Words They Rarely Teach in Medical School: 'I'm Sorry'

[Guest guest]

http://www.nytimes.com/2005/07/26/science/26essa.html?pagewanted=print

July 26, 2005

Learning Words They Rarely Teach in Medical School: 'I'm Sorry'

By RICHARD A. FRIEDMAN, M.D.

There is nothing in the Hippocratic Oath that tells doctors what to do when they

make a mistake with a patient. Nor is there much on this subject in medical

school curriculums or in residency training programs.

But there should be.

Much was made of the Institute of Medicine's 1999 report that 44,000 to 98,000

people die each year in hospitals from preventable medical errors, many of them

presumably made by doctors.

The report spawned many initiatives to address the problem, but there was little

discussion about how doctors, when they have made mistakes, should deal with

their patients.

Not long ago, a patient called me to complain about the treatment she received

from one of the residents I supervise. After starting a new medication, this

patient said that she experienced bad side effects, and that her doctor had

failed to warn her that this drug might interact adversely with other

medications she was taking, something she discovered by herself on the Internet.

What really bothered her was not so much the physical discomfort - headache and

dizziness - but the fact that when she confronted her doctor, a psychiatrist, he

didn't apologize for his mistake. She asked to be switched to the care of

another resident, because she felt her current doctor would resent her for

taking him to task.

When I reviewed this case with the resident, he puzzled over why he was

reluctant to apologize to the patient. Did he feel his medical authority was

threatened? Was he worried about the legal implications of admitting a mistake?

Not really.

Instead, it seemed to the resident that acknowledging the mistake would narrow

the psychological distance between him and his patient, and that felt

uncomfortable.

Everyone assumes that the ever-present threat of litigation has made doctors

more anxious about admitting error, and no doubt it has. But doctors have always

been tight-lipped about their mistakes, in part to preserve an illusion of

medical omnipotence.

Like every doctor, I've made plenty of mistakes along the way.

As a young attending physician, I started a very depressed patient on a type of

antidepressant called a monoamine oxidase inhibitor after she failed to respond

to Zoloft and then to Prozac, drugs that belong to a different class of

antidepressants.

Because the two types of drugs can interact, I waited for what was then

considered enough time before prescribing the new drug. But within two days, the

patient developed a high fever, confusion and dangerously low blood pressure, a

syndrome we now recognize as a result of surging serotonin levels in the brain.

She ended up in the intensive care unit and nearly died from a serotonin

syndrome.

Needless to say, I was distraught about what had happened. I wasn't sure what

went wrong, but I felt that it was my fault, so I apologized to the patient and

her family.

They were shaken and angry, and they quite naturally blamed me and the hospital

for their daughter's near-death experience. But she recovered rapidly and

completely, and in the end, they decided that this was an unfortunate but

" honest " medical error and took no legal action.

Studies suggest that patients are less likely to sue when doctors apologize for

mistakes, and many hospitals now encourage their physicians to admit their

errors. According to an advocacy group called The Sorry Works! Coalition, 16

states have already passed laws giving doctors legal immunity for their

apologies to patients.

Of course, there are plenty of doctors with a nice bedside manner who can get

away with bad treatment. How else to explain patients who often line up in court

to support doctors accused of malpractice?

The surprising truth is that many patients have a hard time knowing whether they

are really getting good medical care.

Because so many diseases fluctuate randomly over time, patients sometimes

spontaneously improve despite incompetent treatment. On the other hand, a

patient who receives exemplary medical care may fare badly simply because the

illness is hard to treat. In other words, doctors are often praised or blamed,

when the outcome is in fact a chance event.

Many, perhaps even most, medical errors probably have little ill effect and go

unnoticed by patients. Many lawyers would disagree, but doctors ought to let

their patients know when they've erred; it humanizes them and builds trust.

In the end, most patients will forgive their doctor for an error of the head,

but rarely for one of the heart.

[Guest guest]

http://www.nytimes.com/2005/07/26/science/26essa.html?pagewanted=print

July 26, 2005

Learning Words They Rarely Teach in Medical School: 'I'm Sorry'

By RICHARD A. FRIEDMAN, M.D.

There is nothing in the Hippocratic Oath that tells doctors what to do when they

make a mistake with a patient. Nor is there much on this subject in medical

school curriculums or in residency training programs.

But there should be.

Much was made of the Institute of Medicine's 1999 report that 44,000 to 98,000

people die each year in hospitals from preventable medical errors, many of them

presumably made by doctors.

The report spawned many initiatives to address the problem, but there was little

discussion about how doctors, when they have made mistakes, should deal with

their patients.

Not long ago, a patient called me to complain about the treatment she received

from one of the residents I supervise. After starting a new medication, this

patient said that she experienced bad side effects, and that her doctor had

failed to warn her that this drug might interact adversely with other

medications she was taking, something she discovered by herself on the Internet.

What really bothered her was not so much the physical discomfort - headache and

dizziness - but the fact that when she confronted her doctor, a psychiatrist, he

didn't apologize for his mistake. She asked to be switched to the care of

another resident, because she felt her current doctor would resent her for

taking him to task.

When I reviewed this case with the resident, he puzzled over why he was

reluctant to apologize to the patient. Did he feel his medical authority was

threatened? Was he worried about the legal implications of admitting a mistake?

Not really.

Instead, it seemed to the resident that acknowledging the mistake would narrow

the psychological distance between him and his patient, and that felt

uncomfortable.

Everyone assumes that the ever-present threat of litigation has made doctors

more anxious about admitting error, and no doubt it has. But doctors have always

been tight-lipped about their mistakes, in part to preserve an illusion of

medical omnipotence.

Like every doctor, I've made plenty of mistakes along the way.

As a young attending physician, I started a very depressed patient on a type of

antidepressant called a monoamine oxidase inhibitor after she failed to respond

to Zoloft and then to Prozac, drugs that belong to a different class of

antidepressants.

Because the two types of drugs can interact, I waited for what was then

considered enough time before prescribing the new drug. But within two days, the

patient developed a high fever, confusion and dangerously low blood pressure, a

syndrome we now recognize as a result of surging serotonin levels in the brain.

She ended up in the intensive care unit and nearly died from a serotonin

syndrome.

Needless to say, I was distraught about what had happened. I wasn't sure what

went wrong, but I felt that it was my fault, so I apologized to the patient and

her family.

They were shaken and angry, and they quite naturally blamed me and the hospital

for their daughter's near-death experience. But she recovered rapidly and

completely, and in the end, they decided that this was an unfortunate but

" honest " medical error and took no legal action.

Studies suggest that patients are less likely to sue when doctors apologize for

mistakes, and many hospitals now encourage their physicians to admit their

errors. According to an advocacy group called The Sorry Works! Coalition, 16

states have already passed laws giving doctors legal immunity for their

apologies to patients.

Of course, there are plenty of doctors with a nice bedside manner who can get

away with bad treatment. How else to explain patients who often line up in court

to support doctors accused of malpractice?

The surprising truth is that many patients have a hard time knowing whether they

are really getting good medical care.

Because so many diseases fluctuate randomly over time, patients sometimes

spontaneously improve despite incompetent treatment. On the other hand, a

patient who receives exemplary medical care may fare badly simply because the

illness is hard to treat. In other words, doctors are often praised or blamed,

when the outcome is in fact a chance event.

Many, perhaps even most, medical errors probably have little ill effect and go

unnoticed by patients. Many lawyers would disagree, but doctors ought to let

their patients know when they've erred; it humanizes them and builds trust.

In the end, most patients will forgive their doctor for an error of the head,

but rarely for one of the heart.