Perspectives on the Acute Care Continuum

The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions. 

Anatomy of a Medical Apology

3/3/2015 5:34:51 PM | 2 comments

A young assault victim once presented to our ED with bruising to his forehead. He had no loss of consciousness, and his neurological exam was normal. I treated him according to established trauma protocols and guidelines and discharged him home.
The next day on my shift, I got a call from an emergency physician Partner at a nearby emergency department.  He described my patient from the day before, and I confirmed that I had treated him. He then informed me that the young man had sustained a subdural hematoma and had died.
I was truly mortified by this news. In hindsight, I wondered if the outcome could have been prevented had I acted more conservatively. Should I have ordered that CAT scan before the patient left — just to be sure? 
I immediately called his mother to apologize. I explained to her what I wished I had done differently. "I'm so sorry," I said. " You have no idea how badly I feel about this, your loss. Please know that I and my colleagues will learn from this, and that it will definitely make a difference in the future." I assured her that we would not charge her for the visit and again affirmed by own grief before saying goodbye.
A few weeks later, a lawsuit was filed related to the case. I wondered if my apology might be coming back to haunt me.

Reasons to Stay Silent

As much as we're loathe to admit it, healthcare providers make mistakes. In 1999, the Institute of Medicine reported that preventable errors were resulting in 100,000 deaths a year. We've since taken great strides toward improving patient safety, but as long as medicine is practiced by fallible human beings, we'll never reduce errors to zero.
In my experience, most providers who make a mistake really do want to apologize to the patient and their families. But too often, they hold back. One survey of people who had dealt with a medical error in the family found that only a third had received an explanation or apology from their physician.
So what stops healthcare professionals from apologizing?
  • Fear of litigation. Some malpractice carriers and risk-management professionals still discourage apologies because they might be construed as admissions of guilt.
  • Culture of medicine. The healthcare professions stress perfection, so errors are seen as failures. When mistakes happen, there's a tendency to be secretive and avoid discussing them.
  • Psychological barriers. Admitting our mistakes makes us feel vulnerable and rattles our self-image as healers.
  • Communication skills. Providers who want to apologize may feel unsure of how to bring the subject up or what to say. They worry that their awkwardness will make a bad situation worse.

Reasons to Apologize 

Apologies are never easy. But as the risk management officer for a large group practice, I believe they're well worth the effort.
First and foremost, apologies provide psychological benefits for everyone involved. Done correctly, they reassure patients that they are heard and cared about, disarming feelings of blame and hostility. When patients see someone taking responsibility for the situation, they're less likely to worry that it will happen to others down the road. Finally, an apology paves the way for patients to continue getting the care they need from their provider during this difficult time.
But what about lawsuits? Well, contrary to the prevailing wisdom, patients are actually 50 percent less likely to sue a physician who discloses an error in a timely manner and offers an apology. In fact, a growing body of research suggests that the risk of lawsuits has far more to do with the relationships between providers and their patients than with the actual care rendered — even when that care results in negative outcomes.
Take a landmark study by Wendy Levinson and colleagues that compared the communication styles of surgeons who had a history of multiple malpractice claims with those who did not. The no-claims physicians spent an average of three minutes longer with patients, helped them understand what to expect during the visit, involved them in decision-making and used appropriate humor.
Other studies have examined plaintiffs' motivations for filing malpractice suits. In one such survey, over 90 percent of respondents who had sued their doctors said they wanted to prevent the same error from happening to others. And 40 percent indicated the suit could have been avoided with an appropriate, sincere explanation and apology.
Fortunately, policymakers are taking these findings on board. About two-thirds of states have enacted apology laws to prevent statements of regret in medical apologies from being admitted into evidence in malpractice cases. It's important to note that these statutes vary in scope. All exclude expressions of sympathy, but some allow statements of responsibility to be admitted. (Providers should check the specific statutes in their respective states.)

How to Apologize

As powerful as apologies can be, a poorly planned or insincere one can do more harm than good. Fortunately, physician and consultant Michael Woods has broken the process into manageable steps in his book Healing Words: The Power of Apology in Medicine.
Woods encourages physicians to focus on the five R's:
  • Recognition. Know when an apology is needed and be willing to act. Your own feelings of remorse or regret are a good guide.
  • Responsibility. If the patient's outcome was directly related to a mistake of yours, consult with your risk manager to discuss the best way to disclose this. When apologizing, it's usually most effective to speak in the first-person singular (e.g., "I made a mistake."). If appropriate, let the patient know what you could have done differently and how you will prevent similar errors in the future.  
  • Regret. Sincerely acknowledge the patient's feelings of anger, hurt and anxiety.
  • Remedy. Discuss what will be done to fix the problem and compensate the patient for their trouble. This is where coordinating with your risk management office can help. In addition to medical intervention, consider the cost of care, lost wages and pain and suffering.
  • Remain engaged. Avoiding the patient or family after an apology can cause them to feel abandoned when they need you most. Staying involved helps everyone work through their feelings and prevents interruptions to the patient’s care.
A question that often gets asked: is it appropriate to apologize for poor outcomes when they’re not the result of an error — or when the cause is uncertain?
The answer is yes. In these cases, physicians should tailor the "responsibility" part of their apology to the circumstances. Tell the patient that while it's not clear what happened, you are responsible for their care and plan to do everything you can to get to the bottom of things.
After the investigation, be sure to follow up. Report your findings and let them know how you will be working to prevent similar occurrences in the future.

Encouraging Apologies

Medical groups and hospitals can foster medical apologies by:
  • Teaching providers the communication skills they need to respond to adverse events
  • Dispelling the myth that apologies will increase liability
  • Working with providers after an error to coordinate appropriate remedies
Many hospitals and groups have formal policies mandating disclosure and apology. For example, six state medical societies are now piloting a process called Disclosure, Apology, and Offer (DA&O) that provides pathways for discussing and investigating adverse events. Findings are reported to the patient, and when appropriate, an apology and settlement are offered. The process is modeled on a similar program that dramatically reduced lawsuits against the University of Michigan Health System, resulting in savings of over $2 million per year. Other systems, including Johns Hopkins, Harvard and Children's Hospital of Atlanta have achieved similar reductions in suits and settlements with this approach.

The Power of Apology

So what happened with my own case? Well, rather mysteriously, the suit was withdrawn after only a month.
According to my lawyer, there were a number of factors involved in the decision. But one of these, she said, was that the family had been touched by my apology and realized that an honest mistake had been made.
No apology can erase the pain these people experienced. But I hope they felt heard. I hope my explanation provided some small measure of closure. And I hope they believed that I took the incident seriously and would do everything in my power to prevent it from happening again. 

[Image credit: "Relación Médico Paciente" by Jorgejesus4, licensed under CC BY-SA 3.0 via Wikimedia Commons]

Ed Heneveld
Michael, thanks for sharing. If you followed guidelines and did your best, then your "apology" should revolve around the unexpected and unfortunate outcome. Expressing sympathy is appropriate. I don't understand what you would or should have done differently when you write "I wished I had done differently". What did you learn and what can you share in a QI process to not let this happen again? Maloccurrence is not malpractice. I appreciate your empathy and maybe your spontaneous expression of shared grief humanized the moment for the family. They do need to hear we learn from our mistakes and we strive to learn from every unexpected outcome.
3/6/2015 8:13:42 PM

Jon Brummond
Nice article. Thanks for contributing!
3/4/2015 10:29:32 AM