“I think you have to be forthright with the patient to help them. And how you word it makes a big difference.”
This quote, from a physician, reflects the challenges physicians face when deciding what to tell patients about medical errors. Researchers who conducted a series of focus groups with doctors and patients say that patients want to be fully informed when an error happens, and believe such disclosure would increase their trust in their doctor. Yet while doctors want to be truthful, a variety of barriers may prevent physicians from disclosing errors to patients.
The findings are being published in the Feb. 26 issue of the Journal of the American Medical Association.
“Patients want far more information than we are providing — and they want and expect an apology. Yet doctors don’t seem to be providing patients with this desired information about medical errors,” said Dr. Thomas Gallagher, the lead author of the paper. “Doctors should realize that there is a gap between what they tell patients after a medical error, and the information and emotional support that a patient expects from the doctor.”
Gallagher, who did the work while at Washington University School of Medicine in St. Louis, is an assistant professor of medicine in the Division of General Internal Medicine at the University of Washington in Seattle.
To get an in-depth view of what patients and doctors think about medical errors, researchers gathered 52 patients and 46 physicians from the St. Louis area into 13 focus groups. Six groups were patients only; four groups were physicians only; and three groups included both doctors and patients.
Other authors of the paper include Dr. Wendy Levinson of St. Michael?s Hospital and the University of Toronto; and Alison Ebers and Drs. Victoria Fraser and Amy Waterman of Washington University in St. Louis.
Patients said they wanted to know if there had been an error, how the error happened, and particularly what the doctor and institution would be doing to prevent the error from happening again. And they would like an apology. Patients were concerned, however, that physicians might hide errors from patients.
“Washington University and BJC Healthcare are committed to full disclosure and honesty with patients and families about errors and adverse events,” said Dr. Victoria Fraser, professor of medicine at Washington University School of Medicine in St. Louis. “We also are training health care workers in how to discuss adverse outcomes because we believe it will enhance patient care.”
A variety of barriers limited what doctors said they would tell patients about errors. “These doctors clearly worried that fully disclosing an error would make a lawsuit more likely,” noted Levinson. “Many doctors were also concerned that telling patients about an error might harm the patient or lower their trust in their doctor. In addition, some physicians saw errors as personal failures, which made them embarrassed to disclose the error to the patient. Furthermore, few doctors have had formal training in how to conduct these difficult conversations.”
As a result, doctors will often reveal only minimal information about errors, not explicitly saying that an error occurred and how recurrences would be prevented. Yet the feeling that information about the error was being hidden from them would make patients even more upset about what happened. Doctors also hesitated to apologize.
“From a patient’s perspective, not getting an apology meant that the doctor did not recognize how upsetting the error was to the patient,” Gallagher said. “Doctors were really worried — they said they wanted to apologize as one person to another, but they feared it would create additional legal liability.”
Hospitals and other health-care organizations sometimes send a mixed message to doctors with their policies regarding medical errors, Gallagher said: “They say, “You should disclose the error, but do not say anything that would imply blame.” Hospitals should consider revising policies to encourage doctors to supply the information that patients want.” In addition, hospitals should consider how to better support the upset emotions of health-care workers involved in errors.
“Forgiveness is something that I think is tougher for the physicians to give themselves than to get from a patient.”
During focus groups that involved both doctors and patients, patients reported being astonished at how deeply doctors regretted and thought about errors that happened many years ago. “One doctor was in tears about an error that happened 10 years ago,” Gallagher said. “Patients were flabbergasted. They had no idea doctors were so upset, and so worried, about errors. If the institutions can help health-care providers cope with their upset feelings, these providers can do a better job of responding to the patient who experienced the error.”
The authors recommend that when a harmful error happens, physicians at a minimum should tell the patient what the error was, why the error happened, how recurrences will be prevented, and apologize. Institutions should strive to create a blame-free culture where health-care workers can discuss errors more openly. In addition, institutions should ensure their policies encourage error disclosure, as well as provide physicians with greater training and support in meeting patients’ needs following medical errors.