally prescribes an overdose of insulin for a diabetic, who in turn has a serious reaction. Instead of admitting the error, the physician tells the patient that he had a reaction to the insulin.
As a result, the patient may go forward unnecessarily frightened that his regular dose of insulin will kill him. He may even seek additional unnecessary workups of his diabetes.
Part of the ethical element is justice. If a doctor makes an error and it harms a patient, justice says the doctor should be helping the patient get in touch with the doctor's insurance company and get reasonable compensation. The doctor should not be putting obstacles in the way and dragging it out for five years.
The second element of a successful resolution is psychological. Every conversation between doctors, hospitals, and patients should build trust, not create bitterness and suspicion. If I don't answer your questions, if I change my story, if I don't answer my phone, if I abandon you in the middle of your pain, no one would see that as psychologically healing.
The third element is legal. If a professional tells you a story he or she knows is not true for his or her own benefit, that is fraudulent concealment. There are places in the U.S. where plaintiffs' attorneys know to allege that or sue for it, and that is often where punitive damages come from.
If the jury hears the story that Dr. Smith and the hospital didn't just make a mistake, but he also deceived people about it for three years, now the jury wants to send this guy a message about his egregious behavior.
The last of the four elements is the business perspective. In what situation are you likely to resolve this claim for the least amount of money?
When the hospital conducts an investigation soon after the harm, honestly reports the results, apologizes, and tells the family that it will help them in every way possible, the research is starting to show that it will resolve the claim for the least amount of money.
The hospital won't spend a quarter of a million dollars on legal fees defending the claim, and patients who feel listened to and respected are less likely to sue.
MSB: Do practitioners benefit from disclosing mistakes and apologizing to patients?
DO: We don't have enough research to answer that question, and I suspect we will never get a definitive answer because there are so many moving parts.
For example, research has revealed that the mistakes most likely to be disclosed now are the ones that the healthcare providers believe that patients would have found out about anyway.
Ethical behavior can bring consequences that deceptive behavior may have avoided. The more we can ensure that the ethically correct thing is the default by all healthcare organizations, the more likely we are to help physicians feel that a fair process has brought needed resolution to all.
There are many reasons to believe that physicians do benefit, and there are physicians writing compelling stories about how wounded they felt because past wrongs were never resolved.
We are also hearing how much more psychologically healing it would have been for the healthcare providers themselves to have been helped to disclose more fully, apologize more completely, and see that a injured patient has been restored as much as reasonable after being harmed in their care.