Back in September I blogged about some research which found that poor bedside manner is associated with an increased likelihood of a doctor having a complaint made against them . To me, this research highlights the very personal and human nature of medicine. I do believe that having a good grasp of the science-based and technical aspects of medicine is important for being a good doctor. However, there is no doubt in my mind that a doctor’s effectiveness as a practitioner is also intimately related to their ability to communicate clearly and with compassion.
One situation where communication between doctor and a patient can be of particular importance is when things go wrong. Doctors can make mistakes (we’re only human, after all), and when we do the results can be catastrophic. In a recent edition of the New England Journal of Medicine (NEJM), two doctors relate what they learned while making a film about the effect medical errors have on patients, their families and the doctors concerned .
It is well accepted that doctors may feel a sense of guilt or shame as a result of their mistake. However, the piece in the NEJM also put forward the idea that family members often have similar or even stronger feelings of guilt, primarily because they feel they were not around to protect their loved one.
Another theme uncovered in the making of this film was the fear patients and their families may feel about further harm that may be endured, including retribution from health care workers, if they were to express their feelings or even ask about mistakes they perceive. The researchers also identified a potential for doctors to turn away from patients who have been harmed, isolating them just when they are most in need.
Overall, the NEJM calls for clarity when things go wrong, and a culture in which it is easier for doctors to say ‘sorry’.
So, why is so difficult for doctors to admit that they have made a mistake. One of the possible explanations, of course, is that a doctor genuinely interested in helping individuals will almost certainly find the thought of harming a patient an uncomfortable one. One strategy here, of course, is to attempt to ignore the issue, or at least suppress it. Also, medicine is a profession where the stakes are high ” not just in terms of patient outcomes but also professional reputation, standing and perhaps even ability to practice at all. In such an environment, a doctor can sometimes find fessing up and saying sorry is beyond them.
And one factor that is almost certainly feeding into this, as the article points out, is the potential for litigation. According to the authors of the NEJM piece: Although full disclosure of medical errors is increasingly recognized as an ethical imperative, health care providers often shy away from taking personal responsibility for an error and believe they must ‘choose words carefully’ or present a positive ‘spin’. Hospitals, insurers, and attorneys frequently advise physicians against using trigger words, such as ‘error,’ ‘harm,’ ‘negligence,’ ‘fault,’ or ‘mistake.’
The authors suggest that what we need is a structure that restores communication and supports emotional needs. In particular, they make a call for patients and their families to have input in any changes that are deemed appropriate. Getting the issues surrounding medical error into the open is a good thing, and involving all relevant parties in the seeking of a solution makes eminent sense to me.
One of the reasons I am writing this is because, as a doctor, I have encountered many occasions where patients feel they have been ‘wronged’, but who also feel angry or bitter because they feel they never got to the truth and/or never had the apology they felt was due to them.
One notable example of this relates to one of the fist patients whose care I was involved in. When I was a medical student, I had the opportunity in my final year to work as a junior doctor on a surgical team. On my very first day, I, the other members of the surgical team and the nursing staff were doing a ward round (which means reviewing and making decisions on all patients under our care). However, we seemed to skip round the bed of one of our patients. The patient was a Greek gentleman, and he seemed visibly upset, to the point of being abusive.
After the ward round, I asked one of the surgical team about this man. He had had a bowel operation and during his recovery complained that he was no longer passing urine. Basically, the medical and nursing staff disbelieved him as there was plenty of fluid going in to him. The situation persisted for some days after which it was discovered that as a result of the operation, a tract (technically referred to as a fistula) has developed between the man’s bladder and bowel, which meant that urine, instead of coming out the usual way, was causing diarrhoea. The man was going to require another operation in an effort to close the fistula. I was told that the gentleman concerned had threatened the medical staff with violence, which is why we were giving him a wide berth.
Later that morning, I went to speak with the man, to see if there was something we could do to help resolve the situation. He was indeed very angry about what had happened to him. He was upset about a number of things, including the fact that a mistake had been made but that the medical staff had disbelieved him when he reported not passing water for some days. He told me that he was so angry at one point that he had considered discharging himself from hospital, getting a gun, and returning to the hospital to make himself heard.
I asked him what he would like from us now. All he wanted was for someone to acknowledge that mistake had been made and apologise. For some patients, the word ‘sorry’ has enormous power. And I suspect saying it more often may do a lot of we doctors a power of good too. My hope is that in the future we develop a culture in medicine where this word is uttered more readily.
2. Delbanco T, et al. Guilty, Afraid, and Alone ” Struggling with Medical Error. NEJM 2007 357(17):1682-1683