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Ethics Case Study
Do you need to talk to patients about mistakes?

From the March ACP-ASIM Observer, copyright 2002 by the American College of Physicians-American Society of Internal Medicine.

By Phyllis Maguire

This is the 28th in a series of case studies with commentaries by ACP-ASIM's Ethics and Human Rights Committee and Center for Ethics and Professionalism. The series uses hypothetical examples to elaborate on controversial or subtle aspects of issues not addressed in detail in the College's "Ethics Manual" or other position statements.

Case history

Dr. Jinks was in a hurry. She'd had several calls today and more than her average number of patients in the hospital. Then one of her newer patients, Mrs. Redd, asked for an antibiotic for her cough and fever. "I've had pneumonia before," Mrs. Redd reminded her.

After examining the patient, Dr. Jinks concluded that Mrs. Redd meets the criteria for outpatient treatment of pneumonia. After she glanced at the outside of the chart and saw no allergy warning sticker, she asked the nurse to give Mrs. Redd ceftriaxone.

About 30 minutes later, the nurse rushed in and said that Mrs. Redd was having a "bad reaction." Dr. Jinks hurried to her patient and found her wheezing and covered with hives. Her blood pressure was also falling.

Dr. Jinks acted quickly to treat her anaphylaxis and in a short time, Mrs. Redd was feeling much better. Her daughter thanked Dr. Jinks profusely and commented on how cool she had been under pressure. Mrs. Redd was also thankful, but a little frustrated. "I guess I'll never be able to take antibiotics," she sighed. "I can't believe I've had another reaction."

Dr. Jinks was taken aback. She asked Mrs. Redd to remain in the treatment room for observation and rushed back to her office.

MistakesGlancing through the patient's chart, she found Mrs. Redd's history from her first visit. She had listed cephalexin under allergies, with a note explaining "bad rash." Somehow Dr. Jinks had missed the note and neglected to fill in the allergy box on the outside of the chart. Evidently the office staff had missed it too.

Dr. Jinks wondered what she should tell her patient. Mrs. Redd had recovered quickly and was going to be fine. Does she need to mention the mistake? After all, the patient and her daughter might lose trust in her. No permanent physical harm had been done, but the emotional harm to their relationship that could result from disclosure might last longer.

Commentary

Although errors are inevitable in medical practice, physicians receive little guidance or training about what to do when they make a mistake. When should physicians tell patients about an error? Does it matter if no lasting harm has been done? Should physicians factor patient characteristics into the decision? Should public perception of the profession matter?

One leading medical ethics textbook claims that for thousands of years, physicians have generated their own codes of ethics with little or no input from society and little consideration for societal expectations. These codes "have rarely appealed ... to a source of moral authority beyond the traditions and judgments of physicians." (1)

Still, one might argue that for the most part, society's expectations have rarely differed from the standards that physicians set for themselves. Over the past couple of generations, however, these expectations have changed profoundly, due in large part to the patients' rights movement that began in the 1960s.

Until 1980, the AMA's code of ethics offered no guidance about the obligation to disclose. Physicians were simply admonished to "deal honestly with patients and colleagues." (2)

While the College's "Ethics Manual" is a bit more definitive, it still leaves room for individual physician judgment. It says: "Physicians should disclose to patients information about procedural or judgment errors made in the course of care if such information is material to the patient's well-being. Errors do not necessarily constitute improper, negligent or unethical behavior, but failure to disclose them may." (3)

Public perceptions. While mistakes have long been part of everyday practice, news stories about the frequency of medical errors have received much more attention over the past decade. In particular, the number of errors cited in the Institute of Medicine report on patient safety alarmed the medical profession and the public. (4)

While the report spurred physicians and health care organizations to step up efforts to assess and reduce medical mistakes, it left many in the general public thinking that the medical establishment is not trustworthy. Although the number of errors cited in the IOM report has since been challenged, the public's wariness has been reinforced by repeated news reports that visiting a doctor's office or hospital may be hazardous to your health.

The public's mistrust of medicine was underscored by a recent newscast about a surgical error. The reporter noted that the story was shocking not because the error occurred, but because the hospital actually admitted that its staff made a mistake.

Physicians have struggled with disclosure in part because they expect perfection from themselves and each other. As one physician-author commented, "Physicians, not unlike test pilots, come to view an error as a failure of character—you weren't careful enough, you didn't try hard enough." (5)

Such unrealistic expectations make it difficult to admit to a mistake. These expectations begin to arise very early in medical training. One study of interns and residents who had made medical mistakes found that young physicians disclosed only about one-quarter of their mistakes to the patient or family. (6) If medical trainees are not learning to discuss errors, is there any chance they will become more forthcoming as they enter practice?

Culture of silence. The medical profession is not entirely to blame for its "culture of silence." Patients have high expectations for their practitioners. As one commentator remarked: "Perhaps the only people who seem to demand perfection more than doctors are patients." (7) A physician wrote: "If the medical profession has no room for doctors' mistakes, neither does society." (8)

Doctors' and patients' unrealistic expectations reinforce each other. Patients and physicians alike expect perfection and society demands full disclosure, yet any error is perceived as a character flaw and grounds for a lawsuit.

Most physicians and patients would likely agree that the patient-physician relationship is based on confidence and trust. Doctors expect their patients to tell them the truth about their medical histories and health behaviors that might affect their medical care. Patients expect their physicians to be competent, to respect privacy and confidentiality, and to be truthful.

But the fact remains that the relationship is an unequal one because physicians have the advantage of specific knowledge and experience. Physicians also usually know the results of labs, biopsies, radiographic studies and other tests before their patients do, and they must assimilate and convey this information to their patients.

Patients are not powerless, however, and often have as much or more to do with the success or failure of the patient-physician relationship as the physician. A patient may choose to switch physicians or advise friends and neighbors to avoid a certain doctor. A patient may be dishonest about his or her medical and social history or refuse to follow medical advice or treatments. And the patient's power to sue looms over physician-patient disagreements, poor outcomes and even simple mistakes.

The patient-physician relationship. In our case, Dr. Jinks wonders if she should tell the patient that a mistake was made, since no lasting harm has been done. There may be instances where revealing a mistake might only cause alarm. Dr. Jinks may feel that Mrs. Redd will lose trust in her if the truth is revealed. Mrs. Redd might even find another doctor.

Dr. Jinks may be tempted to apply the dictum, "First, do no harm," reasoning that because the problem was easily resolved, telling the patient about the incident could damage their relationship. Moreover, she may have a legitimate desire to protect Mrs. Redd and her family from additional concern about their health care.

But do patients want to be protected in this way? One study questioned patients about hypothetical error scenarios that were categorized as mild, moderate and severe. Across the board, patients said they wanted physicians to acknowledge an error. In the case of severe errors, many patients reported that they might indeed switch physicians or file suit—even if the physician were honest. Patients, however, said they were even more inclined to drop or sue a physician who had not disclosed a severe error and they learned about it through other means. (9)

Systemic error. Because many physicians in today's practice environment work as employees or have contracts with health care organizations, admitting mistakes can be even more difficult. Health care organizations often pin blame for an error on an individual provider rather than attempting to make systemic changes to avoid similar problems in the future. Studies of other industries in which errors carry grave consequences—aviation is a prime example—have revealed that singling out individuals for shame and blame does not encourage honesty or correct ongoing problems. (10)

Admissions of mistakes and investigations into errors should not end simply with an assignment of blame. Organizations and physicians should instead engage in an ongoing process to identify ways to improve care.

Last year, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) adopted new patient safety standards that may help develop a "culture of safety." As part of its accreditation process, JCAHO now requires health care organizations to disclose unanticipated injuries, investigate their root causes and take action to prevent their recurrence. It is unclear how JCAHO may measure compliance with this new standard, but health care organizations will have to educate staff about this initiative to show JCAHO that they are taking appropriate steps.

Solutions. Dr. Jinks should not feel alone. Although they are common, mistakes put tremendous pressure on physicians as they struggle with which course to take and how to be "most ethical." Dr. Jinks is rightly concerned about her patient's potential negative response, and she wants to avoid adding uncertainty to the patient-physician relationship.

Although some physicians find that admitting a mistake is very therapeutic (11), Dr. Jinks considers keeping the situation to herself, not as a self-serving gesture but to avoid burdening the patient and family. But would silence be in the patient's best interests? What if Mrs. Redd finds out anyway or is too frightened to try another antibiotic the next time she needs one?

Dr. Jinks should give strong consideration to admitting her mistake honestly and apologetically. Mrs. Redd may gain a new sense of security with the knowledge that she has an honest, caring physician. If the relationship with this patient is shattered by this admission and the patient seeks care elsewhere, Dr. Jinks might be better off knowing this now.

Finally, Dr. Jinks should not pass up the opportunity to evaluate and improve her practice procedures. She should review what happened in this case with her office staff rather than attempt to assign blame to someone else for the missing allergy sticker.

Indeed, if physicians incorporated regular evaluation and improvement efforts into their routines, many medical errors could be avoided. Still, we cannot correct the process without also convincing physicians to openly acknowledge their mistakes.

The American public can be judgmental and it tends to lose faith in institutions when flaws are revealed. There is no reason, however, that the medical profession has to suffer that fate.

Considering medicine's unique relationship with society, we can improve our profession only through honesty, forthrightness and a willingness to address flaws in our systems. Improvement has to start with physicians, and Dr. Jinks is in a good position to do something important. Society wants the truth, and there is rarely a good reason to hide it.

Acknowledgment: The Ethics and Human Rights Committee would like to thank Vincent E. Herrin, ACP-ASIM Member, author of the case history and commentary.

References

1. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. Fifth Edition. Oxford: University Press; 2001:7.

2. American Medical Association. Current opinions of the judicial council of the American Medical Association. Chicago: American Medical Association; 1981:ix.

3. American College of Physicians. American College of Physicians Ethics Manual. Fourth edition. Ann Intern Med. 1998;128:576-594.

4. Institute of Medicine. To Err is Human: Building a Safer Health System. National Academy Press; 1999.

5. Leape LL. Error in medicine. JAMA. 1994;272:1851-1857.

6. Wu AW, Folkman S, McPhee S, Lo B. Do house officers learn from their mistakes? JAMA. 1991;265:2089-2094.

7. Snyder L, Brennan TA. Disclosure of errors and the threat of malpractice. In: Snyder L, ed. Ethical Choices: Case Studies for Medical Practice. Philadelphia: American College of Physicians; 1996:49.

8. Hilfiker D. Healing the Wounds. New York: Pantheon Books; 1985.

9. Witman AB, Park DM, Hardin SB. How do patients want physicians to handle mistakes? Arch Intern Med. 1996;156:2565-2569.

10. Berwick DM, Leape LL. Reducing errors in medicine. BMJ. 1999;319:136-137.

11. Howe EG. Possible mistakes. J Clin Ethics. 1997;8:323-328.

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