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Quality Matters

Quality Matters: Deny and Defend: Apologizing Hampered by Physician Culture, Risk Management

Welch, Shari J MD

doi: 10.1097/01.EEM.0000395426.55635.4c

    “I’m sorry” is one of the most commonly used phrases in any language, with people saying it reflexively throughout the day, but health care practitioners have been effectively gagged by the culture of the system.

    “I'm sorry” can express respect, regret, compassion, and caring. Yet we have disallowed this expression when patients and providers need to exchange them most. But Michael Woods, MD, in his book Healing Words: The Power of Apology in Medicine, says the act of apology is sentinel for providers, patients, and family when something unexpected or untoward occurs.

    The debate over apologies in clinical practice had to occur. It followed on the heels of great revelations: Medicine is practiced and delivered by humans, and humans make mistakes, and therefore, mistakes are made in medicine. This new dialogue began with the 1984 article by Lucian Leape, MD, “Error in Medicine.” (JAMA 1994;272[23]:1851.) It was followed by the Institute of Medicine's books about quality and a vision for health care that was very different from the vision held in preceding generations. The disciplines of quality improvement, patient safety and risk management developed rapidly in the wake of this new understanding.

    The biggest constraint to apology is cultural and begins with the physician. “Deny and defend” has been the standard approach to bad outcomes, and was created by the malpractice insurance industry. Lawyers are prone to warning doctors that patients and families may see an apology as an admission of guilt when the physician may sincerely attempt to show compassion. It becomes difficult to show that apology may reduce risk: How do you measure lawsuits that do not occur? When organizations promote a taboo on apologizing, it is driven by fear and anecdote, not data. Though it is now politically correct to apologize and admit mistakes, behind closed doors the old dialogues continue. Insurers tell their physician clients, “Never use the words ‘I'm sorry.’”

    Risk management also has contributed to the constraints on apologies. Most risk managers have subscribed to the notion that it isn't appropriate to apologize unless the bad outcome was preventable and the organization is responsible for it. The message is that this statement is a confession of guilt by the organization, and physicians and staff are cautioned against making such statements. As Dr. Woods points out, we say, “I am so sorry,” when we learn of a death or other bad news. Even though we have no connection to it or liability for it, we express this most human of responses. Apology has nothing to do with causation.

    Remember, apology is most effective at the front lines and in the clinical trenches. More than 80 percent of malpractice claims are due to poor patient-provider relationships. Providers with good communication skills who talk to their patients in an authentic way have lower rates of being sued. Risk has everything to do with the interpersonal relationships between patients and providers and relatively little to do with the quality of the care that was provided.

    The Five Rs of Apology

    According to Beverly Engel in her 2001 book The Power of Apology, an authentic apology has three elements: regret, responsibility, and remedy. For health care, Dr. Woods adds critical elements: recognition and remaining engaged. Recognition means understanding when an apology is needed, and it is critical that the caregivers not become defensive, withdrawn, or evasive. It is important to recognize early on when the patient's or family's expectations have not been met.

    An expression of regret tells the patient you recognize his fear, anxiety, and pain. It should go something like this. “I am really sorry this happened. It is not what either of us wanted or expected, and I need to tell you how sorry I am.” Responsibility is the step that your medical malpractice insurer and your organization are most worried about. You need to convey that you are responsible for your patient's care, and that you will get to the bottom of how an error happened, working to ensure it isn't repeated. This is surprisingly important to patients and their families. Dr. Woods recommends using first-person singular, not plural, for these expressions. (Examples of what to say will be covered next month.)

    Remedy includes the medical remedy in terms of the patient's condition and also his worries about day-to-day finances. Risk management should help you reassure the patient that the hospital will provide aid if a longer stay or another surgery is required. Evidence is mounting that when the patient does not face a financial burden after a medical error, he is less likely to seek compensation via litigation.

    Too often after an adverse event, complication, or error, providers want to disengage from the patient and the family, but this is the time the provider must remain engaged. It is uncomfortable for the provider, but he must make the patient feel he is there to help deal with the looming consequences. The patient must not feel abandoned by the provider. This is particularly difficult for the emergency physician whose care ends at the ED doors, but this is where phone calls to the family or patient to check on progress are important.

    More and more, hospitals are incorporating apologies into their risk management strategy, effectively reducing risk and the costs incurred when adverse events take place. The program at the University of Michigan Health System enhanced patient safety and provider-patient communication. The policy had three basic tenets:

    • Compensating patients quickly and fairly when unreasonable medical care causes a bad outcome.
    • Rigorous defense of the staff and hospital when treatment and management met the standard of care or did not cause an injury.
    • A focus on learning from mistakes and the patient experience.

    In the first year of the program, dramatic improvement was seen. Of the seven cases that went to trial, the hospital won all but one case, and that case was settled for a smaller sum than anticipated. The system saved $2.2 million in the first year!

    Next month: Talking the talk: What to say when bad things happen.

    Comments about this article? Write to EMN at[email protected].

    Part 1 in a Two-Part Series

    Dr. Welch
    Dr. Welch:
    is a fellow with Intermountain Institute for Health Care Delivery Research, an emergency physician with Utah Emergency Physicians, and a member of the board of the Emergency Department Benchmarking Alliance. She has written two books on ED operational improvement; the latest, Quality Matters: Solutions for the Efficient ED, is available from Joint Commission Resources Publishing.
    © 2011 Lippincott Williams & Wilkins, Inc.