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When medical errors occur, patients want information and physicians want to be truthful. The disconnect happens during the communication between patients and physicians, according to a study published in the February 26, 2003, issue of the Journal of the American Medical Association (JAMA).
"We were trying to understand the communication barriers health-care providers encounter when they disclose errors to patients," said Dr. Thomas Gallagher, lead author of the study and assistant professor of medicine in the Division of General Internal Medicine and the Department of Medical History and Ethics.
Gallagher began this research while on faculty at the Washington University School of Medicine in St. Louis. Gallagher and his colleagues gathered 52 patients and 46 physicians from St. Louis into 13 focus groups, including six with only patients, four with just doctors, and three with both physicians and patients. Among other topics, the groups addressed the perception that medical errors are the result of incompetent individuals, and whether this perception makes it more difficult for doctors to tell patients about harmful errors.
"We found that as a result of medical training and culture, physicians frequently feel personally responsible for errors," Gallagher observed. "This makes it difficult for doctors to tell patients about errors, and also prevents doctors from examining defects in the system, which is the larger issue. Given the complexity of healthcare, most medical errors are a result of systems breakdowns, not incompetence or a 'bad-apple.' We need to shift the focus of error disclosure to an ongoing quality-of-care discussion."
Gallagher and his colleagues learned that patients in the focus groups wanted information about how the error occurred and how recurrences would be prevented, as well as apologies from physicians.
Yet Gallagher and his colleagues noted that practicing physicians worried that apologizing might heighten their legal liability. Physicians' concerns about error disclosure may stem in part from working at hospitals or other health-care institutions where the error disclosure policy is vague, contradictory, or doesn't allow doctors to apologize at all.
"The challenge is that many of those institutional policies send providers a mixed message," said Gallagher. "On the one hand, they require physicians to tell patients that there has been an 'unanticipated outcome', but on the other hand, they tell the physicians not to say anything that would imply blame and not to apologize. Medical students are rarely trained to have discussions like this."
To re-examine error disclosure policies, Gallagher, in association with medical directors at Harborview Medical Center, UW Medical Center, and Group Health Cooperative in Seattle, received grants from the Agency for Healthcare Research and Quality, as well as the Greenwall Faculty Scholars Program in Bioethics. UW Medicine and Group Health are collaborating with Gallagher to develop more effective policies, and are training health-care providers about the new policies and specifically how to talk to patients about errors. A follow-up study will measure the effect of policy and education, and will compare health-care provider attitudes and experiences in disclosing errors.
Too frequently people think of medical error disclosure as a service recovery issue, Gallagher said, and the focus is on minimizing the damage.
Gallagher and his colleagues would like to change this philosophy by framing error disclosure as part of recognizing and repairing system defects.
"We want to make the disclosure conversation more positive and productive," said Gallagher. "Instead of just telling a patient that something bad happened, we'd like physicians to add, '...and here's what we've learned from it.' If such conversations were easier to have with patients, physicians would be more likely to have them."
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