President's Page September 2006 Apology—It's not just for the patient

by David M. Bookout, MD 2006 DCMS President

The year was 1963, and I was doing my senior surgery rotation at a large Dallas private hospital. During that rotation a major calamity for the country and the City of Dallas occurred—President Kennedy was assassinated.

Another event occurred during that rotation, but not with the same national importance. However, it impressed me, as a naïve student, enough that I remember each detail, except for names and dates. The surgeon was a leader in the surgery department and an excellent technician. I was assigned to assist him with a re-exploration of a patient who complained of abdominal pain. After the surgeon opened the abdomen, he immediately grasped and concealed a foreign body, took off his glove, threw it in the trash, and asked for another glove. He promptly closed the abdomen without any comment from nursing, anesthesia, or me. The foreign body was a sponge the surgeon had left during a previous laparotomy.

This was a different era, and I do not know what the family and the patient were told. If that situation occurred in that same hospital today, the physician’s actions would be different. That hospital now is a leader in patient disclosure and apology to a wronged patient.

At the last Conference of the Professions, the author of “On Apology,” Aaron Lazare, spoke about “Apology and the Professions.” Then a panel that included Robert Fine, MD, from Baylor and Kelly Reddell, JD, a plaintiff attorney, discussed the importance of disclosure and its effect on the ultimate outcome in any legal action. Panelists pointed out that physicians’ malpractice suits lead to an increased risk of suicide, addiction, and burnout in physicians.

One panelist proposed that when an adverse event occurs, disclosure could lead to reconciliation and forgiveness. However, an important aspect would include repentance and remorse. Panelists argued that remorse is easy to fake. In our society it has become too easy to say, “I’m sorry,” and the attorneys implied that without consequences and restructuring, there would not be forgiveness. Consequences would include restitution.

Harvard’s 16 teaching hospitals have a policy of routine disclosure and apology after preventable adverse events. They hope this will allow the healing of emotional scars for both patients and physicians involved in such cases. Harvard calls for hospitals to tend to the emotional aftermath for physicians and other healthcare professionals involved a medical error. Most hospitals have committees, as does DCMS, to assist physicians in recovery from substance abuse. I contend that recovery group sessions for physicians dealing with the grief and emotional trauma of a lawsuit are equally important.

Dr Lucian L. Leape, a Harvard health policy analyst, has proposed the following methodology of response. He divides it into two parts: immediate responses and later responses.

Immediately after the event:
1. Acknowledge the event.
2. Express regret.
3. Take steps to minimize further harm to the patient.
4. Explain what happens next.
5. Commit to investigate and find out why the adverse event occurred.

Later:
1. Disclose the results of the internal investigation.
2. Apologize if there is an error or system failure.
3. Make changes to prevent the failure from recurring.
4. Provide continuing emotional support to the patients and health professionals involved. (Silence is lying without words.)
According to Dennis Boyle, MD, assistant professor of medicine at the University of Colorado Health Science Center, “The process of disclosing error requires courage, composure, communicative skills, and a belief that the patient is entitled to know the truth. It typically takes a team of people to carry out the disclosure.”

Such programs should be endorsed. First, disclosing an error is the right thing to do, and it could lessen the litigation, trauma and expense. The University of Michigan Health System says that its disclosure program saves the health system $2 million a year in litigation cost. If you and your hospital don’t have a disclosure policy, it’s time to put one in place.

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