Engel, Kirsten G. MD; Rosenthal, Marilynn PhD; Sutcliffe, Kathleen M. PhD
Although discussions of medical errors and patient safety appear in the medical literature prior to the late 1990s, the 2000 Institute of Medicine report To Err is Human1 catapulted these issues into prominence. Since that time, extensive efforts have been made by the medical community to define the problem, understand its underlying mechanisms, and initiate meaningful change. One vital area deserving further attention is the impact of medical errors on health care providers. Not only is this an inherently difficult subject to discuss, but we are also inclined to believe that these sequelae are less significant than the effects of medical errors on patients and their families. However, effective management and prevention of medical errors ultimately depends on understanding how we, as providers, respond to these events.
To date, research in this area has provided some valuable insight into physicians' intense emotional responses to medical errors and the challenges of finding the necessary support to deal with these feelings. However, most of this work has focused exclusively on homogenous groups of attending-level physicians. The goal of our study was to build on previous work by exploring the experiences and responses of residents across different subspecialties and years of training. Resident physicians are an important and vulnerable population whose early experiences with medical error may shape their future behaviors and coping skills. The critical role that the residency period plays in defining physicians' future practice patterns and responses to medical error is attested to by research in psychology that indicates that, in stressful situations, people tend to rely on behaviors learned early in their experience.2,3 In this sense, interventions and training that prepare residents to deal effectively with error events will have significant implications for their futures and our health care system. Although effective or successful management of medical error cannot be singularly defined, desired outcomes should include the promotion of physicians' health through emotional support and opportunities for learning.
In both medical and popular literature, physician testimonials provide insight into the impact of medical mishaps on health care providers. In the 1980s, Dr. David Hilfiker shared his experiences with medical error in the New England Journal of Medicine and in a subsequent book, entitled Healing the Wounds.4,5 This rural family physician describes events resulting from personal errors in judgment and his struggle to deal with his own intense emotional responses. Dr. Hilfiker recognized the long-term impact of such experiences on the emotional health of physicians and urged the medical profession to support open discussion of these events and constructive means of coping with emotions. In more recent years, other physicians have shared similar stories6–9 and the feelings of anguish, shock, isolation, and guilt they have experienced subsequent to the “sickening realisation of making a big mistake.”7
In addition to these personal testimonials, several research studies have sought to explore physicians' emotional responses to medical error and their mechanisms of coping.10 In a survey of 114 internal medicine house officers, participants reported significant emotional responses when asked to consider their most important mistake.11 Residents experienced feelings of remorse, anger, guilt, and inadequacy in response to these events and 28% feared negative repercussions. As part of their responses to these events, 54% of residents reported speaking with their supervisory attending, whereas 58% stated that they spoke with family members or nonmedical friends. Twenty-seven percent of residents in that study indicated that the atmosphere in the hospital discouraged them from discussing their errors.
A more recent survey study of 402 health care providers explored the reactions of physicians, nurses, and pharmacists to medication errors. The most frequent emotional responses to these events were “guilty,” “worried,” and “nervous.” Among these providers, the highest ranking concerns included “fear for the patient,” “fear of disciplinary action,” and “fear of punishment.” In that study, the authors also found that respondents were more likely to identify friends and family as sources of support than other health care professionals.12
Several qualitative studies have explored the responses of attending physicians to medical errors. Two of these studies involved audiotaped, in-depth interviews of practicing internal medicine physicians and family physicians regarding their experiences with medical error.13,14 Participants described significant emotional responses to their reported events, including self-doubt, disappointment, guilt, embarrassment, and fear. In many cases, these feelings persisted for many months and even years after the actual event. During discussions of coping, participants in both studies stated that they needed support from and wanted to talk with others. However, physicians in both fields reported similar concerns about getting this desired support from their medical colleagues. Newman et al.14 found that 67% of participants spoke with someone other than a medical colleague about the error event and that 55% received the greatest support from their spouses. Christensen et al.13 reported that numerous physicians viewed “discussions with colleagues as threatening, [and] some physicians also viewed them as unhelpful.”
In 2003, Gallagher et al.15 published results of a focus-group study in the Journal of the American Medical Association, which explored the attitudes and emotional responses of both patients and physicians to medical error. The authors found that the physicians were deeply upset by medical errors, but that they were often uncertain about where to find emotional support. Some physicians reported that discussion at morbidity and mortality conferences or privately with a trusted colleague was helpful to them, whereas others described feeling somewhat relieved after disclosing the error to the patient and/or the patient's family.
Our study explored residents' perceptions of medical errors and their responses to these events using in-depth, semistructured interviews. The study protocol received approval from the University of Michigan Institutional Review Board, as well as the appropriate hospital boards at the study site.
Study setting and population.
The research site was a 600-bed U.S. teaching hospital with a large graduate medical education program. Our focus was on the inpatient setting. The participant sample, stratified by specialty, year of residency, and sex, was randomly drawn from a total population of 85 residents within the three specialty residency programs sponsored by the hospital: surgery, medicine, and obstetrics/gynecology (Ob/Gyn). Although the research site was chosen for convenience, we chose to randomly sample residents to more accurately represent the total resident population. The final sample consisted of 26 residents (30% of the population), including five surgery, 17 medicine (11 medicine and six preliminary/transitional), and four Ob/Gyn residents. Fourteen were men and 12 were women. Eleven residents were in their first year of postgraduate training, five in their second year, seven in their third year, two in their fourth year, and one in their fifth year. The disproportionate number of first-year residents in the sample and population reflected the fact that many residents pursue specialty training in other programs after completing the first year. Residents ranged in age from 25–39 years and averaged 29.8 years.
Two of the authors (MR, KS) and another researcher interviewed the selected residents using a semistandardized interview protocol designed to draw out detailed descriptions of three medical mishaps and one “near miss”16 for each resident. Funding for this study was provided by the Office of the Vice President for Research at the University of Michigan.
Resident participation was voluntary and each participant was assured that conversations, although recorded and transcribed, would be stripped of names and other identifying information as much as possible. No attempt was made to guide the conversation to any one aspect or area of training, and interviewees responded to requests for further explanation with as much or as little detail as desired. Interviewees were free to stop the tape recorder or end the interview at any time; none took advantage of this. We informed resident participants of the intention to publish study findings.
For the purposes of this study, we used the Institute of Medicine definition of medical error: “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.”1 A near-miss is defined as “an event or situation that could have resulted in an accident, injury, or illness, but did not, either by chance or through timely intervention.”17 We deliberately chose and emphasized the term “mishaps.” We chose this term, a neutral, nonjudgmental word that encompasses a wide range of mistakes from the near-miss to a serious iatrogenic injury, to cast the widest possible net and avoid the weight of the term “error.” In this manuscript, however, we have used the terms “mishap” and “error” interchangeably.
During the interviews, we probed for what the residents saw as the nature of the errors described, the causes of errors, the principal individuals involved, the outcomes or implications for the patients, and the responses on the part of the resident. A total of 70 mishaps were described by the 26 participating residents. For the current analysis, we extracted a subset of questions at the end of each interview and reviewed the resident's responses in detail. In this final section of the interview, residents were asked to describe their emotional responses to the mishaps they reported, how they dealt with these feelings, and what would have been helpful to them in these circumstances. The selected questions analyzed for this study are shown in List 1; the complete interview guide can be obtained from the authors upon request. We analyzed each participant's comments iteratively with the goal of drawing out categories and themes of discussion. For approximately six of the 26 resident interviews, we reviewed the complete interview because the resident's comments in the final section referred to statements earlier in the interview. Each case was separately reviewed by two authors to ensure appropriate categorization and common understanding of themes. We then met to discuss our findings and ensure agreement.18–20
Residents' emotional responses to medical errors fell into three primary categories: distress, guilt/self-doubt, and frustration/anger. Three additional categories of emotions were expressed less often, including confusion/fear, isolation, and comfortable/lucky. Several residents expressed emotions that fell into two or more categories. However, of the 26 residents interviewed, 25 expressed feelings that fell into one of the three primary categories. The remaining resident described feeling “comfortable” and “lucky” after a case involving a positive outcome for the patient. We identified no clear relationship between the types of responses and the residents' specialty or year of training.
Residents reported being strongly affected by the direct impact of the mishap on the patient (patient impact), but also by the personal implications of the event (personal impact) and by ensuing interactions with other health care providers (interpersonal/team issues). The following sections detail each category of emotional response and provide segments of resident interviews as examples. Within each category, residents' comments will highlight the importance of patient impact, personal impact, and interpersonal/team issues (see Table 1).
Distress was expressed by more than half (16/26) of the residents we interviewed and represents the most common emotional response to medical errors. Residents used many different words to describe their distress, including “terrible,” “upset,” “bad,” and “devastated.”
Residents also frequently expressed feelings of guilt and self-doubt in response to medical errors; more than one third (10/26) of the residents experienced these emotions. They reported regretting missed opportunities to improve patient care, and shared feelings of intense personal responsibility and disappointment.
Just over one third of residents (9/26) expressed feelings of frustration and anger in response to the medical errors that they described. Some of these feelings were in response to patients, to themselves, or to their working conditions. However, residents most often directed their frustration and anger toward other health care providers, whom multiple residents felt displayed disloyalty and made inappropriate accusations. In these cases, residents' emotions were often characterized by intense feelings of blame. Our study participants also expressed frustration and anger due to the performance of other health care providers.
Feelings of confusion and fear were expressed by only three residents. In each of these cases, the residents described near-miss situations that had relatively good outcomes despite potentially serious consequences.
Two residents expressed feelings of isolation in response to medical errors. One second-year medical resident offered this comment: “Most of the time when it happens to you, you feel like you're the only one that it's happening to.”
One second-year medical resident expressed feeling comfortable and lucky in response to medical errors with positive patient outcomes: “I think overall, because the outcome was good, I'm comfortable and I think that we're somewhat lucky that things turned out fine.”
Correlating emotional responses with error severity and personal responsibility
Most of the residents identified more than one mishap during their interview. Because we asked questions about emotional responses to medical errors at the end of the interview without specific reference to a particular mishap, it is not possible to make consistent direct correlations between the type of error and the emotional response. However, a clear pattern does appear within the interviewees' comments. Residents repeatedly expressed that the nature of their emotional response was strongly affected by both the patient outcome and the extent of personal responsibility for the mishap. More intense reactions were reported for mishaps associated with poor patient outcomes and higher levels of personal responsibility.
The comments of two medical interns help to emphasize the importance of patient outcomes in affecting residents' emotional response to medical errors. The first intern commented on her reaction to a case in which the patient died. In this situation, it is difficult to distinguish the resident's emotional response to the patient's death from her reaction to the medical mishap, but it seems clear that the error event intensified her response:
So that was really hard especially because, you know, the patient did die…Looking at it in retrospect now I don't think necessarily anything I specifically did caused his death. I think he would have died anyway, but it was just very difficult to deal with that.
Although the second intern only experienced errors associated with relatively good outcomes, she shared her colleague's sentiment regarding the significance of patient outcome in affecting her emotional response. She remarked:
The bad outcomes to the patients were minimal in these cases. I think I might feel differently if it was a very bad outcome. Fortunately, I have not been involved in a medical mishap that caused…something like that.
The comments made by these two interviewees are consistent with the response of the one second-year medical resident who described feeling comfortable and lucky “because the outcome was good.”
During many interviews, residents' emotional responses to medical errors were closely linked to thoughts about their degree of personal responsibility for a given event. When asked to identify the mishap that was most upsetting to him, a senior medical resident described a diagnostic error that his team was responsible for. Although there was a good outcome in this case, the resident expressed significant anguish due to his own culpability:
Probably the most bothersome for me was the one that we were involved in, the first one. Yeah. So we really felt bad about that, but it was because we were involved in this mishap.
Similarly, an upper-lever surgical resident summarized his emotional responses to medical mishaps by saying, “So it varies as to what my role would have been in a mishap—what I feel about it.” In addition, a medical intern commented on a specific error that he was responsible for:
It's strange because I think you feel worse about a mishap when you did something to a patient and something bad happened, i.e., try to put a line in a patient and get a hematoma.
Mechanisms of coping
Residents identified several different strategies for coping with the emotions that they experienced in response to medical errors. By far the most common coping mechanism was talking with either medical colleagues or family members. Other strategies included learning/changing their practice, taking action, physical activity, and withdrawal/denial. Although some differences were apparent between resident subspecialties, we identified no clear relationship between residents' mechanisms of coping and year of training.
Talking with others was identified by all but one (25/26) of the residents as a primary means of coping with their emotional responses to medical mishaps. This took several forms, including talking with others in the medical profession or with family and friends.
Talking with other medical professionals.
Residents talked most frequently to their resident peers and to attending physicians about their medical errors. During such conversations, residents seemed to seek answers to a common question, as one first-year surgical resident phrased it: “Has this ever happened to you?” Talking about common experiences seemed to assuage residents' feelings of guilt or self-doubt and to minimize their sense of isolation. A senior Ob/Gyn resident described this reassurance:
I think the way to do it is to talk about it and to share your experiences. I mean, I think keeping it to yourself you feel a lot worse. And then you talk to people, especially people who you think you respect and you feel that you've learned a lot from and you find out that they've had similar experiences. It makes you feel better that you're not a bad doctor because this happened.
A first-year transitional resident echoed this sentiment, remarking:
You hear about other things that happen with other people and in some strange way it makes you feel better about, it's like, well, accidents happen and I'm not the only one.
Further, a fourth-year surgical resident, whose conversations with others after a mishap helped to lessen his feelings of frustration, offered this comment:
You've got a whole group of people who are going through the same thing who have experienced similar frustrations and can empathize and sympathize. Even occasionally you get up and can talk to the staff about these things. And they've had similar frustrations and remember what it felt like to be in that position.
Although interactions among residents seemed to be most prevalent, talking with attending physicians also provided an important source of reassurance for residents. Several residents identified attending input and feedback as critical to their ability to cope with medical mishaps. One third-year medical resident remarked:
And in the case where it was my fault I was blessed with an attending who was diligent enough, who forced me to talk about it. Otherwise I would not have… And so I felt like I really was able to deal with that and put it behind me… [Another case] just never got handled, it never got dealt with because the attending wasn't somebody I could approach.
In addition to talking with resident peers and attending physicians, a few interviewees described receiving personal reassurance from other medical personnel. In particular, a preliminary neurology resident remarked:
And I talked to a nurse about it, too, that was involved. And she was very good about it. And [she] said, “You did everything that should have been done. It's really not your fault.”
Formal versus informal discussion.
Residents identified both formal and informal opportunities for discussing mishaps with medical colleagues. Although no significant differences were evident among the resident specialties regarding the types of emotional responses to errors or the importance of talking as a coping mechanism, the different roles of formal and informal discussion did introduce important contrasts. Four of the five surgical residents and three of the four Ob/Gyn residents interviewed identified deaths and complications (D&C) or morbidity and mortality (M&M) conferences as valuable opportunities to talk about adverse events or medical errors. These residents not only expressed that these conferences were helpful in enabling them to share their experiences and to learn how they might do things differently in the future, but also that these structured sessions facilitated and encouraged more informal discussion of errors and problems. One surgical intern described:
D&C conferences … kind of set the example. You know, because we know that this is what we do every week. I mean, I remember on occasions that I've asked, “God, this patient is not doing so well do you think it's because of…?”…And you know I just try to get education from other people to tell me what they think.
Talking with family and friends.
Residents consistently made a clear distinction between talking with medical professionals and with nonmedically-trained family or friends. Although some residents valued their conversations with individuals outside of medicine as a means of “venting” and getting “a public perspective,” these interactions were viewed as less important to the coping process than those with medical colleagues. Many residents voiced concerns that those without medical training could not fully understand or relate to their experience as a physician in these situations. In this sense, family members and friends were viewed as less able to provide the kind of reassurance and support that residents desired.
Several residents expressed a tendency to avoid conversations with nonmedical personnel in coping with their medical mishaps. One senior surgical resident said:
I don't think I would talk to a lay person, I wouldn't feel the need to….I think residents in general probably bond and share with other residents because they all have the same experiences and have a better understanding of what they go through rather than probably a lay person.
Two medical interns made similar remarks. The first intern said, “I don't talk to my family because they don't understand. They're not in medicine.” The second medical intern explained:
Friends outside the hospital..they don't quite understand. And their eyes get big and they say, “You did what to the patient?!?” I think it's a much more supportive atmosphere to talk amongst ourselves. And then we get some constructive criticism back too.
Talking with patients.
Interestingly, only one resident of the 26 residents we interviewed described discussing an error with a patient. For this medical intern, the interaction with the patient provided some relief of the distress related to this event:
I was just honest with the patient. And I think I got tears in my eyes when I said it.… She flat out forgave me.
We did not directly question the residents we interviewed about error disclosure or their interactions with patients, so it is likely that others discussed events with patients or family members, but did not share these experiences during the interview. Nevertheless, the data collected here suggest that interactions with patients or their family members were not a primary means of coping with medical errors among residents. Some insight into this issue is provided by one resident who expressed concern about such disclosure due to feelings of insecurity as a physician-in-training:
Just being a resident and being thought of as a substandard, like “Oh god I'm being taken care of [by a] resident,” kind of puts a barrier up in terms of explaining to the patient. I guess if I had a better relationship with the patient in the first place I probably would have felt comfortable kind of saying, “Hey, this is what happened.”
A majority of residents (18/26) identified learning from medical errors and/or changing their behavior in response to their experiences as important coping mechanisms. A second-year medical resident described his coping strategy:
If it's severe I try and discuss it at length with other people, try to discuss it with other people that might have been involved and to talk it out and try to learn something from it. I think that that's one of the ways I handle it. To try and at least learn a lesson from it.
Interestingly, this resident noted that his level of activation and his motivation to learn were increased by the severity of the error. This was reinforced in a comment by a surgical intern:
If there is a bad outcome, usually you look back and say, “What could we have done differently. Oh this happened.” I think if something happens then it's more likely to be noticed.
As reflected in the following statement by a third-year surgical resident, several residents also highlighted the importance of acknowledging an error in enabling learning and change to occur:
I think part of being a physician is having integrity and acknowledging that you made a mistake and figuring out ways to change it for the future.
Surgical and Ob/Gyn residents identified D&C and M&M conferences as opportunities for formal learning about medical mishaps that complemented informal discussions among team members and peers. Although a few medical residents did mention teaching rounds and mishap conferences as structured forums in which to address medical mishaps, there was little enthusiasm for the effectiveness of these approaches. For these residents, learning seemed to occur through “scattered discussions, nothing systematic”; in contrast, surgical and obstetrical residents participated in D&C or M&M, during which open discussion of errors was an expected and standardized process. Residents seemed universally enthusiastic about structured conferences. As a surgical intern expressed:
This has been a tradition among surgical education for a long time that you present things when they go wrong. And I don't understand why other fields don't do that….I think it is very educational. It makes you feel like you can talk about what happened and what you can do differently next time.
Approximately one third (9/26) of the interviewed residents mentioned taking action as a means of coping with medical errors. Most commonly, residents described making efforts to assist or attend to the patient involved in the mishap. These active efforts seemed to be a direct response to feelings of distress and guilt. One medical senior stated that her team tried “to do whatever we can to make up for what we, for the mishap that happened”; a surgical intern similarly described “just doing as much as I could to help her and her family after the incident.”
Other residents described coping with their emotions by taking action to effect system change or to alert others of perceived problems. A second-year medical resident made this observation:
The only way that I think I could feel better is really feeling like I'm gonna do something about it. Like write a letter, you know, complaining about this case.
One third-year Ob/Gyn resident shared how his long-term plans for action help him deal with feelings of frustration related to the medical mishaps he has experienced:
I will try to create some systems, at least within my office, to reduce mishaps and then if I have roles in the hospital then I would like to be involved with helping to improve the system.
Two residents mentioned physical activity as a means of coping with their emotional responses to medical errors. In particular, the single resident who did not identify talking as a personal coping strategy highlighted the value of athletics in coping with his feelings: “I play basketball or something … really do the things like I want to do—working out.”
Withdrawal or denial was identified by six of the 26 residents as a possible mechanism for coping with emotional responses to medical mishaps. Half of these individuals described merely being aware of other physicians using this strategy, whereas the remaining three residents related their personal experience with this approach. A first-year transitional resident said:
It could be that most people keep it mostly inside, I mean, partly because they don't want to admit that they did something wrong. It's kind of hard to admit that you did something wrong.
Two other residents observed that denial is often coupled with a tendency to blame others for errors.
Of the three residents who described resorting to withdrawal or denial to cope with their medical errors, each seemed to recognize that this was not the ideal means of coping with such circumstances. One senior medical resident reported being grateful to an attending who “forced” her to talk about an event, because otherwise she “would have been perfectly satisfied to have pretended it never happened and try and just swallow it and try and not deal with it at all.” Similarly, a second-year medical resident described:
If I find myself avoiding acknowledging it or avoid talking about it I get concerned. And that does happen.
The residents whom we interviewed reported experiencing intense emotional responses to their medical errors consistent with those described in previous qualitative work conducted with attending physicians. Residents' responses did not appear to vary according to their specialty or year of training.
Although our study design limited our ability to directly correlate the type or severity of residents' errors with their responses, the data do suggest a strong correlation between these variables. Poor patient outcomes and greater perceived personal responsibility were associated with more intense reactions and greater personal anguish among residents.
Although this finding may not be unexpected, it raises an important point that both reinforces and builds upon the results of the survey study of internal medicine residents conducted by Wu et al.21 These authors found that a majority of residents were willing to accept responsibility for their mistakes. Their analysis indicated that those house officers who coped by accepting responsibility were not only more likely report constructive changes in their future practice, but also to experience greater emotional distress.21 Thus, it appears that residents faced with serious adverse events and/or a sense of personal responsibility for an error are inherently motivated to change their future practice behaviors, but that these experiences may challenge their emotional well-being. These findings indicate that it is critical for young physicians to receive adequate support from the educational and hospital environment in these moments of emotional hardship. In addition, our work suggests that training programs need to look for ways to help residents to develop constructive coping skills. To this end, educators may need to focus on maximizing resident activation in response to near misses and events for which residents do not feel personally responsible, motivating and inspiring residents to take the events more seriously and thus to respond. The reporting of near misses has previously been cited as an important part of a systems approach to reducing and managing risk.22 Although medical personnel may find it easier to brush aside near-miss events and those in which they perceive little responsibility, educators and supervisory physicians need to resist this temptation and, instead, emphasize to residents the potential danger that these events represent. By evoking some of the distress experienced naturally in the setting of more severe errors, it may be possible to transform these more frequent occurrences into important learning opportunities. Residents may learn invaluable lessons from candid discussions of how such errors might be prevented in the future and how they may best cope with such events if the do occur.
Residents identified a variety of different strategies to cope with their intense emotional responses to medical errors. Consistent with previous studies, opportunities to talk to and to share difficult experiences with others were critical coping mechanisms for nearly all participants.
Conversations with others seemed to help lessen the intense feelings that residents experienced subsequent to their medical mishaps, largely by providing validation and reassurance. Residents' feelings of distress and isolation were relieved by hearing that others had had similar experiences with medical error, and that these occurrences did not jeopardize their competence as physicians. Moreover, talking and sharing were closely linked with opportunities for learning and change, which represented another important aspect of how residents coped. In discussion with others, residents sought to learn what might have been done differently and how similar mishap situations might be prevented in the future. This process seemed to be empowering for them and, thereby, helped them to deal with their personal distress and frustration. Overall, the process of coping for most residents represented a combination of finding emotional support and acting on opportunities for learning.
We did not fully explore the role of residents disclosing their errors to patients as a part of coping with their experiences in this study, a question that should be addressed in future work. Because we did not question residents directly about any discussion of error with patients, it is not possible to draw any definitive conclusions. However, our data suggest that error disclosure frequently did not occur or was not viewed by the residents as part of their coping process. To date, most of the literature on error disclosure to patients is based on ethical discussions and anecdotal reports.8,23–25 Wu suggests that such disclosure may help to decrease physicians' distress after an error event.21 In his recent book, Medical Errors and Medical Narcissism, Banja argues that error disclosure may provide important psychological benefits to physicians.26 Future work should explore the role of patient error disclosure in residents' emotional responses and coping subsequent to medical error events.
In contrast to previous studies conducted with attending physicians, our findings suggest that residents preferred to speak about error events with medical colleagues, rather than family or friends. For the most part, residents sought reassurance and guidance from each other and supervisory physicians, because they felt that these individuals could best identify with their situation. In residents' eyes, these colleagues were perceived as having the knowledge, authority, and experience to help relieve their anxiety and stress, and to help them effectively alter their future practice to prevent such events. This key role of professional interactions in resident coping is a critical finding. To promote healthy and effective coping with medical errors among residents, training programs must facilitate open discussion of error events among trainees at different levels, as well as with faculty. Interactions with other resident physicians are important as a means of sharing common experiences, minimizing feelings of isolation, and maintaining self-confidence. Conversations with supervisory physicians appear to complement these peer interactions by providing insight, experience, and guidance that further supports residents' coping processes. The role of input from attendings seems to be particularly critical in situations where the resident may be attempting to cope through withdrawal or denial and, thereby, not benefiting from interactions with his or her colleagues. In addition, supervisory physicians need to give particular consideration to blame responses that may exist within their team and help to support open and constructive discussion in these settings.
Residents in our study also emphasized the importance of formal discussions of medical error and adverse events in facilitating more informal discussions with their medical colleagues. Surgical and Ob/Gyn residents spoke positively about the opportunities that D&C and M&M conferences provided for addressing mishap events. They identified these sessions as important aspects of their training and valuable means of coping with error events. These structured conferences provide a forum in which to discuss the mishap openly and to identify strategies or changes that might help to prevent future events. Moreover, these formal discussions seemed to set a precedent for talking about mishaps on a more informal level and, thereby, further aided the coping process for these residents. Formal and informal discussions appear to be both complementary and additive. Although individuals may have varying preferences for these different forums of error discussion, our findings indicate that combining formal and informal discussions may generate a powerful synergy. Although our study site did not offer such formal discussions for medical residents, there is some discussion of the role of M&M conferences in internal medicine programs.27,28 Currently these conferences lack consistent structure across training programs and may encourage residents to assign blame or become defensive, rather than facilitating constructive responses and learning.28 The insight we have gained from this study of resident experiences with medical error should help to guide the development of a more systematic and thoughtful approach to such “error conferences.” These forums would provide an important means for teaching residents about error and help to model appropriate responses to these events.
Resident physicians must cope with intense emotional responses to their medical mishaps and depend heavily on the support and guidance of their medical colleagues, educators, and supervisory physicians. Training programs need to appreciate the challenges that residents face following these events and may promote constructive coping by providing emotional support and opportunities for learning. Our work suggests several strategies to further enhance resident education and development in this area. First, residency programs should capitalize on opportunities to discuss error events associated with good patient outcomes and little perceived resident responsibility. These cases are often overlooked, yet efforts to activate residents in response to these situations may allow for meaningful learning and change. A second strategy is to encourage the development of more widespread “error conferences” that have been traditionally limited to D&C and M&M rounds in surgical fields. Last, future work should consider the impact of error disclosure to patients on resident coping and learning.
1 Kohn LT, Corrigan JM, Donaldson MS (eds). To Err Is Human: Building a Safer Health System. Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC: National Academy Press, 2000.
2 Barthol RP, Ku ND. Regression under stress to first learned behavior. J Abnormal Psychol. 1959;59:134–36.
3 Allnut M. Human factors: Basic principles. In Hurst R, Hurst LR (eds). Pilot Error. 2nd ed. New York: Jason Aronson, 1982.
4 Hilfiker D. Facing our mistakes. NEJM. 1984;310:118–22.
5 Hilfiker D. Healing the Wounds. New York: Penguin Books, 1987.
6 Levinson W, Dunn PM. Coping with fallibility. JAMA. 1989;261:2252.
7 Wu AW. Medical error: The second victim— the doctor who makes the mistake needs help too. BMJ. 2000;320:726–27.
8 Wu AW. A major medical error: medical resident tells of how he coped with it. Am Fam Phy. 2001;63:985–87.
9 Yee P. Brain cramp: the emergency physician's worst nightmare. Ann Emerg Med. 2002;39:329–30.
10 Goldberg RM, Kuhn G, Andrew LB, Thomas HA. Coping with medical mistakes and errors in judgment. Ann Emerg Med. 2002;39:287–92.
11 Wu AW. Do house officers learn from their mistakes? JAMA. 1991;265:2089–98.
12 Wolf ZR, Serembus JF, Smetzer J, Cohen H, Cohen M. Responses and concerns of healthcare providers to medication errors. Clin Nurse Spec. 2000;14:278–90.
13 Christensen JF, Levinson W, Dunn PM. The heart of darkness: the impact of perceived mistakes on physicians. JGIM. 1992;7:424–31.
14 Newman MC. The emotional impact of mistakes on family physicians. Arch Fam Med. 1996;5:71–75.
15 Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. Patients' and physicians' attitudes regarding the disclosure of medical errors. JAMA. 2003;289:1001–7.
16 Fitzpatrick R, Boulton M. Qualitative methods for assessing health care. Qual Health Care. 1994;3:107–13.
17 Quality Interagency Coordination Task Force. Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact. Washington DC: quality Interagency Coordination Task Force (QuIC) to the President, February 2000.
18 Dingwall R, Murphy E, Watson P, Greatbatch D, Parker S. Catching goldfish: Quality in qualitative research. J Health Serv Res Pol. 1998;3:167–72.
19 Mays N, Pope C. Assessing quality in qualitative research. BMJ. 2000;320:50–52.
20 Pope C, Ziebland S, Mays N. Analysing qualitative data. BMJ. 2000;320:114–16.
21 Wu AW. How house officers cope with their mistakes? West J Med. 1993;159:565–70.
22 Larson EB. Measuring, monitoring, and reducing medical harm from a system's perspective: a medical director's personal reflections. Acad Med. 2002;77:993–1000.
23 Finkelstein D, Wu AW, Holtzman NA, Smith MK. When a physician harms a patient by a medical error: ethical, legal, and risk-management considerations. Jour Clin Ethics. 1997;8:330–35.
24 Wu AW, Cavanaugh TA, McPhee SJ, Lo B, Micco GP. To tell the truth: ethical and practical issues in disclosing medical mistakes to patients. JGIM. 1997;12:770–75.
25 Wu AW. Handling hospital errors: is disclosure the best defense? Ann Intern Med. 1999;131:970–72.
26 Banja J. Medical Errors and Medical narcissism. Sudbury, MA: Jones and Bartlett Publications, 2005.
27 Casarett D, Helms C. Systems errors versus physician's errors: finding the balance in medical education. Acad Med. 1999;74:19–22.
28 Orlander JD, Barber TW, Fincke BG. The morbidity and mortality conference: the delicate nature of learning from error. Acad Med. 2002;77:1001–6.