I claim to be a simple individual liable to err like any other fellow mortal. I own, however, that I have humility enough to confess my errors and to retrace my steps. Mahatma Gandhi
What patients look for
Patients and relatives may suffer in two distinct ways from a medically induced injury. First from the injury itself; and second from the insensitive manner in which the incident may be handled afterwards by the medical staff. This emotional impact is particularly difficult to deal with because the harm was caused by the very people in whom they had placed their trust. On the other hand, when medical staff come forward, acknowledge the damage, and take positive action, the support offered can ameliorate the impact.
The term “adverse medical event” or “unintended outcome” is useful, but has been deliberately sanitized to make it neutral and bland. It conceals the gut-wrenching trauma which it can induce.
Appreciating and understanding the experiences of injured patients is essential if one is going to provide individually appropriate and practical help. Patient-centered care does not cease just because a medical error occurs, and we need to continue to honor and respect the needs of the patients and their families who have been harmed.
Imagine that you or your husband, mother or child has suffered a medical injury. What would you want? Well, I imagine you would want to know what happened; you would want an apology; you would want to be looked after ; and, later on, you might want steps to be taken to prevent such things happening again to anyone else. If the injury led to you being unemployed or unable to care for your children, you would want financial support to help you during the recovery period.
These are reasonable expectations, but most healthcare organizations have proved (in the past at least) to be extraordinarily bad at dealing with injured patients; resorting at times, particularly during litigation, to deeply unpleasant tactics of delay and manipulation which seriously compounded the initial problem. Dr Vincent coined the term, ‘second trauma’, to describe what some patients experience when they are abandoned by their healthcare team.
When things go wrong
When a patient is harmed, possibly because of an error, the natural tendency of the medical staff is to clam up. This is the natural human response to a mistake. Even when a child goofs up, the instinctive reaction is to hide the mistake and try to bury it. The medical team feel guilty and ashamed , and believe that they have let the patient down because of their incompetence. The emotional impact on them is disproportionately hard, because they feel they have betrayed their patient’s trust.
While one would expect an apology to the patient to be the natural response, the truth is that it’s especially hard for doctors to say – “I am sorry”. Traditionally, there’s always been a culture of secrecy around professional failings, because of the fear of medico-legal consequences which can damage their professional reputation. This is especially true when the patient is poor, because the doctor knows he can get away with “passing the buck”. Often the doctor doesn’t know what to do, because he has not been trained in how to talk to the patient or her family about the error. He takes refuge in silence and hopes that the problem will go away. Doctors are very busy, and one way of coping with the error is to divert their attention to other patients who need their help.
Sadly, there is very little organizational support for the doctor who has committed an error. Most hospitals in India still don’t have adverse incident reporting and learning systems; and they have not bothered to set up organizational protocols of how to deal with a patient who has suffered medical harm.
How patients get bullied
Sometimes, patients also inadvertently contribute to this conspiracy of silence because they find it hard to ‘speak up,’ ask questions and have their needs for answers met. This is especially true when patients are poor and illiterate, because they still treat the doctor as God. They feel that it would be ungrateful on their part to cross-question the doctor, and because they are vulnerable, they allow themselves to get bullied because they don’t know any better. However, the resentment and anger can build up and come to a boil later on. Sadly, doctors have been given bad advice by their insurance indemnity lawyers, who tell them to clam up, because they are more concerned about the doctor’s liability than their humanity. The good news is that insurers are realizing that encouraging doctors to be open actually helps to reduce the costs of fighting malpractice suits.
The new trend is to encourage disclosure. For example, the COPIC Insurance Company that provides insurance cover to physicians in Colorado, USA, uses a voluntary early intervention program. The 3Rs program, applicable to cases that do not involve death or clear negligence, involves “recognizing” a complication, “responding promptly” and “resolving issues”.
Practice versus theory
While the principle of being honest and open is hard to disagree with, in practice a host of questions immediately arise:
* Should everything be disclosed - even minor errors of no consequence ?
* Should all serious injuries be disclosed, even though knowledge about the damage will
make no material difference to the patient or family? How will this help the patient? * Will patients become unduly anxious once they know how frequently errors occur?
These are all reasonable questions that are beginning to be systematically explored. Whether barriers to disclosure and apology are legal, organizational, financial or psychological, the ethical imperative remains the same- to tell patients the truth and apologize when called for. Taking a proactive approach, including apologizing when appropriate, could actually help avoid lawsuits. Preventive law can be as effective as preventive medicine. You can address issues before they mushroom into something much bigger.
Physicians can’t just be told to do better at disclosing medical errors. They need help to do this well. It’s a very difficult thing to do, because the instinct is to deny and avoid. It’s a real skill and like every single skill in medicine and in life, you need training to get better at it. Effective communication requires practice, repetition and feedback. Some hospitals have set up error disclosure teams, which are taught to show the 3Cs - Concern, Compassion and Commitment.
It’s about feelings, not just words
Sorry Works at www.sorryworks.net has numerous training tools and resources that help doctors and nurses learn how to say sorry. Communication after a medical error is fraught with hazard, and doctors need to remember that, how something is said can have as much impact as what is said. When navigating the critical yet exceptionally difficult conversations that follow a medical error, doctors need to remember that it is more about feelings than just words, more about heart than just methods.
A poorly planned apology can be as bad as or worse than no apology at all, and Dr. Michael Woods , in his book, Healing Words: The Power of Apology in Medicine, suggests using five “R’s” to ensure the apology is authentic. The key is distinguishing between expression of empathy and admission of fault.
* Recognition = A perceptive response by a doctor or nurse that acknowledges her own feelings and those of the patient and family. If the patient is reluctant to talk, this may be an indicator that the medical team is not meeting their needs adequately.
* Regret = An empathetic response by the provider to let the patient know the provider understands their experience and feels badly about it. “I am so sorry. I know this outcome is not what you expected. It is not what I expected either.”
* Responsibility = A statement of transparency that attempts to answer the patient’s questions about their unexpected outcome. What happened? Why did it happen ? What steps will be taken to prevent reoccurrence?
* Remedy = What is being done to correct the problem? Who is going to be responsible for the cost of fixing it?
* Remain Engaged = Be there for the patient. Reassure the patient that you will not abandon her. Focus on and provide for your patient’s continuing care needs. Follow up, even after you hand off to someone else.
Clinicians can use the TRACK process to rebuild the trust that has been disrupted by the medical error. TRACK is an acronym coined by Dr Robert Truog which reminds them about the five key values they need to embody at this time: Transparency, Respect, Accountability, Continuity and Kindness.
Hospitals are coaching physicians how to deal with families after an error, and doctors are asked to “role-play” during case scenarios to help them prepare for errors in real life. Saying sorry is not an apology – it’s an expression of caring. It can be a crucial part of an empathetic and compassionate response to patients who have gone through a traumatic medical event. This helps doctors reclaim their natural capacity for caring and kindness when emotions are running high, rather than thinking of the relatives of the injured patient as potential adversaries.
In 2006, the Harvard Medical School developed this approach for talking about adverse events.
Immediately after the event:
* Acknowledge the event
* Express regret
* Take steps to minimize further harm
* Explain what happens next
* Commit to investigate to find out why the adverse event occurred Later follow-up
* Disclose the results of the internal investigation
* Apologize if there is an error or systems failure
* Make changes to prevent the failure from recurring
* Provide continuing emotional support to the patients and health professionals involved
The disclosure process - a senior doctor’s responsibility
Communication with the patient and family after an adverse outcome is a delicate task, and should not be delegated to a junior doctor. It must be done by a senior doctor. This can be reassuring for the family, who needs to see that experts are now engaged in trying to resolve the matter efficiently. This helps them feel they are in safe hands. Dr James Pichert and Dr Gerald Hickson offer the following useful guidelines for doctors.
* Give bad news in a private place, where you can respond appropriately to the patient and/or family’s reactions.
* Deliver the message clearly. The adverse outcome must be spelled out. ‘I’m sorry to report that the procedure resulted in . . . ’
* Wait silently for a reaction. Give the patient/family time to consider what has happened , so they can formulate their questions. * Acknowledge and accept the initial reaction. The usual reaction to bad news is a mixture of denial, anger, resignation, shock and so on. * Listen to what the family has to say. * Resist the urge to blame or appear to blame other health professionals for the outcome. * Discuss transition support. Tell the patient/family what steps will be taken to provide medical, social or other forms of support.
* Finish by reassuring them about your continued willingness to answer any questions they might have
* Discuss the next steps.
* Schedule a follow-up meeting. Some patients will want to talk only after the crisis has subsided.
* Afterwards, document a summary of the discussion. Ideally, this should be shared with the patient and family.
A healthy disclosure process must: * Allow staff to show respect to the patient (and/or family members) by offering an immediate and sincere apology
* Be conducted as much as possible by those originally involved in the patient’s care
* Allow patients to appoint a support person
* Allow patients to indicate the matters they want to see action taken on
* Allow staff to give carefully structured feedback as matters come to light, rather than delaying feedback until the end of a closed-door investigation * Prevent different staff members from expressing conflicting perspectives on the causes of the unexpected outcome
* Be deployed as a formal process for all high-severity adverse events.