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Role-Modeling and Medical Error Disclosure: A National Survey of Trainees

Martinez, William MD, MS; Hickson, Gerald B. MD; Miller, Bonnie M. MD; Doukas, David J. MD; Buckley, John D. MD, MPH; Song, John MD, MPH, MAT; Sehgal, Niraj L. MD, MPH; Deitz, Jennifer MA; Braddock, Clarence H. MD, MPH; Lehmann, Lisa Soleymani MD, PhD, MSc

doi: 10.1097/ACM.0000000000000156
Research Reports

Purpose: To measure trainees’ exposure to negative and positive role-modeling for responding to medical errors and to examine the association between that exposure and trainees’ attitudes and behaviors regarding error disclosure.

Method: Between May 2011 and June 2012, 435 residents at two large academic medical centers and 1,187 medical students from seven U.S. medical schools received anonymous, electronic questionnaires. The questionnaire asked respondents about (1) experiences with errors, (2) training for responding to errors, (3) behaviors related to error disclosure, (4) exposure to role-modeling for responding to errors, and (5) attitudes regarding disclosure. Using multivariate regression, the authors analyzed whether frequency of exposure to negative and positive role-modeling independently predicted two primary outcomes: (1) attitudes regarding disclosure and (2) nontransparent behavior in response to a harmful error.

Results: The response rate was 55% (884/1,622). Training on how to respond to errors had the largest independent, positive effect on attitudes (standardized effect estimate, 0.32, P < .001); negative role-modeling had the largest independent, negative effect (standardized effect estimate, −0.26, P < .001). Positive role-modeling had a positive effect on attitudes (standardized effect estimate, 0.26, P < .001). Exposure to negative role-modeling was independently associated with an increased likelihood of trainees’ nontransparent behavior in response to an error (OR 1.37, 95% CI 1.15–1.64; P < .001).

Conclusions: Exposure to role-modeling predicts trainees’ attitudes and behavior regarding the disclosure of harmful errors. Negative role models may be a significant impediment to disclosure among trainees.

Dr. Martinez is assistant professor of medicine, Vanderbilt University School of Medicine, Nashville, Tennessee.

Dr. Hickson is senior vice president for quality, safety, and risk prevention, assistant vice chancellor for health affairs, Joseph C. Ross Chair for Medical Education and Administration, and professor of pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee.

Dr. Miller is senior associate dean for health sciences education and professor of medical education and administration, Vanderbilt University School of Medicine, Nashville, Tennessee.

Dr. Doukas is William Ray Moore Endowed Chair of Family Medicine and Medical Humanism and professor of family and geriatric medicine, University of Louisville School of Medicine, Louisville, Kentucky.

Dr. Buckley is associate professor of clinical medicine and vice chair for quality improvement and patient safety, Indiana University School of Medicine, Indianapolis, Indiana.

Dr. Song is director of graduate studies, Center for Bioethics, and associate professor, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota.

Dr. Sehgal is associate professor and associate chair for quality and safety, Department of Medicine, University of California at San Francisco, San Francisco, California.

Ms. Deitz is managing director of evaluation, Office of Medical Education, Stanford University School of Medicine, Stanford, California.

Dr. Braddock is professor of medicine, and vice dean for education, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California.

Dr. Lehmann is director, Center for Bioethics, Brigham and Women’s Hospital, and associate professor of medicine and medical ethics, Harvard Medical School, Boston, Massachusetts.

Funding/Support: Dr. Martinez was supported by an institutional National Research Service Award #T32HP10251, a Martin P. Solomon Scholars Grant, and by the Division of General Medicine and Primary Care at Brigham and Women’s Hospital. The authors have no financial relationships with any organizations that might have an interest in the submitted work and no other relationships or activities that could appear to have influenced the submitted work. None of the funders had any specific role in the design and conduct of the study; in the collection, management, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript.

Other disclosures: None reported.

Ethical approval: Ethical approval was granted by the IRBs at Partners Healthcare and all study sites.

Previous presentations: A short abstract of preliminary research findings was presented at the Society of General Internal Medicine New England Annual Meeting on May 11, 2012, and at the American Society of Bioethics and Humanities Annual Meeting on October 21, 2012.

Supplemental digital content for this article is available at

Correspondence should be addressed to Dr. Martinez, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Medical Center East–North Tower, Suite 6000, 1215 21st Ave. S., Nashville, TN 37232-8300; telephone: (615) 322-7277; fax: (615) 936-1269; e-mail:

© 2014 by the Association of American Medical Colleges