Guest post by Dr. Fiona MacDonald, Dr. Karine Levasseur and Dempsey Wilford
You’ve just undergone surgery. Somehow, a mistake was made. The result is that you were harmed when you expected to be healed.
Hurt, angry and scared, you look to your doctors and ask: “What now? What do you have to say?” And they are silent. .
Medical errors like this occur regularly. One report estimates that for every 18 hospitalizations in Canada, one patient will experience harm.
Yet, doctors are hesitant to apologize for medical mistakes. This occurs despite the fact that many jurisdictions in the U.S., Australia and the U.K. already have “apology legislation.” Here in Canada, nine of our 10 provinces and two territories have this legislation in place to allow doctors and other medical professionals to apologize to patients when things go wrong – without having this apology used as evidence of fault in court.
These laws are designed to transform relationships in medicine for the better by restoring trust between patients and clinicians.
Research shows that medical apologies help repair the relationship and sense of trust between patients and medical professionals.
So why is it so hard for your doctor to apologize?
Fear of litigation and loss of respect
To investigate the impacts and difficulties surrounding medical apology, we’ve conducted research on medical apologies over the last two years.(1)*
Most recently, we have interviewed a variety of stakeholders including patients, caregivers, physicians, psychologists, patient safety advocates, medical school administrators and healthcare administrators on their experiences with medical error and apology.
We heard from doctors and other medical professionals who wished to apologize, but were constrained by different social and professional factors.
Our preliminary results show that clinicians receive mixed messages on the topic of apology. Some messages are rooted in an understanding of the apology legislation and provide a supportive environment to allow an apology to the patient to occur.
But other messages are rooted in:
- fear of litigation
- loss of insurance coverage
- loss of respect
- a culture of perfectionism that starts in medical training
- a feeling of shame about harming a patient
As one senior medical professional said:
“Physicians are not designed to make mistakes. They see it as a horrific personal failure when they have made an error. So it is a huge trauma to physicians.”
An apology is healing
Our research shows that apologizing for medical errors is a crucially important step in healing — for patients, families and medical professionals.
Apologizing helps validate the harms experienced by patients, and helps doctors come to terms with their mistake and restore confidence in their practice.
One patient participant in our study said that an apology is healing and that in the trauma of a critical incident, people expect apologies:
“You do something wrong, you apologize.”
Apologizing involves empathizing with patients and maintaining the integrity of medical relationships. As one senior doctor said:
“From my point of view, the benefits of having apology legislation is (to) allow you to take a different perspective in (your) relationship with patients.
“If that relationship is honest and fulsome, it provides you with an opportunity to feel how the patient feels, or at least close to it.”
Forgiveness is not guaranteed
If there is no apology or a poor quality apology, this has a detrimental effect on the relationship between a patient, their family and the doctor, and also on the sense of trust the patient and family place in medical institutions.
The absence of an apology also leaves patients and families in a communicative vacuum and fails to recognize the ongoing harms and trauma resulting from error.
A poor quality apology can also be botched by failing to acknowledge the mistake or wrongdoing adequately, or at all. Such botched apologies include statements such as, “I am sorry you’re hurt” rather than, “I am sorry I did that to you.”
To be sure, apologies are not a cure-all for harms resulting from a medical error, and forgiveness cannot be guaranteed. Litigation and medical apology are also not mutually exclusive. While an apology is given, litigation may still be needed — especially if the medical error resulted in an inability to work or death.
Apology legislation can contribute to the transformation of health care to become less about anger and the pursuit of lawsuits, and more about empathy, forgiveness and the pursuit of understanding to overcome the culture in medicine of “sealed lips”, and to promote learning.
Accountability can be considered as “continuous improvement” through learning rather than blaming.
Silence after an error is profoundly detrimental.
When a meaningful apology is given after an error, it can promote healing, strengthen medical relationships and transform our understanding of care in medical spaces.
More work is needed to help medical professionals understand the protections of apology legislation and the benefits of apologizing.
In doing so, we can conquer the silence.
♥
Q: Have you ever received a medical apology?
See also:
♥ *Contact Dr. Fiona MacDonald directly if you have a medical apology experience you’d like to contribute to her ongoing research (read this post first to learn more:) The medical apology: have you ever received one?
Canadian Patient Safety Institute’s “Conquer The Silence” initiative
Mandatory reporting of diagnostic errors: “Not the right time?”
The science of safety – and your local hospital
A doctor’s perspective: 10 worst hospital design features
Swan image: Marcus L, Morguefile
♥
This article is republished from The Conversation under a Creative Commons license. Read the original article by Dempsey Wilford, University of Victoria; Dr. Fiona MacDonald, Associate Professor and Department Head, Political Science, University of The Fraser Valley; and Dr. Karine Levasseur, Associate Professor of Political Studies, University of Manitoba.
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NOTE FROM CAROLYN: I wrote much more about our doctor-patient communication in my book, “A Woman’s Guide to Living with Heart Disease” . You can ask for it at your local library or favourite bookshop, or order it online (paperback, hardcover or e-book) at Amazon, or order it directly from Johns Hopkins University Press (and use the code HTWN to save 20% off the list price).
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Heart Sisters 
I would be curious to know which Canadian province has opted out of Medical Apology legislation?
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Hi Mary Lou – my understanding is that Quebec is the only province left that does not yet have apology legislation in place.
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As Carolyn has already posted, Quebec has not implemented this kind of legislation.
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Thank you for the information about apology legislation …. I think that is a good beginning…
I don’t know if Colorado has apology legislation or not; I will need to look into that. I have had three major medical instances that involved:
1) Wrong diagnosis leading to dangerously delayed treatment
2) Post surgical complication of a paralyzed vocal cord that required an additional surgery to repair
3) A surgeon that did an inadequate heart surgery that caused me to go to Mayo Clinic to get the surgery redone.
Each time I wrote a heartfelt letter, not an angry letter, to the physician so they understood what happened, the mistake they made and how it had affected me. I did this, not expecting an apology, but because I did not want anyone else to suffer what I suffered because of their inadequate care or a mistake in judgement if I could do anything to prevent it.
Not one of them reached out to me to thank me for the letter or empathize or apologize or to see how I was doing recovering from their mistake.
In the back of my mind, I figured maybe they think if they admit what happened they will get sued. And the litigious culture we live in supports that….
I have seen doctors get sued for ridiculous things AND I have seen outrageous mistakes where I felt like telling a patient’s family they should get themselves a lawyer. This type of culture chips away at the humanity of healing. I feel that there is a joint problem of Doctors putting themselves up as perfect and patient’s expecting doctors to be perfect.
Life is not perfect, all human beings are imperfect. Medicine is an art and a practice and mistakes will be made. Some forgiveable, some not so forgiveable.
Training needs to start in Medical School, keeping our doctors deeply rooted in their humanity. Seeing their patients as human beings, body, mind and soul…. not “diseases” or “cases” or the “old lady in room 326”.
It is sooo easy…. think of each patient as your mother, sister, brother, child and how you would like them to be treated.
I gained closure with the medical mistakes made in my instance by writing letters. I am okay with not getting an apology from those three physicians.
However, THEY missed a huge opportunity to improve themselves as doctors and human beings by not responding.
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Hi Jill – I don’t know about the apology legislation in your state either (but interestingly, many studies suggest that while fear of legal liability is often listed as the main reason docs won’t apologize, it is NOT the most common reason actually experienced).
I think what needs to be stressed in each of your examples is that the only alternative to an apology that doctors prefer seems to be SILENCE. And that is often the worst possible response.
Patients like you know that something has gone wrong, as described in each of your scenarios. Your doctors knew that something went wrong, and they clearly knew that you knew it, too. Yet they respond with silence, as if they believe that this is all patients deserve. As this study suggests: “Silence after an error is profoundly detrimental.” I wish more clinicians believed that.
I too did not expect an official apology for being misdiagnosed with acid reflux and sent home from the ER in mid-heart attack. What I really want is mandatory reporting of diagnostic error, so that in my hospital, that ER doc would have had a standard workplace protocol in place to follow when I was ultimately correctly diagnosed and treated. Somebody in that hospital needed to know that this error had occurred, and that error also needed to be discussed at rounds, taught to med students, discussed by hospital ‘quality care’ admin so that we can all reduce the risk of more women being similarly misdiagnosed in the future!
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In the case of the inadequate heart repair, I also had a meeting with the Director of Cardiology for Kaiser Colorado and brought him a photo of all the diseased muscle that Mayo had to remove that the first surgeon left behind.
My understanding following that was they had a departmental meeting and Kaiser Colorado now refers all patients needing septal myectomy to a Center of Excellence like Mayo rather than to their local CV Surgeons.
Satisfying but non-the less SILENCE from the surgeon himself is disturbing.
Personally I will never let that surgeon touch me again and whenever I have a cardiac Cath done, I check to make sure he is not the surgeon on call during my procedure. He is a good technical surgeon for CABG or valve replacement….he just should not have been doing septal Myectomies……
But because he did not come forward and discuss what happened with me even when I made a gesture towards him …. I have totally lost respect for him as a human being, whether he is a good surgeon or not. The same with the other two doctors…. I have lost all respect for them.
You are right… that silence creates a dark chasm that gets wider and deeper over time.
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I am especially interested in your experience, Jill. It seems so hard for some people to acknowledge their limitations. Someone might be a perfectly good surgeon for many procedures, but should know when a patient will be better off under the care of someone else with more experience. Not only docs, but this is heartsisters. They should know when to refer. Did Kaiser send you to Mayo, or did you take the initiative?
I commend you for using your experience to improve outcomes for others.
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Legislating morality without changing the existing cultural context adds to injury. How do you think the medical culture can be changed to allow for physicians’ humanity and thus their errors?
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Such a good question, Dr. Anne. This issue isn’t about “legislating morality” (nobody is forcing any clinician to apologize); my understanding from this and other medical apology studies is that that apology legislation is just one step in addressing the longstanding excuse for not apologizing (legal liability in court), separate from the many known benefits to both parties of a sincere apology.
Culture is a far broader issue, but let me share this little story that happened in our local hospital just last month that gave me a lot of hope! Our cardiac social worker met one of the Emergency physicians she knew walking around the CCU corridor upstairs (which is admittedly a rare sighting). She asked him if he were looking for somebody, and he said he needed to talk to the patient he had sent home from the ER the day before. Apparently, she returned to the ER with worsening symptoms following his shift but this time, diagnosed appropriately with a heart attack. He had made a mistake in initially telling her this problem was “not her heart”.
He told the social worker, “I just want to find her and tell her how sorry I am…”
I was so moved when the cardiac social worker told me this story. Gives me great respect for that physician’s humanity. I hope that other doctors will come to view this kind of empathetic response to be as normal in medicine as it is in any other area of life.
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Hello Dr. Stohrer,
I am a retired ICU nurse and a patient of several specialty physicians….so I have been watching patient /doctor dynamics for almost 50 years. Although there are still patients that prefer the patriarchal or matriarchal physician that will pat them on the head and tell them not to worry, I believe that the model is changing.
As patients and physicians see themselves in a partnership each with mutual respect for each other and various responsibilities to bring to the relationship…. caring and compassion can blossom. Where there is true caring and compassion, fear is lessened in both parties and acceptance can occur….. even when mistakes are made.
As patients Google their disease, their doctors need to help them sort through information and become teachers. Flexibility for belief systems and cultures are essential …
One of the moments I remember the most with my Cardiologist is when I was only at my second appointment with him and he said “If you were my sister this is the path of treatment I would recommend.” We are all in the family of man … we just forget it sometimes. The training needs to begin in medical school and at the bedside with every physician who mentors new physician.
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