It’s time to apologise
BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h4695 (Published 02 September 2015) Cite this as: BMJ 2015;351:h4695
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To The Editor
We read with great interest the editor’s choice “It’s time to apologize” by Dr. Fiona Godlee.
Disclosure of medical errors and apology is an important issue in healthcare, yet physicians are still struggling to conceptualize this issue. When things go wrong during a medical procedure, patients' expectations are fairly straightforward: They expect an explanation of what happened, an apology if an error was made, and assurance that something will be done to prevent its recurrence with another patient.1
In the aftermath of an adverse event, an apology can decrease blame and anger, increase trust, bring comfort to the patient, forgiveness to the doctor, and help restore trust to their relationship. An appropriate apology may prevent the problem escalating into a complaint and decrease the likelihood of a medical malpractice lawsuit. Yet, for many doctors saying "I'm sorry" remains a difficult and uncomfortable thing to do.2, 3
A distinction should be made between apologies and expressions of consolation. When a patient experiences an unfortunate outcome that is not the result of health care provider error, it is appropriate to offer consoling comments, such as “I am sorry for what happened.” An apology, on the other hand, is necessary when the provider has harmed the patient physically or psychologically through a behavior that could or should have been avoided.4 The reaction of the patient and/ or his family to the apology may differ according to the culture and social status of the patients.
Physicians are subject to guilt, grief and shame, when their actions harm others, even if the fault is unclear. These feelings, combined with the fear of litigation that pervades medicine, may form a barrier in the proper communication with patients and their families after a medical error.
Since statements of sympathy and regret can be used to prove legal liability in medical malpractice cases, lawyers routinely advise doctors against apologizing and against being open about what happened.5 Physicians who admit errors may face the discredit of their peers, the anger and disappointment of their patients and their families, legal involvement, and financial loss. Saying I'm sorry, from a legal perspective (according to different laws), may be considered an admission and hence may lead to the loss of malpractice insurance coverage. A law that precludes an apology from admission in a malpractice case can help resolve the problem. Regulations that prohibit insurance companies from using an apology to avoid coverage or increase premiums would also encourage honesty and openness.6,7
Other barriers might include the culture of medicine and the inherent psychological difficulties in facing one’s mistakes and apologizing for them. Despite these barriers, incorporating apology into conversations between physicians and patients can address the needs of both parties and can play a role in the effective resolution of disputes related to medical error.2Several institutions have now had positive experiences with policies that involve disclosing and apologizing for medical errors. Programs of disclosure and apology at the Lexington (Kentucky) Veterans Hospital, the University of Michigan Health System, and Johns Hopkins, among others, have resulted in significant reductions in legal expenses.4 Future research and regulations will dictate physician decisions about when and how to apologize.
Hassan Chamsi-Pasha, FRCP, FACC. Cardiac department, King Fahd Armed Forces Hospital, Jeddah, Saudi-Arabia. (drhcpasha@hotmail.com)
Abdullah Hanoun, MD, MRCS. Orthopedic department , Yeovil District Hospital,Yeovil.BA21 4AT (abdullah.hanoun@YDH.NHS.UK)
Mohammed Ali Albar, MD, FRCP. Medical ethics department, International Medical center, Jeddah, Saudi-Arabia.
References
1. Leape LL. Apology for errors: whose responsibility? Front Health Serv Manage. 2012 Spring; 28(3):3-12.
2. Robbennolt JK. Apologies and medical error. Clin Orthop Relat Res. 2009; 467(2):376-82.
3. Bismark MM.The power of apology. N Z Med J. 2009; 122(1304):96-106.
4. Nicole G; GARC, Government Affairs and Reimbursement Committee of the AAPA
Apologizing for adverse outcomes. JAAPA. 2007; 20(9):47-8.
5. Frenkel DN, Liebman CB .Words that heal. Ann Intern Med. 2004; 140(6):482-3.
6. Kern SI. It's still not safe to say 'I'm sorry'. Med Econ. 2009; 86(1):40.
7. Al-Bar MA, Chamsi-Pasha H. Contemporary Bioethics: Islamic Perspective. Springer.2015.(Open access),http://link.springer.com/book/10.1007/978-3-319-18428-9
Competing interests: No competing interests
Blame is a one-way street, in which we blame others, but not ourselves. But if we are honest with ourselves, we realize that right and wrong, and good and bad, are a two-way street. So let’s have more balanced, honest conversations with ourselves and others, and stop our sanctimonious pretense, because it's a dead-end street that goes nowhere.
Competing interests: No competing interests
Re: It’s time to apologise
I hate the lazy assumption in your first paragraph that the overthrow of Saddam Hussein needs to be apologised for. He invaded two neighbouring countries and killed about four million people. Of course there are still terrible things happening there, but it is by no means certain that they would be any better if Saddam Hussein and his sons were still in charge. Stick to medicine and avoid joining the "herd of independent minds."
Competing interests: No competing interests