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Apologizing to a patient is the right thing to do,” says Michael S. Woods, MD, a general surgeon at St. Vincent’s Regional Medical Center in Santa Fe, N.M. “It is the respectful thing in any relationship in terms of trust whenever there is a violation, whether it is real or perceived.” Dr. Woods, the author of Healing Words: The Power of Apology in Medicine, teaches and consults with corporations around the country about apology as well as physician leadership.1-2 In fact, his study of apology stemmed from examining the subject of physician leadership, and he and other experts consider the vital components of leadership to be effective communication, integrity, honesty, and respectful treatment of other individuals.3,4
Dr. Woods also works with Doug Wojcieszak, a public relations consultant whose victims’ rights group proposed “Sorry Works!” This program recommends apologies and settlements when medical mistakes occur. (See “A History of Sorry Works!” p. 26.) Dr. Woods says Wojcieszak comes from an interesting angle that he supports. “Something I increasingly try to hammer home when I speak is that one of the most important components of the apology law has nothing to do with the backhand of the reduction of litigation as much as the fact that it gives the physician the green light to say ‘I’m sorry,’” says Dr. Woods.
The Benefit of Healing
Providers may be less than open when things go terribly wrong because of feelings of fear, shame, and guilt regarding the consequences to the patient as well as to themselves.1,3 Apology heals by restoring the patient’s dignity and self-respect, providing assurance of shared values, and assuring patients that they are not at fault, they are now safe, and that the caregiver shares their suffering.4,7
Two Senses of Apology
There are circumstances other than when errors occur in which a physician’s apology may carry the power to improve patient care. Peter Barnett, MD, MPH, a clinical associate professor of medicine at the University of New Mexico in Albuquerque, says that in general there are two senses of apology.
“The first sense of apology regards the situation,” he says. For example, you might say, ‘I’m sorry you have cancer,’ or ‘I’m sorry that our system doesn’t allow your family doctor to be taking care of you in the hospital.’ It’s an expression of sympathy, but I think apology works better.”
The other sense of apology regards responsibility, says Dr. Barnett, citing the example, “I’m sorry I gave you the wrong drug.”
Situational needs for apology include when patients have been waiting a long time, such as when a hospitalist meets them in the emergency department. “In those cases you would say, ‘I’m sorry that you had to wait so long,’” says Dr. Barnett. “It’s not my fault, but I really am sorry.”
Bridging the Gap
Dr. Barnett, who practices hospital medicine part-time along with his major focus in addiction medicine, was formerly the director of the UNM hospitalist team. He explains that one of the primary reasons hospitalists may need to apologize to patients is that the hospitalist and patient have no prior relationship that could serve as a foundation for interpreting each other’s behavior.8
He believes apologizing for the delays and inconveniences that happen in the hospital “can help bridge the relationship gap in hospital medicine. Because what people believe about their primary care physicians is that they know and care about them,” he says. “To minimize their anxiety about you, show them that you do care about them by getting to know them well, and apology is the one of the best ways of doing that.”
When asked to elaborate what he means by “getting to know them well,” Dr. Barnett says, “I might tell someone, ‘I’d like to get to know you better; what can you tell me about yourself that would help bring me up to speed?’” It’s open-ended, he says, and you let the patient choose the topic. “Most people will say something. … It’s empathic inquiry with really good reflective listening; that is probably the simplest way of summarizing what it takes.”
Dr. Barnett suggests this kind of inquiry can mitigate the gaps in relationships that may lead to misunderstandings, edgy situations, and errors that may later call for apology. He recommends asking or saying some of the following to patients:
- What do you know about your illness?
- What do you believe about your illness?
- What are your feelings, values, beliefs, and preferences about/for your treatment?
- What can you tell me about your experiences in the hospital?
For patients who have been ill many times and have had a lot of medical experience, you could ask:
- Could you tell me about your doctors?
- What do you like about doctors?
- What don’t you like about your doctors?
These questions can help you discern who they are as a patient, and it gives patients the opportunity to be candid with you.
“It’s not about finding information that’s embarrassing or critical to your predecessor physicians, but it allows you to not make the same mistakes inadvertently,” says Dr. Barnett, who considers it concrete information. “I want them to have good medical care. I don’t want to make them unhappy. I want to avoid pitfalls. I think the two of us—the patient and I—should avoid pitfalls together.”
Asking the patient in a straightforward way what they want and don’t want gives the patient an opportunity to give the physician advice on how to stay out of trouble with them.
Apology When Disclosing Errors
The matter of assuming responsibility for errors is more complicated as it pertains to the use of apology, but it is an “idea whose time has come.”9 Although it is hard to quantify, plenty of evidence shows that apologizing for errors reduces the number of lawsuits and may reduce the settlement value of malpractice claims.3,5-7,10-26 Although there is not always agreement about the specifics of full disclosure, above all patients have the right to know what happens during their medical care and, therefore, restricting the information that is given to a patient can have legal ramifications.
Beyond this, writes Lucian Leape, MD, adjunct professor of health policy at the Harvard School of Public Health and an internationally recognized leader in the patient safety movement, wrote in the March-April issue of Physician Executive that apology is a “therapeutic necessity” that allows the patient to recognize a physician’s humanity and fallibility as well as his or her remorse at having caused harm.9 In the long run, apologizing to patients defuses more situations than it aggravates, and it pays off emotionally, financially, and in practice morale.5,6,9
Data from studies of medical practices that issue apologies in circumstances where accountability is clearly established show that litigation claims are reduced. In one 1992 study, 24% of people who sued physicians said they did so because the doctor was dishonest and withheld information. Nineteen percent said that they either sued to deter subsequent malpractice or for revenge.11,12 In each case of legal action, the investigators hypothesized that the doctor could have avoided the lawsuit by taking responsibility and apologizing up front and making amends at that time. It has been estimated that more than half of claims relegated to litigation could be avoided with use of prudent disclosure and apology.3,21
“My mantra, if you will,” says Dr. Woods, “is that [when] you apologize because it’s the right thing to do, all the benefits naturally ensue.”
Anticipating Apology
The issue of complications, adverse events, and errors carries its own protocol in terms of whether and how apology is offered. “Hopefully some of these have been anticipated,” says Dr. Barnett. “For instance, when you spoke with the patient about their pneumonia, you’ve said something about the possibility that pneumonias could become complicated, and [they] might have some kind of complications; or if they’ve had a heart attack, [you mentioned that] they might have some complications. So you’re actually already warning people about what could happen and you’ve said you’re going to try to prevent it, but it could [still happen].”
Apology can be appropriately offered when those events do occur and you genuinely express disappointment that you and the patient share.
“There are some quite complicated systematic problems [related to apology and hospital medicine],” says Dr. Barnett. “Some are communication aspects and some are legal ones. What I have heard from the attorneys is that you want to keep the apology relatively simple, … and it shouldn’t include any statements about other people who may have been involved, such as pharmacy or nurses.”
The other important issue related to hospitalists and apology, says Dr. Barnett, is that because of the lack of relationship, the severity of illness of the patients you are treating, and the strangeness of systems, people come to the hospital expecting errors. They expect them and may be afraid of them. In particular, when a medication error is made, they expect those errors to be disclosed to them.7,27 Dr. Barnett believes patients are waiting and watching, and hoping that nothing happens to them. Complicating the issue, he says, is that “many hospitalists are fairly guarded in this respect. The emotional deck is sort of stacked against everybody, so if the hospitalist is sensitive about the situation, that tends actually to make the situation worse. If you can apologize sincerely and simply, the patient may be reassured that you’re not trying to conceal anything, you’re honest, you’re on top of it, and you’ll do your best to deal with it,” he says, adding, “they know that that stuff happens; they hope that it is not hidden, ignored, or mismanaged.”
Start Early and Let It Flow
Dr. Woods’ advice is to offer apology earlier rather than later and to widen the spectrum of those to whom you wish to show your empathy, sympathy, respect, and compassion.
“What I promote to organizations is that they drive this into the consciousness of the organization by getting people to apologize for the least infraction—not waiting for the grave errors.” He interprets this as apologizing “when you’re running 30 minutes late, apologize when you’ve interrupted the patient or the family when they’re speaking. These are the things we would do for our spouse or our significant other or our family members; why is it any different at work?”
He also believes it is inherent for doctors as leaders to “apologize to your staff members, apologize to the nurses.” Because the image you express serves as a role model in this regard and will permeate your practice culture. Drive respectful treatment as a basic common social courtesy into the organizational consciousness, says Dr. Woods, and then in any circumstance where an apology is offered, it is perceived as authentic.
Conclusion
Hospitalists may find a need to apologize to patients and families for situations and circumstances in the hospital environment as well as the gap in relationship that exists when hospitalists and patients first encounter each other. Apologizing early rather than later as well as simply and authentically goes a long way to help achieve the ethical and business objectives held by most hospital physicians. TH
Andrea Sattinger wrote about error reporting in the May issue.
References
- Woods MS, Star JI. Healing Words: The Power of Apology in Medicine. Santa Fe, N.M.: Doctors in Touch; 2004.
- Woods MS. Applying Personal Leadership Principles to Health Care: The DEPO Principle. Orlando, Fl.: American College of Physician Executives; 2001.
- Leape LL. National Patient Safety Foundation. Understanding the power of apology: how saying “I’m sorry" helps heal patients and caregivers. Focus on Patient Safety. 2005;8:1-3.
- Lazare A. On Apology. Oxford, U.K.: Oxford University Press; 2004.
- Boothman RC. Apologies and a strong defense at the University of Michigan Health System. Physician Exec. 2006 Mar-Apr; 32(2):7-10.
- Weber DO. Who’s sorry now? Special report: patient trust and safety. Physician Exec. 2006 Mar-Apr:32(2)6-14.
- When Things Go Wrong: Responding to Adverse Events. A Consensus Statement of the Harvard Hospitals. Burlington, Massachusetts: Massachusetts Coalition for the Prevention of Medical Errors; 2006.
- Barnett PB. Rapport and the hospitalist. Am J Med. 2001;111:31S-35S.
- Leape LL. Full disclosure and apology—an idea whose time has come. Physician Exec. Mar-Apr 2006 32:16-18.
- Beckman HB, Markakis KM, Suchman AL, et al. The doctor-patient relationship and malpractice. Lessons from plaintiff depositions. Arch Intern Med. Jun 27 1994;154(12):1365-1370.
- Cohen JR. Apology and organizations: Exploring an example from medical practice. Fordham Urban Law J. 2000;27(5):1447-1482.
- Cohen JR. Advising clients to apologize. South Calif Law Rev. 1999;72:1009-1069.
- Entman SS, Glass CA, Hickson GB, et al. The relationship between malpractice claims history and subsequent obstetric care. JAMA. 1994 Nov 23-30;272(20):1588-1591.
- Gesensway D. Hospitalists and the malpractice insurance crisis. The Hospitalist. 2002Jul/Aug;11-13.
- Levinson W, Roter D, Mullooly JP, et al. Physician-patient communication: the relationship with malpractice claims among primary care physicians and surgeons. JAMA. 1997 Feb19;227(7):553-559.
- Lo B. Ethical and policy implications of hospitalist systems. Dis Mon. 2002 Apr;48(4):281-290.
- Mello MM, Studdert DM, Brennan TA. The new medical malpractice crisis. New Engl J Med. 2003 Jun 5;348(23):2281-2284.
- Shapiro RS, Simpson DE, Lawrence SL, et al. A survey of sued and nonsued physicians and suing patients. Arch Intern Med. 1989 Oct;149(10):2190-2196.
- Zimmerman R. Doctors' new tool to fight lawsuits: saying 'I'm sorry.' Malpractice insurers find owning up to errors soothes patient anger. 'The risks are extraordinary.' J Okla State Med Assoc. 2004 Jun;97(6):245-247.
- Ambady N, LaPlante D, Nguyen T, et al. Surgeons' tone of voice: a clue to malpractice history. Surgery. 2002 Jul;132(1):5-9.
- Wu AW. Handling hospital errors: is disclosure the best defense? Ann Intern Med. 1999 Dec 21;131(12):970-972.
- Localio AR, Lawthers AG, Brennan TA, et al. Relation between malpractice claims and adverse events due to negligence. Results of the Harvard Medical Practice Study III. N Engl J Med. 1991 Jul 25;325(4):245-251.
- Brennan TA, Sox CM, Burstin HR. Relation between negligent adverse events and the outcomes of medical-malpractice litigation. N Engl J Med. 1996 Dec;335(26):1963-1967.
- Hickson GB, Federspiel CF, Pichert JW, et al. Patient complaints and malpractice risk. JAMA. 2002 Jun 12;287(22):2951-1957.
- Stelfox HT, Gandhi TK, Orav EJ, et al. The relation of patient satisfaction with complaints against physicians and malpractice lawsuits. Am J Med. 2005 Oct;118(10):1126-1133.
- Pham HH, Devers KJ, Kuo S, et al. Health care market trends and the evolution of hospitalist use and roles. J Gen Intern Med. 2005 Feb;20(2):101-107.
- Harris Interactive(R). Telephone survey conducted for the American Academy on Physician and Patient, March 3-6, 2006.
Apologizing to a patient is the right thing to do,” says Michael S. Woods, MD, a general surgeon at St. Vincent’s Regional Medical Center in Santa Fe, N.M. “It is the respectful thing in any relationship in terms of trust whenever there is a violation, whether it is real or perceived.” Dr. Woods, the author of Healing Words: The Power of Apology in Medicine, teaches and consults with corporations around the country about apology as well as physician leadership.1-2 In fact, his study of apology stemmed from examining the subject of physician leadership, and he and other experts consider the vital components of leadership to be effective communication, integrity, honesty, and respectful treatment of other individuals.3,4
Dr. Woods also works with Doug Wojcieszak, a public relations consultant whose victims’ rights group proposed “Sorry Works!” This program recommends apologies and settlements when medical mistakes occur. (See “A History of Sorry Works!” p. 26.) Dr. Woods says Wojcieszak comes from an interesting angle that he supports. “Something I increasingly try to hammer home when I speak is that one of the most important components of the apology law has nothing to do with the backhand of the reduction of litigation as much as the fact that it gives the physician the green light to say ‘I’m sorry,’” says Dr. Woods.
The Benefit of Healing
Providers may be less than open when things go terribly wrong because of feelings of fear, shame, and guilt regarding the consequences to the patient as well as to themselves.1,3 Apology heals by restoring the patient’s dignity and self-respect, providing assurance of shared values, and assuring patients that they are not at fault, they are now safe, and that the caregiver shares their suffering.4,7
Two Senses of Apology
There are circumstances other than when errors occur in which a physician’s apology may carry the power to improve patient care. Peter Barnett, MD, MPH, a clinical associate professor of medicine at the University of New Mexico in Albuquerque, says that in general there are two senses of apology.
“The first sense of apology regards the situation,” he says. For example, you might say, ‘I’m sorry you have cancer,’ or ‘I’m sorry that our system doesn’t allow your family doctor to be taking care of you in the hospital.’ It’s an expression of sympathy, but I think apology works better.”
The other sense of apology regards responsibility, says Dr. Barnett, citing the example, “I’m sorry I gave you the wrong drug.”
Situational needs for apology include when patients have been waiting a long time, such as when a hospitalist meets them in the emergency department. “In those cases you would say, ‘I’m sorry that you had to wait so long,’” says Dr. Barnett. “It’s not my fault, but I really am sorry.”
Bridging the Gap
Dr. Barnett, who practices hospital medicine part-time along with his major focus in addiction medicine, was formerly the director of the UNM hospitalist team. He explains that one of the primary reasons hospitalists may need to apologize to patients is that the hospitalist and patient have no prior relationship that could serve as a foundation for interpreting each other’s behavior.8
He believes apologizing for the delays and inconveniences that happen in the hospital “can help bridge the relationship gap in hospital medicine. Because what people believe about their primary care physicians is that they know and care about them,” he says. “To minimize their anxiety about you, show them that you do care about them by getting to know them well, and apology is the one of the best ways of doing that.”
When asked to elaborate what he means by “getting to know them well,” Dr. Barnett says, “I might tell someone, ‘I’d like to get to know you better; what can you tell me about yourself that would help bring me up to speed?’” It’s open-ended, he says, and you let the patient choose the topic. “Most people will say something. … It’s empathic inquiry with really good reflective listening; that is probably the simplest way of summarizing what it takes.”
Dr. Barnett suggests this kind of inquiry can mitigate the gaps in relationships that may lead to misunderstandings, edgy situations, and errors that may later call for apology. He recommends asking or saying some of the following to patients:
- What do you know about your illness?
- What do you believe about your illness?
- What are your feelings, values, beliefs, and preferences about/for your treatment?
- What can you tell me about your experiences in the hospital?
For patients who have been ill many times and have had a lot of medical experience, you could ask:
- Could you tell me about your doctors?
- What do you like about doctors?
- What don’t you like about your doctors?
These questions can help you discern who they are as a patient, and it gives patients the opportunity to be candid with you.
“It’s not about finding information that’s embarrassing or critical to your predecessor physicians, but it allows you to not make the same mistakes inadvertently,” says Dr. Barnett, who considers it concrete information. “I want them to have good medical care. I don’t want to make them unhappy. I want to avoid pitfalls. I think the two of us—the patient and I—should avoid pitfalls together.”
Asking the patient in a straightforward way what they want and don’t want gives the patient an opportunity to give the physician advice on how to stay out of trouble with them.
Apology When Disclosing Errors
The matter of assuming responsibility for errors is more complicated as it pertains to the use of apology, but it is an “idea whose time has come.”9 Although it is hard to quantify, plenty of evidence shows that apologizing for errors reduces the number of lawsuits and may reduce the settlement value of malpractice claims.3,5-7,10-26 Although there is not always agreement about the specifics of full disclosure, above all patients have the right to know what happens during their medical care and, therefore, restricting the information that is given to a patient can have legal ramifications.
Beyond this, writes Lucian Leape, MD, adjunct professor of health policy at the Harvard School of Public Health and an internationally recognized leader in the patient safety movement, wrote in the March-April issue of Physician Executive that apology is a “therapeutic necessity” that allows the patient to recognize a physician’s humanity and fallibility as well as his or her remorse at having caused harm.9 In the long run, apologizing to patients defuses more situations than it aggravates, and it pays off emotionally, financially, and in practice morale.5,6,9
Data from studies of medical practices that issue apologies in circumstances where accountability is clearly established show that litigation claims are reduced. In one 1992 study, 24% of people who sued physicians said they did so because the doctor was dishonest and withheld information. Nineteen percent said that they either sued to deter subsequent malpractice or for revenge.11,12 In each case of legal action, the investigators hypothesized that the doctor could have avoided the lawsuit by taking responsibility and apologizing up front and making amends at that time. It has been estimated that more than half of claims relegated to litigation could be avoided with use of prudent disclosure and apology.3,21
“My mantra, if you will,” says Dr. Woods, “is that [when] you apologize because it’s the right thing to do, all the benefits naturally ensue.”
Anticipating Apology
The issue of complications, adverse events, and errors carries its own protocol in terms of whether and how apology is offered. “Hopefully some of these have been anticipated,” says Dr. Barnett. “For instance, when you spoke with the patient about their pneumonia, you’ve said something about the possibility that pneumonias could become complicated, and [they] might have some kind of complications; or if they’ve had a heart attack, [you mentioned that] they might have some complications. So you’re actually already warning people about what could happen and you’ve said you’re going to try to prevent it, but it could [still happen].”
Apology can be appropriately offered when those events do occur and you genuinely express disappointment that you and the patient share.
“There are some quite complicated systematic problems [related to apology and hospital medicine],” says Dr. Barnett. “Some are communication aspects and some are legal ones. What I have heard from the attorneys is that you want to keep the apology relatively simple, … and it shouldn’t include any statements about other people who may have been involved, such as pharmacy or nurses.”
The other important issue related to hospitalists and apology, says Dr. Barnett, is that because of the lack of relationship, the severity of illness of the patients you are treating, and the strangeness of systems, people come to the hospital expecting errors. They expect them and may be afraid of them. In particular, when a medication error is made, they expect those errors to be disclosed to them.7,27 Dr. Barnett believes patients are waiting and watching, and hoping that nothing happens to them. Complicating the issue, he says, is that “many hospitalists are fairly guarded in this respect. The emotional deck is sort of stacked against everybody, so if the hospitalist is sensitive about the situation, that tends actually to make the situation worse. If you can apologize sincerely and simply, the patient may be reassured that you’re not trying to conceal anything, you’re honest, you’re on top of it, and you’ll do your best to deal with it,” he says, adding, “they know that that stuff happens; they hope that it is not hidden, ignored, or mismanaged.”
Start Early and Let It Flow
Dr. Woods’ advice is to offer apology earlier rather than later and to widen the spectrum of those to whom you wish to show your empathy, sympathy, respect, and compassion.
“What I promote to organizations is that they drive this into the consciousness of the organization by getting people to apologize for the least infraction—not waiting for the grave errors.” He interprets this as apologizing “when you’re running 30 minutes late, apologize when you’ve interrupted the patient or the family when they’re speaking. These are the things we would do for our spouse or our significant other or our family members; why is it any different at work?”
He also believes it is inherent for doctors as leaders to “apologize to your staff members, apologize to the nurses.” Because the image you express serves as a role model in this regard and will permeate your practice culture. Drive respectful treatment as a basic common social courtesy into the organizational consciousness, says Dr. Woods, and then in any circumstance where an apology is offered, it is perceived as authentic.
Conclusion
Hospitalists may find a need to apologize to patients and families for situations and circumstances in the hospital environment as well as the gap in relationship that exists when hospitalists and patients first encounter each other. Apologizing early rather than later as well as simply and authentically goes a long way to help achieve the ethical and business objectives held by most hospital physicians. TH
Andrea Sattinger wrote about error reporting in the May issue.
References
- Woods MS, Star JI. Healing Words: The Power of Apology in Medicine. Santa Fe, N.M.: Doctors in Touch; 2004.
- Woods MS. Applying Personal Leadership Principles to Health Care: The DEPO Principle. Orlando, Fl.: American College of Physician Executives; 2001.
- Leape LL. National Patient Safety Foundation. Understanding the power of apology: how saying “I’m sorry" helps heal patients and caregivers. Focus on Patient Safety. 2005;8:1-3.
- Lazare A. On Apology. Oxford, U.K.: Oxford University Press; 2004.
- Boothman RC. Apologies and a strong defense at the University of Michigan Health System. Physician Exec. 2006 Mar-Apr; 32(2):7-10.
- Weber DO. Who’s sorry now? Special report: patient trust and safety. Physician Exec. 2006 Mar-Apr:32(2)6-14.
- When Things Go Wrong: Responding to Adverse Events. A Consensus Statement of the Harvard Hospitals. Burlington, Massachusetts: Massachusetts Coalition for the Prevention of Medical Errors; 2006.
- Barnett PB. Rapport and the hospitalist. Am J Med. 2001;111:31S-35S.
- Leape LL. Full disclosure and apology—an idea whose time has come. Physician Exec. Mar-Apr 2006 32:16-18.
- Beckman HB, Markakis KM, Suchman AL, et al. The doctor-patient relationship and malpractice. Lessons from plaintiff depositions. Arch Intern Med. Jun 27 1994;154(12):1365-1370.
- Cohen JR. Apology and organizations: Exploring an example from medical practice. Fordham Urban Law J. 2000;27(5):1447-1482.
- Cohen JR. Advising clients to apologize. South Calif Law Rev. 1999;72:1009-1069.
- Entman SS, Glass CA, Hickson GB, et al. The relationship between malpractice claims history and subsequent obstetric care. JAMA. 1994 Nov 23-30;272(20):1588-1591.
- Gesensway D. Hospitalists and the malpractice insurance crisis. The Hospitalist. 2002Jul/Aug;11-13.
- Levinson W, Roter D, Mullooly JP, et al. Physician-patient communication: the relationship with malpractice claims among primary care physicians and surgeons. JAMA. 1997 Feb19;227(7):553-559.
- Lo B. Ethical and policy implications of hospitalist systems. Dis Mon. 2002 Apr;48(4):281-290.
- Mello MM, Studdert DM, Brennan TA. The new medical malpractice crisis. New Engl J Med. 2003 Jun 5;348(23):2281-2284.
- Shapiro RS, Simpson DE, Lawrence SL, et al. A survey of sued and nonsued physicians and suing patients. Arch Intern Med. 1989 Oct;149(10):2190-2196.
- Zimmerman R. Doctors' new tool to fight lawsuits: saying 'I'm sorry.' Malpractice insurers find owning up to errors soothes patient anger. 'The risks are extraordinary.' J Okla State Med Assoc. 2004 Jun;97(6):245-247.
- Ambady N, LaPlante D, Nguyen T, et al. Surgeons' tone of voice: a clue to malpractice history. Surgery. 2002 Jul;132(1):5-9.
- Wu AW. Handling hospital errors: is disclosure the best defense? Ann Intern Med. 1999 Dec 21;131(12):970-972.
- Localio AR, Lawthers AG, Brennan TA, et al. Relation between malpractice claims and adverse events due to negligence. Results of the Harvard Medical Practice Study III. N Engl J Med. 1991 Jul 25;325(4):245-251.
- Brennan TA, Sox CM, Burstin HR. Relation between negligent adverse events and the outcomes of medical-malpractice litigation. N Engl J Med. 1996 Dec;335(26):1963-1967.
- Hickson GB, Federspiel CF, Pichert JW, et al. Patient complaints and malpractice risk. JAMA. 2002 Jun 12;287(22):2951-1957.
- Stelfox HT, Gandhi TK, Orav EJ, et al. The relation of patient satisfaction with complaints against physicians and malpractice lawsuits. Am J Med. 2005 Oct;118(10):1126-1133.
- Pham HH, Devers KJ, Kuo S, et al. Health care market trends and the evolution of hospitalist use and roles. J Gen Intern Med. 2005 Feb;20(2):101-107.
- Harris Interactive(R). Telephone survey conducted for the American Academy on Physician and Patient, March 3-6, 2006.
Apologizing to a patient is the right thing to do,” says Michael S. Woods, MD, a general surgeon at St. Vincent’s Regional Medical Center in Santa Fe, N.M. “It is the respectful thing in any relationship in terms of trust whenever there is a violation, whether it is real or perceived.” Dr. Woods, the author of Healing Words: The Power of Apology in Medicine, teaches and consults with corporations around the country about apology as well as physician leadership.1-2 In fact, his study of apology stemmed from examining the subject of physician leadership, and he and other experts consider the vital components of leadership to be effective communication, integrity, honesty, and respectful treatment of other individuals.3,4
Dr. Woods also works with Doug Wojcieszak, a public relations consultant whose victims’ rights group proposed “Sorry Works!” This program recommends apologies and settlements when medical mistakes occur. (See “A History of Sorry Works!” p. 26.) Dr. Woods says Wojcieszak comes from an interesting angle that he supports. “Something I increasingly try to hammer home when I speak is that one of the most important components of the apology law has nothing to do with the backhand of the reduction of litigation as much as the fact that it gives the physician the green light to say ‘I’m sorry,’” says Dr. Woods.
The Benefit of Healing
Providers may be less than open when things go terribly wrong because of feelings of fear, shame, and guilt regarding the consequences to the patient as well as to themselves.1,3 Apology heals by restoring the patient’s dignity and self-respect, providing assurance of shared values, and assuring patients that they are not at fault, they are now safe, and that the caregiver shares their suffering.4,7
Two Senses of Apology
There are circumstances other than when errors occur in which a physician’s apology may carry the power to improve patient care. Peter Barnett, MD, MPH, a clinical associate professor of medicine at the University of New Mexico in Albuquerque, says that in general there are two senses of apology.
“The first sense of apology regards the situation,” he says. For example, you might say, ‘I’m sorry you have cancer,’ or ‘I’m sorry that our system doesn’t allow your family doctor to be taking care of you in the hospital.’ It’s an expression of sympathy, but I think apology works better.”
The other sense of apology regards responsibility, says Dr. Barnett, citing the example, “I’m sorry I gave you the wrong drug.”
Situational needs for apology include when patients have been waiting a long time, such as when a hospitalist meets them in the emergency department. “In those cases you would say, ‘I’m sorry that you had to wait so long,’” says Dr. Barnett. “It’s not my fault, but I really am sorry.”
Bridging the Gap
Dr. Barnett, who practices hospital medicine part-time along with his major focus in addiction medicine, was formerly the director of the UNM hospitalist team. He explains that one of the primary reasons hospitalists may need to apologize to patients is that the hospitalist and patient have no prior relationship that could serve as a foundation for interpreting each other’s behavior.8
He believes apologizing for the delays and inconveniences that happen in the hospital “can help bridge the relationship gap in hospital medicine. Because what people believe about their primary care physicians is that they know and care about them,” he says. “To minimize their anxiety about you, show them that you do care about them by getting to know them well, and apology is the one of the best ways of doing that.”
When asked to elaborate what he means by “getting to know them well,” Dr. Barnett says, “I might tell someone, ‘I’d like to get to know you better; what can you tell me about yourself that would help bring me up to speed?’” It’s open-ended, he says, and you let the patient choose the topic. “Most people will say something. … It’s empathic inquiry with really good reflective listening; that is probably the simplest way of summarizing what it takes.”
Dr. Barnett suggests this kind of inquiry can mitigate the gaps in relationships that may lead to misunderstandings, edgy situations, and errors that may later call for apology. He recommends asking or saying some of the following to patients:
- What do you know about your illness?
- What do you believe about your illness?
- What are your feelings, values, beliefs, and preferences about/for your treatment?
- What can you tell me about your experiences in the hospital?
For patients who have been ill many times and have had a lot of medical experience, you could ask:
- Could you tell me about your doctors?
- What do you like about doctors?
- What don’t you like about your doctors?
These questions can help you discern who they are as a patient, and it gives patients the opportunity to be candid with you.
“It’s not about finding information that’s embarrassing or critical to your predecessor physicians, but it allows you to not make the same mistakes inadvertently,” says Dr. Barnett, who considers it concrete information. “I want them to have good medical care. I don’t want to make them unhappy. I want to avoid pitfalls. I think the two of us—the patient and I—should avoid pitfalls together.”
Asking the patient in a straightforward way what they want and don’t want gives the patient an opportunity to give the physician advice on how to stay out of trouble with them.
Apology When Disclosing Errors
The matter of assuming responsibility for errors is more complicated as it pertains to the use of apology, but it is an “idea whose time has come.”9 Although it is hard to quantify, plenty of evidence shows that apologizing for errors reduces the number of lawsuits and may reduce the settlement value of malpractice claims.3,5-7,10-26 Although there is not always agreement about the specifics of full disclosure, above all patients have the right to know what happens during their medical care and, therefore, restricting the information that is given to a patient can have legal ramifications.
Beyond this, writes Lucian Leape, MD, adjunct professor of health policy at the Harvard School of Public Health and an internationally recognized leader in the patient safety movement, wrote in the March-April issue of Physician Executive that apology is a “therapeutic necessity” that allows the patient to recognize a physician’s humanity and fallibility as well as his or her remorse at having caused harm.9 In the long run, apologizing to patients defuses more situations than it aggravates, and it pays off emotionally, financially, and in practice morale.5,6,9
Data from studies of medical practices that issue apologies in circumstances where accountability is clearly established show that litigation claims are reduced. In one 1992 study, 24% of people who sued physicians said they did so because the doctor was dishonest and withheld information. Nineteen percent said that they either sued to deter subsequent malpractice or for revenge.11,12 In each case of legal action, the investigators hypothesized that the doctor could have avoided the lawsuit by taking responsibility and apologizing up front and making amends at that time. It has been estimated that more than half of claims relegated to litigation could be avoided with use of prudent disclosure and apology.3,21
“My mantra, if you will,” says Dr. Woods, “is that [when] you apologize because it’s the right thing to do, all the benefits naturally ensue.”
Anticipating Apology
The issue of complications, adverse events, and errors carries its own protocol in terms of whether and how apology is offered. “Hopefully some of these have been anticipated,” says Dr. Barnett. “For instance, when you spoke with the patient about their pneumonia, you’ve said something about the possibility that pneumonias could become complicated, and [they] might have some kind of complications; or if they’ve had a heart attack, [you mentioned that] they might have some complications. So you’re actually already warning people about what could happen and you’ve said you’re going to try to prevent it, but it could [still happen].”
Apology can be appropriately offered when those events do occur and you genuinely express disappointment that you and the patient share.
“There are some quite complicated systematic problems [related to apology and hospital medicine],” says Dr. Barnett. “Some are communication aspects and some are legal ones. What I have heard from the attorneys is that you want to keep the apology relatively simple, … and it shouldn’t include any statements about other people who may have been involved, such as pharmacy or nurses.”
The other important issue related to hospitalists and apology, says Dr. Barnett, is that because of the lack of relationship, the severity of illness of the patients you are treating, and the strangeness of systems, people come to the hospital expecting errors. They expect them and may be afraid of them. In particular, when a medication error is made, they expect those errors to be disclosed to them.7,27 Dr. Barnett believes patients are waiting and watching, and hoping that nothing happens to them. Complicating the issue, he says, is that “many hospitalists are fairly guarded in this respect. The emotional deck is sort of stacked against everybody, so if the hospitalist is sensitive about the situation, that tends actually to make the situation worse. If you can apologize sincerely and simply, the patient may be reassured that you’re not trying to conceal anything, you’re honest, you’re on top of it, and you’ll do your best to deal with it,” he says, adding, “they know that that stuff happens; they hope that it is not hidden, ignored, or mismanaged.”
Start Early and Let It Flow
Dr. Woods’ advice is to offer apology earlier rather than later and to widen the spectrum of those to whom you wish to show your empathy, sympathy, respect, and compassion.
“What I promote to organizations is that they drive this into the consciousness of the organization by getting people to apologize for the least infraction—not waiting for the grave errors.” He interprets this as apologizing “when you’re running 30 minutes late, apologize when you’ve interrupted the patient or the family when they’re speaking. These are the things we would do for our spouse or our significant other or our family members; why is it any different at work?”
He also believes it is inherent for doctors as leaders to “apologize to your staff members, apologize to the nurses.” Because the image you express serves as a role model in this regard and will permeate your practice culture. Drive respectful treatment as a basic common social courtesy into the organizational consciousness, says Dr. Woods, and then in any circumstance where an apology is offered, it is perceived as authentic.
Conclusion
Hospitalists may find a need to apologize to patients and families for situations and circumstances in the hospital environment as well as the gap in relationship that exists when hospitalists and patients first encounter each other. Apologizing early rather than later as well as simply and authentically goes a long way to help achieve the ethical and business objectives held by most hospital physicians. TH
Andrea Sattinger wrote about error reporting in the May issue.
References
- Woods MS, Star JI. Healing Words: The Power of Apology in Medicine. Santa Fe, N.M.: Doctors in Touch; 2004.
- Woods MS. Applying Personal Leadership Principles to Health Care: The DEPO Principle. Orlando, Fl.: American College of Physician Executives; 2001.
- Leape LL. National Patient Safety Foundation. Understanding the power of apology: how saying “I’m sorry" helps heal patients and caregivers. Focus on Patient Safety. 2005;8:1-3.
- Lazare A. On Apology. Oxford, U.K.: Oxford University Press; 2004.
- Boothman RC. Apologies and a strong defense at the University of Michigan Health System. Physician Exec. 2006 Mar-Apr; 32(2):7-10.
- Weber DO. Who’s sorry now? Special report: patient trust and safety. Physician Exec. 2006 Mar-Apr:32(2)6-14.
- When Things Go Wrong: Responding to Adverse Events. A Consensus Statement of the Harvard Hospitals. Burlington, Massachusetts: Massachusetts Coalition for the Prevention of Medical Errors; 2006.
- Barnett PB. Rapport and the hospitalist. Am J Med. 2001;111:31S-35S.
- Leape LL. Full disclosure and apology—an idea whose time has come. Physician Exec. Mar-Apr 2006 32:16-18.
- Beckman HB, Markakis KM, Suchman AL, et al. The doctor-patient relationship and malpractice. Lessons from plaintiff depositions. Arch Intern Med. Jun 27 1994;154(12):1365-1370.
- Cohen JR. Apology and organizations: Exploring an example from medical practice. Fordham Urban Law J. 2000;27(5):1447-1482.
- Cohen JR. Advising clients to apologize. South Calif Law Rev. 1999;72:1009-1069.
- Entman SS, Glass CA, Hickson GB, et al. The relationship between malpractice claims history and subsequent obstetric care. JAMA. 1994 Nov 23-30;272(20):1588-1591.
- Gesensway D. Hospitalists and the malpractice insurance crisis. The Hospitalist. 2002Jul/Aug;11-13.
- Levinson W, Roter D, Mullooly JP, et al. Physician-patient communication: the relationship with malpractice claims among primary care physicians and surgeons. JAMA. 1997 Feb19;227(7):553-559.
- Lo B. Ethical and policy implications of hospitalist systems. Dis Mon. 2002 Apr;48(4):281-290.
- Mello MM, Studdert DM, Brennan TA. The new medical malpractice crisis. New Engl J Med. 2003 Jun 5;348(23):2281-2284.
- Shapiro RS, Simpson DE, Lawrence SL, et al. A survey of sued and nonsued physicians and suing patients. Arch Intern Med. 1989 Oct;149(10):2190-2196.
- Zimmerman R. Doctors' new tool to fight lawsuits: saying 'I'm sorry.' Malpractice insurers find owning up to errors soothes patient anger. 'The risks are extraordinary.' J Okla State Med Assoc. 2004 Jun;97(6):245-247.
- Ambady N, LaPlante D, Nguyen T, et al. Surgeons' tone of voice: a clue to malpractice history. Surgery. 2002 Jul;132(1):5-9.
- Wu AW. Handling hospital errors: is disclosure the best defense? Ann Intern Med. 1999 Dec 21;131(12):970-972.
- Localio AR, Lawthers AG, Brennan TA, et al. Relation between malpractice claims and adverse events due to negligence. Results of the Harvard Medical Practice Study III. N Engl J Med. 1991 Jul 25;325(4):245-251.
- Brennan TA, Sox CM, Burstin HR. Relation between negligent adverse events and the outcomes of medical-malpractice litigation. N Engl J Med. 1996 Dec;335(26):1963-1967.
- Hickson GB, Federspiel CF, Pichert JW, et al. Patient complaints and malpractice risk. JAMA. 2002 Jun 12;287(22):2951-1957.
- Stelfox HT, Gandhi TK, Orav EJ, et al. The relation of patient satisfaction with complaints against physicians and malpractice lawsuits. Am J Med. 2005 Oct;118(10):1126-1133.
- Pham HH, Devers KJ, Kuo S, et al. Health care market trends and the evolution of hospitalist use and roles. J Gen Intern Med. 2005 Feb;20(2):101-107.
- Harris Interactive(R). Telephone survey conducted for the American Academy on Physician and Patient, March 3-6, 2006.