American College of Physicians: Internal Medicine — Doctors for Adults ®

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Owning up to a mistake takes courage—and practice

Role-playing a conversation in which you disclose an error can help prepare you for an unexpected response

From the June ACP Observer, copyright 2005 by the American College of Physicians.

By Deborah Gesensway

SAN FRANCISCO—The young man in the hospital waiting room can't believe what he is hearing: A physician, long known to the family, is telling him that his mother has just died. Moreover, the physician admits that the mother probably would still be alive if someone at the hospital had given her chest X-ray a timely review.

But the son isn't so much angry as guilt-ridden. After the nervous physician has finished a stream of medical jargon, the son has but one response to make: "Didn't I bring her in soon enough?"

The physician hesitates, failing to address the son's guilt.

Fortunately, this interaction took place during a role-playing session at an Annual Session workshop on disclosing medical errors. The residents who attended learned that practice is paramount when it comes to admitting a medical mistake.

"The content of disclosure is key," panelist Thomas H. Gallagher, FACP, of Seattle's University of Washington School of Medicine, told attendees. "Picking your words when you are disclosing the error is important."

Learning 'the power of silence'

Referring back to the scenario, David Gary Smith, FACP, another workshop panelist, said the "doctor" should have forcefully told the "son" that he had no reason to feel guilty. A doctor's response "should be unequivocal that [the son] didn't do anything wrong," said Dr. Smith, the internal medicine residency program director at Abington Memorial Hospital near Philadelphia.

Practicing how to disclose errors to patients and their families can not only help a physician prepare for an unexpected response, such as the "son's" guilty reaction, but also can help teach the power of silence. As the "doctor" in the role-playing session got increasingly nervous, she talked on and on, failing to give the "son" time to digest the painful information.

She also made another common disclosure mistake: resorting to medical jargon. And panelists noted the importance of understanding what body language can communicate—and practicing the different types. Audience members commented that the "physician" could have been more effective, and perceived as more apologetic and caring, if she had held the "son's" hand, particularly because in the scenario they had known each other for years.

Dr. Smith also suggested that residents should not be sent into these situations alone. "This is not the time for the attendings to disappear," he said. Housestaff should learn about their hospital's policy regarding who discloses mistakes to patients and family members. At Dr. Smith's hospital, for instance, policy dictates that there will be timely disclosure of medical errors. Often, the chief-of-the-medical-staff makes disclosure to the relevant parties.

One tricky issue: handling the situation when, as in this case, the mistake occurred because of a systems error. "Why was there no radiologist at the hospital to read the chest X-ray earlier, and how do you say that without sounding like nobody is taking the blame?" Dr. Gallagher asked.

Liability concerns

Research has shown that patients want to be told about harmful errors, Dr. Gallagher said. Patients also say they want an apology—something surveyed physicians agree to in principle. But physician surveys also point to barriers when it comes to disclosing errors and apologizing for them.

Many physicians worry that such conversations will be awkward, uncomfortable and possibly lead to a lawsuit. In about 20 states, Dr. Gallagher said, bills are being considered that would make an "apology" offered to a patient not admissible in court. But how far such "I'm sorry" bills would go in shielding disclosure conversations from malpractice lawsuits varies widely, he added. Often, courts would exempt the actual apology but would allow the remainder of the disclosure conversation to be entered as evidence.

According to Dr. Gallagher, it is unclear as to whether disclosure increases or decreases the chance of being sued. Emerging evidence suggests that overall, disclosure may lower such a risk, but it is not a "magic bullet" for preventing litigation. Internists should consider the disclosure conversation a clinical intervention that has "risks and benefits," he said, one where in most circumstances the latter outweighs the former.

He also pointed out that doctors probably will need to hold more than one conversation with a patient or family. Such conversations should include information about how the doctor and hospital are learning from the mistake and what measures are being taken to ensure it won't happen again.

"We need to include error disclosure," Dr. Gallagher said, "in quality improvement efforts."

Deborah Gesensway is a freelance health care writer in Toronto.

The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.

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