Acknowledgment of medical errors and the disclosure of the adverse events to patients has changed significantly over time. Over the past 40 years, such admissions have evolved from a topic that was rarely acknowledged in healthcare to one where identification and management are central to the ongoing safe provision of care.
Although there was a time when patients were not told about a medical error, the expectation among patients now is that their physicians will be honest with them about information relevant to their care. This is related to a change in the culture of medicine, spurred by the publication of an influential 1999 Institute of Medicine report, To Err is Human, which helped to usher in greater attention and commitment to patient safety. This report also helped to put medical errors in a broader context, by replacing the outdated and oversimplified model of the “bad apple” healthcare professional, with one of a complex health care system with multiple factors that can contribute to bad outcomes.
From an ethics perspective, disclosing adverse events to patients is predicated on the idea that physicians have obligations to tell the truth. Patients cannot be a partner in their care and physicians cannot engage in shared decision-making if patients do not have enough of their health information to make informed decisions. One of the roles of the disclosure process is to support the relationship in which it occurs. Truth telling is important because it helps to preserve the patient-physician relationship.
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When medical errors affect patients, the disclosure process will proceed more smoothly when there is an accompanying apology. An apology, as anyone who has been the recipient of one knows, can help patients feel heard, feel better, or maintain or even strengthen the relationship with their physician. This is because apologies can help patients feel cared for, validated, and respected.1 For patients who are also worried about a similar error befalling others, the apology can help assure them that others will not be similarly harmed in the future.
For good reasons, physicians have generally been squeamish about issuing an apology to a patient after an adverse event. Physicians may worry that providing an apology will lead to greater responsibility for liability or that admitting fault is humiliating. Numerous states have passed “inadmissibility laws” that encourage physicians to apologize to patients after a medical error and allow such admissions of fault to be inadmissible in malpractice suits. The effect of these laws on malpractice suits is still unclear, but the moral basis for these laws is that the apology has value in and of itself, beyond simply the disclosure of the error.2
The value and use of apologies can extend broadly beyond medical errors. In fact, apologies can be most effective in the challenges of daily practice. Apologies can be offered, for example, when a patient has had to wait to see a physician or when a misunderstanding leads to a delay in diagnosis. When physicians take the lead on these discussions, it can help to prevent more complicated and lengthy disagreements in the future. Patients who hold onto anger about feelings of mistreatment may manifest more significant overreactions to smaller offenses in the future.
Aaron Lazare, MD, was the foremost scholar on the role of apology in medical practice who helped to establish an enduring conceptual framework for describing, understanding, and analyzing apologies.3 He defined an apology as “an acknowledgement of responsibility for an offense coupled with an expression of remorse.” Beyond simply saying, “I’m sorry,” there are 3 critical components of an effective apology, and the lack of any one of these can lead to a “failed” apology, exacerbating the offense. The first element is a genuine acknowledgment and responsibility for the offense. The second is an expression of remorse, humility, or regret for the offense. The third is an attempt to provide reparations to help heal the relationship.
Some common pitfalls illustrate how apologies can go awry. Saying “I’m sorry for whatever I did,” or “mistakes were made” fails to address the first element, taking responsibility for the offense. Saying “I’m surprised this happened because I’m one of the most experienced and capable physicians in the hospital,” is not likely to address the second element: Failing to express remorse or humility can lead to an unsuccessful apology that exacerbates the original offense. Finally, saying “our hospital works very well, this was clearly an aberration,” doesn’t provide the needed plan for reparations that many patients expect after an adverse event.
A better approach designed to strengthen relationships will address all of the critical elements of apology directly and empathically. Here’s an example that can be used in everyday practice. “I see that you had to wait 80 minutes to see me this afternoon. I know having to wait is unpleasant. I’m sorry about the delay; for that I take full responsibility. There was a problem with our scheduling system that resulted in some patients waiting longer than they should have. I’ve already asked our office manager to look into the problem and identify a solution before the end of the week. Will you let me know if you have any feedback about this so I can pass it along to him? Now tell me how you are doing and how I can be helpful today.”
If you read that aloud, you see the entire apology took less than 15 seconds. Simply saying, “I’m sorry,” and leaving it at that may exacerbate tensions with patients, which can lead to more time-consuming problems in the future. The apology process takes just a short amount of time, and can have a potentially large payoff. Consider it an investment in the future.
David J. Alfandre MD, MSPH, is a healthcare ethicist for the National Center for Ethics in Health Care (NCEHC) at the Department of Veterans Affairs (VA) and an Associate Professor in the Department of Medicine and the Department of Population Health at the NYU School of Medicine in New York. The views expressed in this article are those of the author and do not necessarily reflect the position or policy of the NCEHC or the VA.
References
- Lazare A. Apology in medical practice: An emerging clinical skill. JAMA. 2006;296:1401–1404.
- Dresser R. The limits of apology laws. Hastings Cent Rep. 2008;38:6-7.
- Lazare A. On apology. Oxford University Press. 2004
