Avoid putting self-image, pride ahead of patient
Avoid putting self-image, pride ahead of patient
Don’t react defensively when medical errors occur
When a physician discovers that he or she has been party to a medical error that caused harm to a patient, the realization is followed by a succession of emotions that, if not managed appropriately, can cause the physician to react in a way that ruptures the physician/ patient relationship and possibly precipitate a malpractice lawsuit.
That behavior — a mixture of fear, defensiveness, pride, and embarrassment — can amount to "medical narcissism," in which a physician is more concerned with preserving his or her own professional identity than with caring for the patient, according to John Banja, PhD, associate professor of clinical ethics and assistant director for health sciences and clinical ethics at Emory University’s Center for Ethics in Atlanta.
Banja’s interest in medical narcissism and the factors that cause breakdowns in communication between patients and physicians began a decade ago, when, while working with hospital ethics committees, he noticed that many ethical dilemmas really boiled down to ruptured relationships between physicians and patients that began with delivery of bad news — sometimes news of a medical error — and deteriorated when the physician started feeling threatened, either by the prospect of delivering the news or by the reaction of the patient and family to the news.
Narcissism: A common human trait
When physicians attempt to conceal or rationalize medical errors, medical narcissism is often the root cause of their behavior.
"It started to dawn on me that the health care professional [who attempts to conceal or rationalize a medical error] felt an assault on his or her professional self — that need we have to appear competent, useful, adequate, and professional," says Banja. "The kinds of situations that assault that professional self are ones that make the health care provider feel inadequate or embarrassed."
During the highly emotionally charged process of delivering a death notice or other bad news, Banja says, the physician often will find his or her judgment or abilities challenged by the family or patient.
Empathy, ethics, and narcissism
"When a potentially volatile piece of information is being touched on and the conversation goes badly, it’s almost always because the health care professional feels they are being assaulted, and they don’t handle those feelings appropriately," Banja explains. "That poor handling consists of his or her psychological defenses being aroused and the health care provider trying to preserve his ego, and this may come off as him sounding brusque or condescending."
If the physician feels his professional self threatened, that may lead to him distancing himself from the patient by refusing to take phone calls, dominating conversations with the patient or family, or deflecting discussions that he doesn’t like by using evasive techniques, such as saying, "let’s look on the bright side," or changing the subject completely, Banja continues.
Understanding why these breakdowns happen and what can lead to poor communication of medical errors requires study of three factors: empathy, ethics — and, Banja says, narcissism,
As he describes it, the empathetic health care provider is vitally interested in the patient’s experience of what is happening and what the principles of autonomy, nonmaleficence, and beneficence mean to that patient. Ethics deal with how each individual’s ideas of right and wrong affect the health care relationship. Narcissism in this context is not the clinical psychological diagnosis of narcissism but a lack of empathy and regard for the patient and an inability of the physician to extract himself from his world of beliefs and feelings to consider that the patient might be experiencing the situation differently.
If the narcissistic provider is unable to consider that the patient or family member sees things differently from the way the physician sees things, he or she will reflexively consider that the other person’s reaction or experience is wrong, Banja says.
"Needless to say, the behaviors associated with narcissism — lack of empathy, lack of other-regard, intense self-preoccupation and self-interest, emotional distancing, etc. — are not conducive to a good relationship," he says.
Banja acknowledges that owning up to a medical error, particularly one that results in harm, is one of the most difficult patient communications a health care provider can have.
Avoid these common communication mistakes
The way that the patient or family is told the bad news will affect the outcome and the patient/ physician relationship. Among the mistakes Banja says he has seen in communicating medical error information are the following:
- It wasn’t really an error. The physician might convince himself that what happened wasn’t really a medical error but rather a complication or the result of the patient being very sick before the event ever occurred.
- Maybe the error didn’t really cause the subsequent harm. Banja illustrates this point by relating the story of an anesthesiologist who turned off a ventilator during surgery and forgot to turn it back on. The patient suffered irreversible brain damage due to anoxia, but the anesthesiologist argued that he wasn’t convinced that the lack of oxygen was the cause of the patient’s resulting condition.
- Yes, there was an error — but the patient was going to die anyway. Banja says this approach rationalizes an error with an end-of-life patient by saying there was an error, while the patient died from the underlying condition.
- It was the nurse/family/patient’s fault. Blaming others, including the patient, is common, Banja says. "The surgeon might say, Yes, I left a sponge in the patient, but that’s because the nurse gave me an incorrect sponge count, so I closed, and now look what happened.’" Or, the physician might blame the patient’s health, the patient’s care of him- or herself prior to seeing the physician, or the patient’s insurance coverage for contributing to the error.
"What was the real eye-opener for me in studying the architecture of a medical error is that when a health care professional is intent on wiggling out of [disclosing an error], the health care professional can always rationalize, somehow, concealing a piece of that phenomenon," Banja explains.
Telling a patient or family member that a medical error has happened and has caused harm "is the mother of all disclosures," Banja says, and the instinct to go on the defensive is a natural human reaction. That instinct "is the narcissism in us all" and is not limited to those who work in health care, he says.
But the effect that withholding information or hiding an error can have on the credibility of a practitioner and on the physician/patient relationship can be far-reaching. Banja examines the legal, psychological, and ethical implications of medical errors for patients and health care professionals in Medical Errors and Medical Narcissism, published in 2004.1
"A prominent reason for telling a patient the truth is that we respect their autonomy. If I harmed you, but didn’t tell you, our relationship proceeds on false pretenses," Banja says. "If you get a hint that I am withholding information from you or being ambiguous, you are going to suspect my character. And if trust is an important ethical ingredient, that trust will be terribly diminished and eroded."
How and why to say sorry’
A coalition called Sorry Works! has made strides in gaining acceptance of the idea that many medical malpractice lawsuits arise simply because families and patients felt dismissed by hospitals and physicians who did not own up to errors, apologize for errors, or show willingness to take steps to safeguard against the recurrence of errors.
Banja concludes that the fear of malpractice and anxiety over being blamed form the basis for much narcissistic behavior and failure to disclose medical errors.
"There’s fear of malpractice suits, being reported to the state medical board, censure, embarrassment — all those things play into the temptation to conceal medical errors. Physicians will say they always talk to their patients about errors, but what they don’t say, or don’t realize they leave out, are words like error,’ harm,’ and mistake.’
"It’s rare that a physician will say something as straightforward as, I’m sorry this error occurred and that it harmed you.’"
Sorry Works! and other efforts like it encourage hospitals to take a proactive approach to making amends when medical errors occur by making full disclosure to patients and families and providing clear steps that will be taken to prevent similar errors from being repeated. Three states have passed or are in the process of adopting legislation based on the Sorry Works! model, which has been credited with reducing malpractice costs at several major hospital systems in the United States.
Banja cautions that any apology-based, institutional method of handling error disclosure should involve both the health care practitioner and the institution so that the clinician is not made to feel that the institution is blaming him or her for the error.
Medical training needs to change
In addition to institutional policies on communicating medical error information, Banja says medical schools need to teach students how to deal with making mistakes.
"Historically — and it may not be as common now — the training atmosphere of health care insisted on errorlessness. Failure was seen as a moral failure, not just a failure in training," he explains. "What we need to do on the teaching level is eradicate the idea of perfectionist expectations in health care. We have to teach nurses and medical students how to have these conversations and how to control these feelings.
"We should pay attention to errors and reduce errors, but we also should understand the uncertainty and riskiness of health care, and that errors are always going to happen."
Reference
- Banja J. Medical Errors and Medical Narcissism. Boston: Jones and Bartlett Publishers; 2004.
Sources
- John Banja, PhD, assistant director for health sciences and clinical ethics; associate professor of clinical ethics, Center for Ethics, Emory University, 1462 Clifton Road NE, Atlanta, GA 30322. Phone: (404) 712-4804. E-mail: [email protected].
- Sorry Works! information is available at www.sorryworks.net.
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