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Research Institute: Patients Don't Forgive and Forget about Medical Errors

One of the leading risk management theories states that we can minimize our risk of being sued if we voluntarily inform patients of medical errors and apologize. It is said that the vast majority of patients will simply forgive us, forget about their injury, and not seek compensation (i.e., sue us for malpractice).

The proclivity of patients to forgive and forget was evaluated in a Johns Hopkins study, which examined patient reactions to various ways of handling medical errors. The authors simulated three approaches to an error: no apology, partial apology (empathy without admission of fault), and full apology (with admission of fault). The simulations were filmed and then shown to 200 subjects, who were asked to provide their reactions to the scenarios.

One of the most intriguing outcomes of the study was that the subjects were not able to reliably discern the scenarios which involved an apology from those which merely involved empathy. In other words, the study subjects did not interpret the scenarios in the same manner as the investigators had constructed them. This is significant as it seriously undermines the theory. After all, how can we rely on patients forgiving and forgetting when they cannot reliably discern whether we are actually apologizing?

However, the other results raise even bigger concerns. For the scenarios in which the observers perceived an apology (whether or not an apology actually occurred), they rated the involved physician as being much more trustworthy. However, despite the fact that it produced greater trust, the perception of an apology had NO effect on the likelihood that the person would sue.

What the authors found was that patients could not reliably discern an apology. And, even when the person believed that an apology occurred, it had no effect on the likelihood that he or she would sue. The authors concluded that what patients hear may be more important than what we actually say. However, in terms of avoiding lawsuits by apologizing, what the study showed is that it doesn’t matter what we say or what the patient hears. They sue anyway.

This outcome is not surprising. The idea that lawsuits occur because of broken relationships which can be healed with an apology is fundamentally flawed. Lawsuits are a tool which injured parties use to obtain financial compensation from the person who injured them. Lawsuits are about money and apologies do not pay the bills.

Disclosing medical errors to patients: it's not what you say, it's what they hear.

Wu AW, Huang IC, Stokes S, Pronovost PJ

J Gen Intern Med. 2009 Sep;24(9):1012-7. Epub 2009 Jul 4.

Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Room 653, Baltimore, MD 21205, USA. awu@jhsph.edu

OBJECTIVE: To determine if volunteers' reactions to videos of physicians disclosing adverse events are related to the physician apologizing and accepting responsibility.

DESIGN: Survey of viewers randomized to watch videos of disclosures of three adverse events (missed mammogram, chemotherapy overdose, delay in surgical therapy) with designed variations in extent of apology (full, non-specific, none) and acceptance of responsibility (full, none).

PARTICIPANTS: Adult volunteer sample from the general community in Baltimore.

MEASUREMENTS: Viewer evaluations of physicians in the videos using standardized scales.

RESULTS: Of 200 volunteers, 50% were <40 years, 25% were female, 80% were African American, and 50% had completed high school. For designed variations, scores were non-significantly higher for full apology/responsibility, and lower for no apology/no responsibility. Perceived apology or responsibility was related to significantly higher ratings (chi-square, 81% vs. 38% trusted; 56% vs. 27% would refer, p < 0.05), but inclination to sue was unchanged (43% vs. 47%). In logistic regression analyses adjusting for age, gender, race and education, perceived apology and perceived responsibility were independently related to higher ratings for all measures. Inclination to sue was reduced non-significantly.

CONCLUSIONS: Patients will probably respond more favorably to physicians who apologize and accept responsibility for medical errors than those who do not apologize or give ambiguous responses. Patient perceptions of what is said may be more important than what is actually said. Desire to sue may not be affected despite a full apology and acceptance of responsibility.

Medical-legal education with a passion for medicine and compassion for patients.