Physicians still resist full disclosure of errors

Even as the health care system continues to adopt the idea of full disclosure after a medical error, with many leaders touting it as the key to improving patient safety and ethics, new research is confirming something that many risk managers already suspected: Doctors are the least enthusiastic about the idea.

A study from the University of Iowa examined why doctors are reluctant to disclose. The study involved a review of more than 300 previously published papers on factors that hinder or help doctors' disclosure of mistakes.1 The research suggests doctors are profoundly disturbed by their involvement with a medical error and their distress can hinder any efforts at disclosure, says Lauris Kaldjian, MD, PhD, associate professor of internal medicine at the University of Iowa Roy J. and Lucille A. Carver College of Medicine and director of the college's program in biomedical ethics and medical humanities.

"The physician's focus should always be on the patient, but at the moment of a medical error, we also must consider the professional who was involved in that error," Kaldjian says. Often an error is not directly an individual person's fault, but a system-based problem, he says. "Yet disclosing errors can be a very individual issue because sometimes only one person knows about it and, as a result, disclosure becomes an individual responsibility."

Not just malpractice concerns

Another researcher points out that, contrary to some assumptions, malpractice concerns are not always the reason a physician is reluctant to disclose.

Thomas H. Gallagher, MD, a researcher at the University of Washington School of Medicine in Seattle, recently surveyed physicians in the United States and Canada to gauge their attitudes regarding the disclosure of medical errors.2,3 In Gallagher's research, physicians' estimates of how likely they were to be sued did not affect whether they supported disclosing errors to patients. The medical profession should consider whether the culture of medicine itself represents a more important barrier than the malpractice environment to the disclosure of harmful medical errors to patients, Gallagher says.

Kaldjian agrees and says he advises risk managers to consider the emotional impact on a physician who is involved with an error. "One comment from the focus groups clearly showed how emotionally traumatic errors are for physician, by referring to that 'sinking feeling' when a doctor realizes that an effort to help someone has actually harmed them," Kaldjian says. "Whatever else you say about medical errors, we need to remember that it's really difficult terrain."

Too often, he says, risk managers and other hospital leaders focus exclusively on the potential malpractice liability and assume that that also is the main concern of the doctor. While a looming lawsuit is certainly on the physician's mind, he or she is likely to be more concerned about failing the patient, Kaldjian says.

The best thing a risk manager can do is to acknowledge that concern up front, he says. "Don't go in with the attitude that the physician is only concerned about money and lawsuits," Kaldjian says. "Let the doctor know that you appreciate what a terrifically difficult time this is."

Feedback is essential

The research also showed that some physicians are frustrated with reporting systems set up by hospitals to encourage error reporting because there is little or no feedback. Some doctors said they felt like they were "sending a message into a black hole." Kaldjian says this frustration can make them less likely to take time out of a busy schedule to report an error.

The solution to that problem is plenty of feedback, he says. Let the doctors know they have been heard and that you appreciate their input.

Some doctors said the bottom line in terms of positive motivation to report an error was the desire to be straightforward with patients, but some also noted that talking about errors "doesn't earn you points" with patients. The culture of competition in medicine can discourage doctors from being straightforward about mistakes, even among colleagues, they reported.

Kaldjian also explains that physicians can sometimes feel like they are left holding the bag when, in actuality, the system failed. And they can feel that no one understands their unique concerns when it comes to disclosure. He suggests that risk managers can improve disclosure by acknowledging those problems.

"I, as an MD, would want the risk manager to come to me and acknowledge that there are barriers and challenges to disclosure that no one else involved in this error faces," he says. "The emotions, the anxiety, the risk to professional reputation, all these negatives need to be acknowledged before you start pushing me to disclose. Empathize, in detail, and you can really disarm a lot of the negatives that stand in the way of a physician and full disclosure."

References

1. Kaldjian LC, Jones EW, Rosenthal GE. Facilitating and impeding factors for physicians' error disclosure: A structured literature review. Jt Comm J Qual Patient Saf 2006; 32:188-198.

2. Gallagher TH, Waterman AD, Garbutt JM, et al. U.S. and Canadian physicians' attitudes and experiences regarding disclosing errors to patients. Arch Intern Med 2006; 166: 1,605-1,611.

3. Gallagher TH, Waterman AD, Garbutt JM, et al. Choosing your words carefully: How physicians would disclose harmful medical errors to patients. Arch Intern Med 2006; 166:1,585-1,593.

Sources

For more information on encouraging physicians to disclose medical errors, contact:

  • Thomas H. Gallagher, MD, University of Washington School of Medicine, Warren G. Magnuson Health Sciences Center, Box 356340, 1925 N.E. Pacific St., Seattle, WA 98195-6340. Telephone: (206) 616-7158. E-mail: thomasg@u.washington.edu.
  • Lauris Kaldjian, MD, PhD, University of Iowa Roy J. and Lucille A. Carver College of Medicine, 5137 Westlawn, Iowa City, IA 52242-1178. Telephone: (319) 335-6705. E-mail: lauris-kaldjian@uiowa.edu.