Friday, May 23, 2008

Should Doctors be more ready to say Sorry?

Recently a New York Times article Doctors say "I'm Sorry" before "See you in Court" and a follow-up editorial Doctors Who Say They're Sorry addressed the uncomfortable issue of medical errors, especially those associated with having caused harm to patients.

For practising medical practitioners out there, medical errors are considered a near-taboo subject, one which is best left behind the radar screens of scrutiny. Yet we are aware that medical errors, especially those which are inadvertent or which result from unexpected patient/individual reactions or peculiarities, do happen, albeit not too frequently.

Many of these can be safely diffused by being honest and direct with the patients involved, and by careful candid explanation as to why these had happened and why they should not have, and that they would not be allowed to recur.

Most importantly, these types of errors should be treated as high priority and with empathetic sensitivity. Affected patients must be given every avenue to resolve or lessen the harm with the least incurring of pain, suffering or costs.

Of course, medical centres and hospitals must work together with doctors to address these so that cost sharing or waiver/compensation can be implemented expediently and efficiently. The patient should leave the facility satisfied that all that could be done, had been done.

More egregious are those errors due to diagnostic inaccuracy or therapeutic misadventure, incompetency or careless negligence--which are often deviously obfuscated, with blame deflected, or simply denied a full hearing or explanation to harmed patients. It is this group which when exposed, that oftentimes cause much anger and demand for compensation or even calls to reprimand or to punish the erring doctor or facility. Hence, the resultant litigation process which every doctor dreads.

But, admitting to medical mistakes is easier said than done. Besides, in most medical cultures, it is not permissible or safe to do so. Yet, we know that more can and should be done.

Although some 10 years ago, when Lucian Leape's group from the Institute of Medicine reported that as many as 98,000 patients died as a result of medical errors in the United States ("To Err is Human")--many are adamant that this was exaggerated. Many still denied the actual enormity of the problem.

Then some time in the early 2000s, when the Consumer Association of Penang (CAP), SM Idris alluded to a similar state of unrecognised medical errors in Malaysia, as the then editor of the Berita MMA, I objected quite vehemently that to extrapolate based on the experience in the US was wrong and unacceptable.

I called instead for more in-depth study and urge our health community to research this by gathering more accurate data, so that we can get a clearer picture as to the scale and the scope of this serious problem. I also called for pre-emptive attention to detail and a systemic overhaul of procedures and processes to help reduce these possible errors from taking place.

Perhaps CAP's statement to the press was too artless and seemed to denigrate the overall goodness of the medical care experience, that I had felt duty-bound to defend.

Since then however, I have been privy to several adverse patient experiences resulting from complaints to the Malaysian Medical Council (MMC). Most of these complaints are about unexpected adverse outcomes resulting from some medical therapeutic options which have gone awry, and/or unhappiness with the patient-doctor communication or implied dishonesty.

(Most of these MMC complaints are however, not ethical in nature and does not impute serious professional misconduct. This is not to say that there have not been medical errors or misadventure having taken place, but that the MMC is not the board or forum for resolving disputes as to negligence or incompetence, unless there is a recurrent pattern of egregious conduct which can endanger other patients. Unfortunately many among the public has mistaken the latter as the role of the MMC.)

Sometimes inadequate information is given or not at all; at other instances, when untoward bad outcomes result, not enough information or explanation is given. Too much delaying tactics or deflection to very legitimate queries, create unresolved feelings that the doctor and the hospital are hiding something.

It is this need to have closure and/or meaning that many aggrieved parties seek out the MMC or worse the courts to prove medical negligence, and ultimately seek retribution and recompense.

Of course, there are many lawyers out there who are quite ready for such pro bono work to litigate against such incompetent doctors or hospitals, and so the problem escalates.

Thus, many medical centres and doctor groups have begun experimenting with the new deal of becoming more forthcoming, and saying sorry first and early too.

Some 30 states in the US have enacted laws to protect the admissibility of such apology-related disclosure from medical malpractice challenges. And it appears that it is working. In some medical centres, early resolution with smaller compensation claims have already resulted, with some medicolegal costs falling by as much as two-thirds!

Thus perhaps for Malaysians too, this might be a way forward. Saying 'Sorry' and admitting candidly a medical error should not be taken as license to litigate, but as trying to resolve a bad situation from becoming worse. However, there must be mechanisms to protect such disclosure too, and perhaps we should also legislate to ensure that admissibility of such information is protected from medical malpractice claims.

Another approach is through a wider Mediation process which has already been in place in Singapore. At the last MMC meeting in mid-May, Dr Thurairatnam, (a past-president of the Malaysian Dental Association and Dental Council member) presented a short lecture on how this can come to fruition--the MOH is considering some way to explore this option further.

"Sorry seems to be the hardest word," so sang Elton John, but perhaps we as doctors can learn to say so earlier, sooner than later, and be ready to help our patients resolve better as a result, when medical care goes wrong.


Richard said...

Apology is such a vital component in the process of early intervention as conflict escalates after an adverse medical event.

The statement as well as the actual acceptance of genuine apology is however such a subjective phenomenon that this process easily risks being viewed cynically as merely another 'procedure' to secure patient/family acceptance of a poor outcome.

'Genuineness' of apology is what is going to be looked for each time. This can be difficult for doctors who have been trained in a system where admitting error has the odour of moral failure.

'Apology' by healthcare professionals has wide ranging implications and it is very important for potential 'apologizers' to have a very clear understanding about what these may be.

Individual institutional policies and procedures should be defined. Doctors should know for sure what the policy of their medical indemnifier is regarding apology.

And of course there is the fine but critical difference between expressing regret and empathy for a poor outcome, and actually apologizing for making a medical mistake of of some form.

Not easy, apologizing! Yet so important under carefully understood conditions!


Dr D Quek said...

I agree. Apologies are such difficult and scary animals for most of us doctors because, (I think you've got it right) it implies a moral failure on our part. More than that, it also exposes our lesser than perfect image that we have inculturated into our profession. Perhaps we have to work towards a better modus operandi to make medical apologies more systematic and acceptable--while ensuring that legal barriers are reduced if not eliminated. How about a new project in next year's APHM Conference? DQ

Richard said...

That's a good idea, tackling the topic in 2009 perhaps. Will bring it up for discussion. Will we need a priest to take us through the core training on 'how to do it'?!!

One of the obstacles besides the medical invincibility factor is inherent in the DNA of Malaysian private practice; something I've had a chance to reflect on in the last few years. And that is the way we are pitched in indirect financial competition vs each other. A factor that in all likelihood contributes to the reluctance to be forthright in a variety of relationships in the field. Not just with patients and their families.

On 15 July I will be putting together a talk at the APHM Int Conference (where the theme is patient safety). It's titled "Conflict of Interest in Medical Decision making – Impact on Patient Safety Systems in Malaysian Private Hospitals. Something clicked recently! Hope to see you there.