How should a physician apologize after a medical error?

I had thought that apologizing was a straightforward act, but I now realize that it is a nuanced art form. We’ve all heard the “mistakes were made” version, usually issued by politicians who attempt to insert a layer of passive voice insulation between themselves and their screw-ups.

There is also the ever present conditional apology which by definition falls short of complete responsibility acceptance. The template here is: “I’m sorry for my oversight which wouldn’t have happened if …”

There have been several apologies in the news recently. First, President Obama offered a faux mea culpa with regard to his indisputable and repeated “misrepresentations” on his broken promise that we could all keep our own doctors and health insurance plans.

Here’s what he said: “I am sorry that they are finding themselves in this situation based on assurance they got from me.”

Finding themselves? Really? I grade this as beyond lame on the apology scale.

CBS’s flagship and enduring news magazine 60 Minutes apologized for using a source on a Benghazi piece who was a liar.

“We were wrong to put him on the air,” said Lara Logan a few days prior to airing a formal apology. The latter included, “It was a mistake to include him in our report. For that, we are very sorry.”

While some have criticized this apology as inadequate, I am more lenient here. They admitted they screwed up, apologized and didn’t blame anyone for their mess up. Sure, they could have fallen harder on their sword or fired a few folks, but I think they crossed the minimum standard for contrition and acceptance of responsibility.

Recently, a newspaper issued a retraction for comments published 150 years ago. The Patriot-News, a Pennsylvania newspaper earlier this month issued a retraction for referring to Lincoln’s Gettysburg Address as “silly remarks.” Their recent editorial included the statement: “The Patriot-News regrets the error.” I congratulate them on reaching this belated, enlightened position. They certainly cannot be accused of a rush to judgment. Let’s look for other retractions from them for other errant opinions they published in the 19th century.

Martin Bashir, issued 2 minute on air apology on MSNBC for a diatribe against Sarah Palin. While the apology seemed genuine, most of us would have lost our jobs for similar behavior.

What should doctors do when we make a mistake? Of course, from a moral perspective, there is no controversy . We should do what we expect others to do. When we err, we should admit it and apologize for it.

Of course, some errors are trivial and do not require us to march into the confessional. If a patient receives liquid diet when a soft diet was ordered, the world will continue to spin. No foul here. But substantive errors must be disclosed.

The dilemma for physicians is fear that admission of error, which is morally required, may be used as a cudgel if the physician is sued for medical malpractice, which is an unfair arena. Personally, I believe that this concern that apologizing will increase legal risk is exaggerated and that a genuinely contrite physician may reduce legal vulnerability by explaining candidly what went wrong. It should be self-evident that an adverse event or a mistake is not tantamount to medical negligence, but so many misunderstand this.

Nevertheless, physicians should choose their words carefully when disclosing medical errors to patients and their families. Many states have physician apology laws that state that expressions of regret are not admissible in medical malpractice trials. These laws are narrowly crafted. If the physician’s statement goes beyond expressions of regret and empathy, it is admissible.

Inadmissible: “I’m very sorry that this complication occurred and that a second surgery will be necessary.”

Very admissible: I’m sorry that I nicked the spleen and I had to remove it.”

So, how was this post? Verbose? Self-serving? Tedious? Factual errors? Arrogant?

If so, don’t blame me. Sometimes, mistakes are made.

Michael Kirsch is a gastroenterologist who blogs at MD Whistleblower

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  • Thomas D Guastavino

    A huge part of the problem is the fact that we are cant even define what is an error. Giving penicillin to a patient with a known anaphylactic reaction is an error. Giving penicillin to a patient who has an anaphylactic reaction without a prior allergy history is not. A patient that develops a post operative infection when every precaution has been taken is not an error, but is being treated as if it is.

    • rbthe4th2

      How about:
      a patient who gives you evidence and says can you please run these blood tests that are in X paper here, and are backed up by a nationally recognized, board certified, teaching hospital doctor in his article Y
      it takes at least 5-6 doctors before the tests are run
      some problems are found
      doctor who ran the test says just do Z treatment
      but the Z treatment will raise a level that can be toxic
      Who made the original error? The doctors who refused to run a simple blood test and ignored the patient? The doctor who ran the tests but didn’t correlate the results?
      I understand what you are saying above. I don’t see how it covers this though …
      If someone you had developed complications later because the patient said they had the issue and you didn’t do anything, don’t you call that an error? Everyone I know would.

  • DoubtfulGuest

    Oh man…where do I even start? How about with a Thank You, Dr. Kirsch, for your post on this topic.

    Dr. Guastavino, I agree with you that many adverse events are defined as errors when they shouldn’t be. We need to somehow shift public perception to have more reasonable expectations of their medical care. I also don’t think it’s necessarily self-serving or dishonest to accept partial responsibility. System errors with multiple factors might be the most common kind? I hope you’d still disclose and apologize when you know darn well you did make a mistake?

    Re: the physician as “captain of the ship”… well, no, and yes. The doctor cannot control most outcomes 100%. Patients and staff also share responsibility for good outcomes. Sometimes even then things go wrong and there’s nothing anyone could have done better. However, the doctor IS responsible for making sure the patient doesn’t get thrown under the bus when problems arise. And Do Not Cover Up Mistakes. We Will Figure It Out Eventually.

    Unfortunately, it appears the law doesn’t allow patients to give up our right to sue…we’re not viewed as fully competent to decide? Less opportunity for the lawyers if we could, eh? Just sayin’.

    So, how to apologize? Let’s start with what not to do. Do not stonewall. Do not shift all blame to the patient (I took responsibility for my part of miscommunications and I also apologized to the Dr. for running late). Do not lie. Do not change the patient’s records (DOCUMENT any honest, well meaning corrections or late notes). Do not withhold information the patient needs to make decisions about their care. Do not sabotage the patient’s efforts to help correct your mistakes.

    For me, personally, a full explanation of events is necessary for me to stop the endless thought loops of “What happened? What happened? What happened? What…” and so on for several years now. I can handle the information. I expect there would be some of “Our office manager couldn’t get ahold of me and she thought I wanted you to do X when we meant for Y to happen”. That’s cool, I’m not mad at the office manager. Things happen. At this point I’m much angrier at the way I’ve been treated in the aftermath.

    As far as how to word the apology…at this point I’m not picky. I really would prefer a normal-person apology with normal-person responsibility taking (i.e. not dancing around certain words to avoid liability). If the doctor is really so terrified that he can’t do that, I’d accept the namby-pamby version. What I really need is for the doctor to care how I was affected, show me that, and also have a good talk with me about how to prevent these problems in the future.

    • Thomas D Guastavino

      Good advice, so good in fact that it should apply to everyone. The government would be a great place to start.

      • DoubtfulGuest

        Agree! But seriously, what should patients do? Surely you don’t mean it’s okay for us to be thrown under the bus when actual errors are made? At some point a sense of right and wrong has to kick in on the individual level. We have to do what we know is right even when others don’t.

        I don’t want any doctors to be afraid of me. I wouldn’t support you being blamed for something that’s not your fault. I repeatedly offered, on my own initiative, to sign an agreement not to sue my doctor. In case I misunderstood anything about my care, he is welcome to explain it to me at any time. What should patients do?

        • Thomas D Guastavino

          Patients should do what patients, and for that matter any other disatisfied customer, have always done. Ask questions until you get a satisfactory answer. If you dont seek another opinion. The need for tort reform is clear.

          • Martha55

            It’s difficult to cultivate a relationship with someone when that person can’t apologize for mistakes made. Of course the doctor-patient relationship has been replaced with a seller-buyer relationship where my motivations as a buyer to find the best deal.

            Since doctors aren’t perfect and will make a mistake, it’s buyer beware

          • DoubtfulGuest

            It’s not like buying tires. My disease is now being taken care of by other doctors, thanks. Re: the doctor who made mistakes and deceived me, another opinion from whom? A lawyer? I agree with tort reform. Why are all these lawyers in the way?

          • meyati

            How do you know that the current truth is wrong-the doctor truly believes what he’s saying-other doctors have said the same thing-the Internet isn’t giving me a clue about permanent side-effects. What I got for an apology was “I thought the side-effects were all in the head. Now I see I was wrong.” The other part was a few months later. “I hate to come in here. You’re always so nice, and I injured you.” I am mad at standard American medical practice and education that doesn’t teach these doctors correctly-

        • rbthe4th2

          Great posts DG. Dr. Guastavino, with all due respect, this is something I’ve alluded to in previous posts. We patients, do understand mistakes are made. Like I’ve said, apologize, take responsibility, and lets get on with it. I had a doc that did it, and there may be a problem with something he tried. Am I going to sue him? Heck no! I’m going to tell him keep on trying. He’s trying to help me out and I agree. I’d rather have a doc who has the gumption and a pair to help me. We only have praise for him. Its not as much as whether you are perfect but HOW/WHAT/WHEN you respond to an issue that matters.
          The stonewalling, shifting the blame to the patient, seen it before. Sabotaging the patients efforts to help me correct mistakes. Check.
          My care has been goofy since then because the doctor also threatened to pass along negative stuff on me if I didn’t ‘do as he said’. Do you think that’s condusive to a relationship? Don’t you think other patients want that known?
          How much are we required to pay out of pocket for the multiple opinions? Shouldn’t the one doc be responsible for our care and get it right, vs. us having to go all over and the like, getting worse, when the problem comes down to physician attitude?

          • DoubtfulGuest

            Great points, Randy. I might add that the very reforms Dr. Guastavino wants to see would likely best come about if the public knew what explanations and apologies from doctors sounded like. We need a reference point. As individuals, we must do the right thing. You know how people say “We live in a litigious society”? That thinking spreads by word of mouth, people hear that their neighbor Joe sued after his surgery “went bad”, and lawyers discourage people from thinking critically about it. If Joe’s surgeon would explain and apologize to Joe, then the story among the neighbors would, in many cases, be “Joe had unexpected complications but his surgeon is a good guy and did everything he could to fix it”. The “No, you first” mentality when it comes to doing the right thing, is a little scary. I’m doing what I can, and am open to advice from these doctors if there’s anything more I can do to change things.

          • rbthe4th2

            I know one doctor that could teach them what apologies are like. I would agree with that. The basic issue I run up against is that because of attitude and making things out to be the patient when the problems are that doctors don’t read the medical literature I give them to chase up the problem. I even tried in writing, give me the basis for X and no one can do it, won’t answer me or blames it on another doctor. Frankly, there is why people sue doctors and why they blast them, because if a position says tell me your most intimiate stuff and then if I make a mistake, hide, etc. do you think that engenders trust? There’s your lawsuits right there.

  • Suzi Q 38

    Just be honest, choose your words carefully, and deliver the apology.
    Get us the help we need to rectify the error.
    Do not let our condition worsen because you are afraid to be human and admit the error.
    Believe it or not, in most states it is very difficult to sue.
    Patients appreciate the apology as long as it is sincere.

    • rbthe4th2

      This is where I have the problem. Due to doctor attitudes, I’ve gotten worse because of the ‘oh he’s a problem’. Why aren’t docs trying to solve that?

  • DoubtfulGuest

    As a patient, I have no problem assuming *some* financial risk with my medical care. It’s part of being part of my care team. We work as a team, we share the risks. There is a line of course, and I’m not exactly sure where that is. Some patients desperately need compensation in order to recover from their injuries. In situations that are no one’s fault, I’m not sure the doctors, nurses, or other staff should eat the cost. Certainly these folks and the hospital/facility should help out so the patient isn’t devastated financially. But healthcare is not like ordering a manufactured item, that we can return and complain when it arrives in less than perfect condition.

  • guest

    When I had complications, I felt like crap. I knew what it was like to be a patient, and I knew the hospital course my patient(s) had were not what they had planned or expected. I wanted to hug them, tell them I knew they must be so upset, and that I was so sorry for my actions that might have led to their current situation.

    What I said was ” I am so sorry you are having to deal with this issue. I wish you the best in your recovery.” The lawyers were happy, but it did not feel very human.

    • DoubtfulGuest

      Your comment is intriguing. I would be very interested in learning more about lawyers’ roles after adverse medical events if you could please tell us more? I’m particularly interested in finding out the extent of their “advisory role” after it’s been determined there’s a problem but the patient has thus far filed no claim or formal complaint? Either way, thank you for your thoughts. For those of us whose doctors responded very unkindly, it’s a bit more comforting to imagine your scenario instead.

  • Karen Freitag Franz

    I had a cardiac catheter ablation when they were still a new procedure, for WPW .. My doctor had never done the procedure alone. He ended up ablating the Av node, leaving me with WPW and complete heart block. He apologized and promised that all my future cardiac care would be free. I was happy with that promise. When I tried to make an appointment I was given the runaround. I found out later that the hospital lawyers got involved and insisted he deny ever making that promise.

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