The hardest thing: admitting error

I was inspired by Daniel Sokol’s unequivocal tone and compassion in describing patients who have been denied the truth after suffering harm from medical error.

How uninspiring, then, to see that the only doctors replying to the article are preoccupied with chastising him for a lack of empathy towards the medical profession. The implication of Nassrally’s reference to these situations as “dilemmas” is that, although he supports the principle of disclosure, he accepts that other doctors may still regard themselves as legitimate arbiters. Vetrugno’s notion that consequences for cost of litigation should have an overriding bearing, is frankly disturbing.

Certain principles in medicine are so fundamental and sacred that it is grotesque to seek to temper them. Surely the right of a patient to be informed about an error that has caused them harm, is one of these? I interpret Sokol’s unequivocal stance as a reflection of this. I am grateful for his clarity of expression.

I wonder whether the direct pecuniary interest Mr Sokol as a barrister might have in saying that it is an ethical responsibility of doctors to advise patients to seek legal advice might be a conflict of interest that should have been declared? Does an ethicist have an ethical responsibility to declare interests, is there an ethicist's ethicist Mr Sokol could have sought advice from?

Giuseppe Vetrugno and Fabio De-Giorgio

Giuseppe Vetrugno, Medical Directorate, Catholic University of the Sacred Heart, Rome, Italy

Fabio De-Giorgio, Institute of Legal Medicine, Catholic University of the Sacred Heart, Rome, Italy

When reading D.K. Sokol’s (1) article, somehow one feels like falling into McTwisp’s burrow and emerging in Wonderland just in time to watch the delirious dance of the Mad Hatter after the slaying of the Jabberwock and the capture of the Red Queen (2).

Do you really want us to believe that, in these days where the medical profession is often the target of multi-million litigation claims, if we were to discuss our errors with a patient, he/she would be more inclined to justify our actions?

Yes, it is true, scientific publications are full of articles that talk about complications, adverse or anyway unintended effects of medical treatments. In the end, these are “errors”. However, their disclosure to the scientific community has the aim to encourage the advancement of knowledge, which is based also on the opportunity to learn from one’s own and other’s errors.

In other fields, instead, the need for maximum transparency seems to serve very different purposes. We are pressingly invited to sacrifice the right to a defense of the author of the “error” (the doctor) in the name of the sacred right of protection of the “victim” (the damaged patient), who seems entitled to everything. And so, while a common citizen may abstain from self-accusation even in front of a judge, in the case of a doctor citizen the same behavior is deemed as indecorous.

Where is the balance?

Swiss RE data show that in 2002, in the United States alone, the average medical liability indemnity payment to a claimant had been $ 1 million (3). And, in this scenario dominated by the Red Queen and by the dreaded Jabberwock, here bursts in the liberating proposal of Prof. Sokol, who plays the part of the next Alice in Wonderland: when we make an error, let’s tell everybody we have made an error.

Wonderful: a true godsend for those who will seek compensation from the insurance company that covers us and that, from that moment on, will decide to drop our coverage or to continue to cover us only if we will pay increasingly unsustainable premiums.

The case of a patient who sustained damage to her eye is reported (4) and the authors imply that the outcome would have been “dramatically” different had the case been managed differently in terms of communication.

Because ultimately this would be the magic word: communication.

The question is: can communication be the cure-all?

Indeed, the literature contains examples of failures of this kind of approach, albeit pursued for other purposes. We will just recall the experience of Roizen MF et al. (5), for whom “some patient will benefit from more and other from less detailed information”. On the other hand, the findings of the studies that focus on people’s desire to be informed or not are contradictory and provide no clear conclusion (6): therefore, a communication strategy based on transparency cannot be the solution to the problem.

Hence, we need to use other “magic words” that, when spoken one after the other, would have indeed a much more powerful effect in this situation than “Abracadabra”: “No-Fault Legislation or Compensation” (7).

It is a direct compensation system of medical iatrogenic damage where victims need not prove fault to receive compensation: the patient is quickly compensated and the doctor, liberated from the threat of a lawsuit, will feel freer to admit his/her mistakes.

It is no coincidence that most of the scientific contributions on this topic come from authors who are from countries where the “non-fault” system had been in place for a long time (New Zealand, Australia, Sweden, Norway, Denmark).

To err is human. Apparently, there is nothing magical in errors. Yet, because of an error, a remote ancestor of ours came down from the tree and, since then, many other “errors” have followed. This is the magic of errors, because by erring (which comes from the Latin verb “errare”, i.e. to wander - and wandering is the way we discover the world) we can make progress and move forward.

To criminalize errors or to pillory them in front of the patients (which is the same thing) in the context of doctor-client dynamics that have become distorted to such an extent means to take the magic out from the errors, that same magic that allowed us to get where we are today.

Instead, steering medical error toward the path of social acceptance, also through the adoption of automatic compensation systems, may be the first step towards doctors disclosing errors not under the fear of what their patients could claim, but instead driven by the desire to take another step toward the future together with them.

References
1. Sokol DK. The hardest thing: admitting error. BMJ 2012;344:e3085.
2. Carrol L. Alice's Adventures in Wonderland, 1865 and Through the Looking-Glass, and What Alice Found There, 1871.
3. http://www.swissre.com.
4. Wright J, Oppermans G. The disclosure of medical errors: a catalyst for litigation or the way forward for better patient management Wright J, Oppermans G. The disclosure of medical errors: a catalyst for litigation or the way forward for better patient management? AvMA Medical & Legal Journal 2008;15:193-6.
5. Roizen MF, Klock PA, Klafta J. How much do they really want to know? Preoperative patient interviews and the anesthesiologist. Anesth Analg. 1996 Mar;82(3):443-4.
6. Kain ZN, Wang SM, Caramico LA, Hofstadter M, Mayes LC. Parental desire for perioperative information and informed consent: a two-phase study. Anesth Analg. 1997 Feb;84(2):299-306.
7. Gaine W.J. No-fault compensation systems. BMJ 2003;326:997-998.