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Emergency Medicine News:
doi: 10.1097/01.EEM.0000396565.41801.64
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Full Disclosure Policies: Risk for Physicians?

Hossfeld, George MD

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An unlikely movement in hospital risk management involves a revolutionary change in attitude. Known as “full disclosure,” it is the groundbreaking attempt to disclose fully the medical errors that cause unnecessary harm to patients, answer the questions of those patients and families, and offer an early apology along with financial compensation to the injured party. Several institutions (including my own university hospital) have pioneered this approach with early results showing exciting promise of reduced liability costs, as well as early resolution and improved relations with patients and families instead of previously deeply contentious (and expensive) legal battles. Sounds like a win-win situation at first glance. I admit that I would not have predicted success for this approach, but results have shown just that.

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I have previously discussed the oft repeated and ridiculously exaggerated claim of 100,000 deaths each year due to medical error. (“The Second Great Lie: the Institute of Medicine Report,” EMNow 2010;32[2]: http://bit.ly/2ndLie.) As I said then, the IOM used scandalous and deceptive methodology to arrive at that figure, a fact that some of its authors admitted in subsequent publications. If that IOM figure were correct, medical error would kill more people each year in the United States than cancer, heart disease, and AIDS combined! One would be a fool to go anywhere near a hospital.

Undeniably, we physicians are human. The brightest, finest trained, most conscientious, and talented among us all make mistakes. I make a dozen doozies before noon most days. My patients and their families do, too. I sincerely believe, however, with my 32 years of practice experience, that the number of medical errors that cause serious harm is small. That infamous surgeon who amputated the wrong limb may have actually existed, but that story has taken on the exaggerated life of the urban myth, repeated ad infinitum.

I'm all in favor of truth, honesty, and the American Way, just like Superman. But I have a couple of concerns about this policy. First and not solely related to this application is the preposterous standard by which we physicians are judged. Perfection is a bar set a little too high for me. I seriously doubt that an admission that I did my best for my patient but a bad outcome still happened (with or without some degree of error on my part) is the kind of lukewarm apology my administrator is seeking. It's not justice either.

The second concern is that every case description I have read involves an obvious guilty party, be that a nurse, physician, or pharmacist. What happens when a hospital seeks to provide full disclosure and offer financial contrition to quickly settle a potentially expensive case, but the provider steadfastly denies personal guilt? What if a physician had warned that an unsafe situation existed, and had lobbied for additional staffing or resources, only to have that prediction come true?

I've reviewed medicolegal cases for about 30 years, and it is a rare event that any medical error is clearly black and white. Everything is different shades of gray in real life. As I've perused the literature on the subject, and I admit that my research has not been comprehensive, I have not found a discussion of what must be a common conflict. There are plenty of references to the “second victim” being the doctor who has to live with himself after making the error. In such cases, many authors refer to a physician's guilt and shame, aversion to public acknowledgement of his error, and the healing that is afforded by peer counseling and making a full apology.

It just all sounds too convenient to match my perception of reality. What may be an obvious physician error to a hospital administrator or lawyer is usually far more muddled in actuality. I believe that this very likely situation is not nearly as amenable to “full disclosure” policies, and I have to wonder if there won't be intense pressure applied to the physician to admit his error or for the hospital to apologize for him anyway. That sure doesn't fit the model.

After more than three decades of practice in various hospitals, I hope I'm not stepping on toes when I say that some hospital administrators have been known to sell the occasional physician or physician group down the river when it worked to their advantage. The dollars being bandied about with the risk of a possible huge malpractice settlement might cloud one's ethical conscience in such a case.

I'd be interested in hearing from any physicians who have been involved in such cases.

Comments about this article? Write to EMN and Dr. Hossfeld at emn@lww.com.

Dr. Hossfeld is an assistant professor of emergency medicine at the University of Illinois-Chicago. He is a past president of the Illinois College of Emergency Physicians, and has been involved in the legal side of emergency medicine for more than 25 years. A collection of his columns is available on the EMN web site: http://bit.ly/GHossfeld.

© 2011 Lippincott Williams & Wilkins, Inc.

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