To Err is Human, to Disclose It to Patients Is Optional
By Neil Osterweil, Senior Associate Editor, MedPage Today
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine,
University of California, San Francisco
May 11, 2007
IOWA CITY, Iowa, May 11 -- What physicians say about disclosing errors to
patients and what they actually do when they make an error may be two different
things, said investigators here.
In a survey of physician and trainee attitudes regarding disclosure of errors to
patients, more than 90% of faculty physicians and residents said they would
disclose errors resulting in either minor or major harm to patients, reported
Lauris Kaldjian, M.D., Ph.D. and colleagues from the University of Iowa and
other centers.
But reactions in real life seem to be different. Only 41% of respondents
confessed to disclosing an actual, albeit minor, medical error, and only 5% said
that they had told a patient about a major error resulting in disability or
death, the authors wrote in the online version of the Journal of General
Internal Medicine.
"Most doctors recognize that they're fallible, but they still strive for
perfection and, for the most part, hold each other accountable to a high
standard of practice that approximates perfection," said Dr. Kaldjian, director
of the Program in Biomedical Ethics and Medical Humanities at the Carver College
of Medicine.
"The idea persists that the physician rides into the clinic on the white horse,"
Dr. Kaldjian said. "To come in as the healer and then realize that you have
harmed is a difficult thing to accept, let alone admit."
He and his colleagues at Iowa, Yale, and Penn State conducted a survey of
faculty physicians, residents, and medical students at their respective centers.
They asked questions about minor errors, such as "Have you ever made a mistake
that prolonged treatment or caused discomfort and told the patient (or the
patient's family) that a mistake was made?" and major errors, such as "Have you
ever made a mistake that caused disability or death and told the patient (or the
patient's family) that a mistake was made?"
The survey participants were also presented with a hypothetical case in which a
physician fails to note a patient's allergy to cephalosporins and gives him one
of the drugs to treat pneumonia. They were then asked how they would respond to
each of three possible outcomes: no harm to the patient, minor harm (diffuse
itching and a rash) or major harm (respiratory distress, anaphylactic shock, and
myocardial infarction).
Study outcome measures were actual and hypothetical error disclosure, attitudes
toward disclosure, and demographic factors.
The authors received responses from 538 physicians, residents, and students for
a response rate of 77%.
When it came to the hypothetical situations, they found that faculty respondents
were more likely than either residents or students to disclose an error
resulting in no harm, with 80% of faculty, 63% of residents, and 50% of students
willing to 'fess up (P<0.001).
Nearly all respondents agreed that they would disclose errors causing minor harm
(99% of faculty, 95% of residents, and 93%, of students, P=0.06), and the vast
majority also said they would report the most egregious errors (97% of
physicians, 90% of residents, and 94%, of students, P=0.03).
The more senior physicians were less likely than either residents or students to
worry about malpractice litigation (76% vs 83% vs 91%, P<0.001), professional
discipline (46% vs 66% vs 86%, P<0.001), loss of reputation (54% vs 67% vs 76%,
P<0.001), or blame from colleagues (47% vs 62% vs 75%, P<0.001), the authors
found.
Faculty physicians were also less to agree that the decision to disclose
"depends on whether I think the information will help or harm the patient" (21%
vs 44% vs 52%, P<0.001) or to believe that disclosure would help alleviate their
guilt feelings (50% vs 69% vs 74%, P<0.001), the researchers wrote. Faculty and
residents were more likely than students to agree that error disclosure
"strengthens my patient's trust in me as a physician" (64% vs 65% vs 46%,
P<0.001).
Slightly less than half of all respondents (47%) acknowledged having made at
least one medical error, including 62% of faculty and 36% of residents. Of this
group, 46% acknowledged making a minor error, and 9% confessed to a major error.
But when it came to real-world disclosure of errors to patients, only 41% of
faculty and residents said they'd told a patient about an actual minor error and
only 5% had disclosed an actual major error.
On the other end of the spectrum, 19% said they had not disclosed an actual
minor error and 4% said they had failed to tell a patient about an actual major
error.
"There appears to be a gap between physicians' attitudes and practices regarding
error disclosure, " the authors wrote.
"Willingness to disclose errors was associated with higher training level and a
variety of patient-centered attitudes, and it was not lessened by previous
exposure to malpractice litigation."
Dr. Kaldjian said that while the survey data suggested that about half of the
respondents were infallible, "it seems fair to assume that all of us have made
at least a minor error, if not a major error, sometime in our careers."
The authors acknowledged that the self-report nature of the survey is subject to
"social desirability" bias-that is, the tendency of respondents to put
themselves or the profession in a more favorable light, despite the anonymous
design of the survey).
"Under the right circumstances, physicians should be able to act with courage
and compassion to communicate clearly with patients and families about errors,"
they wrote. "Creating such circumstances requires concerted efforts to build a
culture of learning and healing that supports the physician's self-identity as a
healer, at a time when it may be threatened, and promotes the dignity and well
being of the patient after he or she has been harmed."
The authors also acknowledged that the study was cross-sectional and could
therefore not account for changes over time or differences between the
participating centers. They also pointed out that the survey was limited to
faculty, residents and students in teaching hospitals and represented only
internal medicine, family medicine, and pediatrics, so the results may not be
generalizable to physicians in other specialties or practice types.
The study was funded by the Robert Wood Johnson Foundation's Generalist
Physician Faculty Scholars Program. The authors had no conflict-of-interest
disclosures.
Action Points
a.. Explain to patients who ask that policies governing physician disclosure
to patients of medical errors vary from one institution to the next
http://www.medpagetoday.com/PublicHealthPolicy/PracticeManagement/dh/5631