Carlson, Robert H.
ORLANDO, FL—It may not seem so at the time, but disclosing medical errors to patients and administrators is ultimately good for physicians and the entire medical team. While this can be a humbling, if not humiliating experience for a physician, acknowledging errors ultimately improves the physician-patient relationship and opens the door to studying what caused the error. And “coming clean” helps those responsible deal with their own problems of conscience over the incident.
In any event, it is becoming harder to cover up errors as knowledgeable patients, standards committees, and regulators are demanding disclosure.
But conflicting emotions about the issue are strong and in actual practice many errors are still not being reported as such.
In an Educational Session here at the ASCO Annual Meeting, experts discussed patients' and physicians' attitudes about error reporting and offered suggestions on management strategies.
The patient safety movement and increasing regulatory requirements for disclosure are two reasons for the increased emphasis on error disclosure and transparency, said Thomas H. Gallagher, MD, Assistant Professor of Medicine at the University of Washington Medical Center.
Studies have shown that patients want disclosure even for errors that cause minor harm, he said. “But there is compelling evidence that this disclosure doesn't take place the way we'd like it to.”
To explore this gap between the demand for disclosure and actual practice, Dr. Gallagher and colleagues conducted a series of surveys and focus groups with patients and physicians in the US and Canada, the results of which were published in 2003 in the Journal of the American Medical Association (2003; 289:1001–1007).
The US-Canada comparison was especially relevant, he said, because many people say the malpractice climate is the primary driver about safety and disclosure.
However, “even though Canadian physicians get sued about a fifth as often as their US counterparts, physician attitudes were similar in both countries,” he said.
Figure. Thomas H. Ga...Image Tools
Similar surveys in Sweden and New Zealand, countries with totally no-fault medical malpractice systems, showed that physicians are still very anxious about disclosure—not because they worry it will trigger a lawsuit, but because they worry about being shamed and scorned after admitting an error, Dr. Gallagher said.
His own surveys, he said, showed that patients fear that physicians and other health care workers are inclined to hide errors.
“They did not think physicians were evil or mal-intentioned; they just think it is human nature to keep [errors] to yourself,” he said.
Patients want to hear someone explicitly say that there has been an error, for that person to say he or she is sorry about the error, to explain it and its implications, and to explain in general why it happened and how it could be prevented, Dr. Gallagher said.
“In our focus group these last two were really important to patients because they wanted a sense that a lesson had been learned from the error.”
Oncology patients in particular believed medical errors were a challenge to them. “Oncology patients feel so vulnerable, they realize cancer is such a serious diagnosis, and they believe they are so ill that even a minor error could cause serious consequences,” he said.
Physicians surveyed all agreed in principle that harmful errors should be disclosed, that they wanted to be truthful, Dr. Gallagher said.
But the physicians also said they experience a variety of barriers to disclosure. “There was clearly concern that disclosure could precipitate a lawsuit, but many doctors also said they worried that disclosure could be harmful to the patient, either by making the patient unduly anxious or by disrupting the therapeutic relationship,” he said.
Many physicians surveyed also felt that disclosure would be awkward and uncomfortable, in part because many physicians conceptualize error as a personal failing. “That is very hard to admit to a patient,” Dr. Gallagher said.
Other physicians explained that they had no formal training in error disclosure and did not know what to say.
“These barriers lead to a phenomenon that doctors described as ‘choosing their words carefully,’” Dr. Gallagher said. “They might tell the patient that there was an adverse event, but they wouldn't explicitly say the adverse event was due to an error, or that it was preventable.”
The physicians believed a patient would ask clarifying questions if he or she were really interested, and that the physician's job is to provide a basic nugget of information. Some saw this as a balance between how much information they provide to the patient upfront and how much they would wait for the patient's questions.
“All of the doctors said they would like to say they were sorry, just as one human being to another, but they worried that saying ‘I'm sorry’ would heighten their legal liability in ways that felt very, very scary,” Dr. Gallagher said.
The notion of patient care error includes everyone involved, from the physician and health care team to the entire healthcare system, said another speaker, Antonella Surbone, MD, PhD, Head of the Teaching Division of the European School of Oncology and Clinical Associate Professor of Medicine at New York University Medical School.
In her presentation, Dr. Surbone, a member of the ASCO Ethics Committee, said team errors can arise from different levels of training and expertise among team members; unclear assignment of duties; and the complex interplay of loyalties, fears, and insecurities of all the team members.
“If you are a first-year fellow witnessing a mistake committed by your attending, it's not just that you don't have the courage to report it, you don't feel safe enough to question someone else,” she said. On the other hand, “sometimes some members of the team have excessive self-confidence” and don't believe they need to report all errors.
Ideally there is a balance in the individuals versus the collective sense of responsibility, Dr. Surbone said.
But when a team errs, it can mean that one person—typically the physician—must disclose to the patient an error committed by another team member.
“In the practice of oncology, it is really difficult to maintain a balance between having an excessive sense of responsibility or having an overwhelming sense of impotence, and we swing between one and the other,” Dr. Surbone said.
Errors of Silence
Not disclosing pertinent facts to a patient can be considered a medical error, Dr. Surbone said, even if an actual error has not occurred. Her example is the clinical trial, in which oncology researchers have a responsibility to inform patients of the uncertainty involved in a trial, but without raising or subtracting hope.
Researchers also have a responsibility to warn patients of negative preliminary results in an ongoing trial, and to inform study subjects of the definitive results before they are released through the media.
She cited the experience of a young woman with breast cancer who learned through news reports that the bone-marrow transplant trial she took part in had a negative outcome.
“That had a very shattering effect on her,” Dr. Surbone said, and that woman—magazine writer and editor Katherine Russell Rich—was another speaker at the session, recounting in a riveting yet soft-spoken manner the harrowing details of what she had experienced, contrasting her emotional reaction to two examples of medical errors during her treatment — one that was handled well by the physician involved and one that was not.
A short excerpt from her 1999 New York Times Magazine “Lives” article is included in Dr. Surbone's chapter in the ASCO 2005 Educational Book, and Ms. Rich is also the author of a 1999 memoir about her experience, The Red Devil: To Hell with Cancer—And Back (Crown), published 11 years after being diagnosed with Stage 4 breast cancer at the age of 32.
Dr. Surbone concluded with suggestions for strategies to manage medical error:
▪ That physicians and other health care workers learn the importance of transparency.
▪ That they recognize the potent, devastating effect of silence on patients, physicians, family, and society.
▪ That physicians seek help when struggling with the consequences of a medical error on their inner lives.
© 2005 Lippincott Williams & Wilkins, Inc.