Doctor-Patient Bond Frays After Medical Mistake

WEDNESDAY Oct. 24, 2007 -- Serious medical errors don't just affect the health of the patient, they can quickly destroy the patient's relationship with his or her doctor, too, experts say.

Too often, a health care mistake causes shame and fear in the physician responsible, leading to stilted, unsatisfying conversations with -- or avoidance of -- the affected patient, say the authors of an article in the Oct. 25 New England Journal of Medicine.

All of this can quickly move patient and doctor into an adversarial or litigious position.

But that's not always necessary, said one of the article's co-authors.

"Trust is an enormously important part of medicine -- if people aren't straight with you, you do not trust them," said Dr. Tom DelBanco, a professor of general medicine and primary care at Harvard Medical School.

"So, being upfront and honest, indicating that you want to do something about what happened, makes all the difference in the world," said Delbanco, who co-wrote the article with Harvard colleague Dr. Sigall Bell.

In many cases, doctors who frankly admitted their mistake and told patients how they would safeguard against future errors avoided litigation by doing so, Delbanco said. Those doctors also maintained strong, long-lasting bonds with the patient and the patient's family.

According to Delbanco, several patients interviewed for the article (and a related film) said that, " 'We don't expect you to be perfect, everybody makes mistakes. We just want you to be honest when it happens. We can deal with that.' "

In fact, "There are now some malpractice [insurance] companies that teach doctors to be honest and open," Delbanco noted. "There is slowly growing evidence that it may actually prevent lawsuits."

Medical errors have gotten a lot more attention recently, ever since the U.S. Institute of Medicine issued its 1999 report, To Err is Human. That report estimated that the deaths of more than 100,000 Americans each year are tied to some form of medical mistake.

In the wake of such errors, doctors often feel shame and guilt, as well as fear linked to the looming threat of lawsuits. For legal reasons, "I think that doctors are very confused about what they can and cannot say" to patients after an error comes to light, Delbanco said. That includes the use of simple words such as "mistake," "error," or even "I'm sorry."

"It depends on their institutions' views, it depends on the lawyers that they may or may not talk to," Delbanco said. "Very often, they are not only confused, but depressed, because they feel like they cannot say what they really feel like saying."

People who care deeply for a patient affected by a medical mistake often shoulder their own level of guilt after the incident. "Family members, in particular, can feel extraordinary guilt," Delbanco said, and often berate themselves, thinking, " 'If I had done this, this wouldn't have happened,' 'If I had been there, I would have prevented it,' 'If only I had been more forceful, the doctor wouldn't have done this.' "

Such was the case for those close to a young man with sickle cell anemia, mentioned in the NEJM article. The unnamed patient received morphine while in the hospital -- despite a well-documented allergy to the painkiller. He slipped into kidney failure and coma soon after, and his sister said she felt as if she "failed her family in terms of 'I should have been there.' That's a guilt that everyone shares."

Doctors who acknowledge that a mistake has happened, and outline steps to prevent such mistakes going forward, can ease a lot of distress for themselves and the patient, experts say.

But, in many cases, physicians have "a lack of confidence in their communication skills -- they just aren't sure how to have these conversations," said Dr. Thomas Gallagher, associate professor of medicine at the University of Washington School of Medicine, in Seattle.

Gallagher said Delbanco's and Bell's article echoes the findings of studies he has led, which revealed profound differences in the ways doctors and patients communicated after a serious medical error.

But he also believes the landscape around medical errors is changing. Already, about 30 states have enacted so-called "I'm sorry" laws, which, to a certain degree, make a doctor's apology for an error inadmissible in a court of law.

That should help ease patient-doctor conversations. But Gallagher said many of these laws still "provide very little protection for clinicians. They allow you to say 'I'm sorry,' but they don't allow you to make any expression that a mistake happened or to admit liability."

And, he said, it's not entirely clear that admitting to mistakes always wards off a lawsuit. "It's not a magic bullet," Gallagher said. "There will clearly be some cases where disclosure is what precipitates a lawsuit."

So, work remains to be done in finding strategies that allow patients and doctors to remain close even after a mistake occurs.

For his part, Delbanco said he is currently screening his film for third-year students at Harvard Medical School -- at the request of the school's dean -- to help them become better physicians. "Traditionally, there's been little coaching in this area," he said. "That's changing."

His advice to patients: If a serious medical error occurs, "be very aggressive in asking for communication. Patients should not be afraid of opening their mouths." And if that communication is not forthcoming, "Ask why and with whom can they speak?" he said.

And a hasty "I'm sorry" from a physician may not always be adequate, Delbanco added.

"Apology only means something when you show what you are going to do for that person -- and for the next person," he said. "Otherwise, they are just words."

More information

There's more on preventing medical errors at the U.S. Agency for Healthcare Research and Quality.

Posted: October 2007


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