The financial and personal ramifications of a doctor apologizing to a patient.

The financial and personal ramifications of a doctor apologizing to a patient.

The financial and personal ramifications of a doctor apologizing to a patient.

Health and medicine explained.
Nov. 6 2009 7:15 AM

It's So Hard To Say I'm Sorry

The financial and personal ramifications that come when a doctor apologizes to a patient.

Doctor. Click image to expand.
Doctors sometimes have to say sorry

When you're a doctor, you sometimes have to come to terms with making a mistake: giving a patient the wrong diagnosis or the wrong treatment, causing an injury, or perhaps something worse.

In one case I still think about, Andy (I've changed his name to protect his privacy) was a healthy teenager with migraines. "Take 600 milligrams of ibuprofen to start, and if that doesn't work, I'll prescribe something else," I told him. But in the month that followed, Andy's headaches grew worse.

I found nothing abnormal when I examined him. When I reviewed his records, I noted that he was taking anxiety medication prescribed by a psychiatrist. Perhaps that could be causing his symptoms, I thought, so I referred him back to psychiatry and to a neurologist before sending him home.

The next morning, I received a message from the emergency room. After his appointment, Andy had had a seizure in a store. In the emergency room, a doctor noticed something important when he looked at Andy's eyes with an ophthalmoscope: swelling of the optic disc, located in the back of the eye. Papilledema, as it is called, is a cardinal sign of increased pressure inside of the head. Had I seen it, I would have done exactly what the E.R. doctor did—ordered a stat CT scan, which revealed that Andy had deposits of fluid in his brain. Had it worsened, the pressure could have caused Andy's brain to herniate down into his spinal cord, which may have killed him. When I had examined Andy's eyes the same way, I missed the papilledema.

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There are at least 25 definitions of the word error in medical literature. But the regret, fear, shame, and self-loathing I felt were all the definition I needed. How could I have done this?

Depending on what estimate you choose to go by, medical errors kill as many as 100,000 people each year. Doctors, nurses, and other health care providers make many more nonlethal mistakes. Studies tell us that patients—understandably—want to know when a mistake has been made with their health, and several professional organizations, including the American Medical Association, say doctors should disclose screw-ups. Nevertheless, there is a long-standing culture of concealment in medicine. While outside observers often attribute it to our fear of being sued, there's something more: Doctors don't like to admit they are fallible—it cracks our visage of authority.

In recent years, however, there has been a shift toward full disclosure—even toward apologizing for our mistakes. Despite physicians' resistance, this change has helped regain our patients' trust and prevented malpractice suits.

We didn't start disclosing and apologizing out of the goodness of our hearts. Like most changes in medicine, a series of events had to nudge us along. First came the Institute of Medicine's 1999 report "To Err Is Human," which contained that oft-cited statistic of 100,000 deaths and lifted the veil from our culture of concealment (although more than a few people dispute that number). In 2001, the Joint Commission, an organization that accredits hospitals—the medical equivalent of the Good Housekeeping seal for consumer products—mandated that hospitals disclose unanticipated medical outcomes. States entered the debate, too, when they began trying to encourage transparency by passing "apology laws," some of which make a statement admitting fault inadmissible in court, though these laws do not make a physician immune to a malpractice suit. Today, 35 states have laws protecting doctors' apologies and statements of regret.

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Apologies have had a positive impact on doctors, patients, and hospitals. In 2001, the University of Michigan Health System adopted a policy for handling medical errors that centered on the principle of disclosure and apology. After one year, the hospital saved $2.2 million in malpractice claims, and the savings have continued. (The University of Michigan's emphasis on disclosure and apology is just one part of its policy. It also quickly compensates patients for any harm done, which has probably saved money by cutting legal expenses.)

Literature suggests that a simple apology won't keep a wronged patient from turning to a lawyer—just look at this study from September. Dr. Albert Wu of Johns Hopkins and his colleagues showed 200 volunteers randomly selected videos simulating doctors disclosing an error to a patient. Wu and his team varied the extent of the apology (full, nonspecific, none at all) and acceptance of responsibility (full, none). Patients responded more favorably to physicians who apologized and took responsibility for a mistake. But even subjects whose scenarios came with a full apology and disclosure didn't reconsider their desire to seek legal advice.

But there may be other reasons why apologies work, ones researchers haven't considered yet. To better understand this, we need to look outside of medicine. In a study published in 2004, professor Peter Kim of USC and his colleagues showed that for so-called errors of competence, apologizing helped to restore trust. They're the kind of mistakes doctors make most frequently—while performing surgery, for example, or, like me, missing an important finding on a physical exam. Kim believes that people may be willing to forgive competence errors because they see them as an anomaly; those who make that kind of mistake are willing to try harder to avoid repeating it in the future.

Then there's the one factor that's very difficult to reproduce in any study: the heat of the moment. The emotions doctors and patients may experience during a crucial conversation about an error are difficult to replicate in a study. In Wu's work, researchers didn't vary the degree of empathy or other emotions expressed by the fictitious doctors.

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I didn't know any of these things about disclosure or apologies when I was taking care of Andy. I just knew that I had to make amends. Soon after Andy recovered, I called his mother. I could hear the resentment in her voice when she picked up the phone. I swallowed hard and told her what she had already figured out—that I had missed the swelling in Andy's eye. I said how sorry I was for what had happened and for my mistake. Most of all, I told her, I was sorry for putting Andy through any pain. After what happened, I spent a great deal of time reviewing photographs of papilledema and checked the eyes of every patient I could to make sure I knew what a normal optic disc was supposed to look like. I had no intention of making this mistake again.

The resentment in her tone soon dissolved. She thanked me for my honesty and told me she wanted to move forward in the best way possible for her son. I told her if that meant she wanted Andy to have another doctor, I would be happy to recommend some physicians. It was one of the most emotional and overwhelming conversations of my life, but I felt relieved (and exhausted) when I hung up.

A few weeks later, I found Andy and his mom in my exam room. I was still their doctor, they told me. I thanked them for their confidence in me, and we moved on to the business at hand.

I'd like to think that becoming less of a doctor and more of a person by expressing my heartfelt regret was a big part of regaining their trust. But given Albert Wu's findings and the fact that nobody offered to compensate Andy and his family, I'm not sure. The odds certainly were also in my favor: Even when patients are harmed, most of them—apology or not—don't seek redress.

So maybe I just got lucky. But Andy and his family were the luckiest of all—despite my mistake, he's still alive.