Needless to say, his response elicited a mixture of shock and joy. The shock resulted from the discrepancy between what he, as a respected attorney, was saying, and the recommendations of legal representatives of some malpractice insurance providers that advocate an “Above all, admit no wrong” policy. The joy came from the intuitive recognition that taking responsibility and apologizing for the error is the decent thing to do, as well as being the only thing that will lead to true forgiveness. Additionally, many practitioners intuitively recognize that the “admit-no-wrong” approach is more likely to lead to legal action than prevent it.
Because this is such an emotional issue for many practitioners, let’s look at an example from outside veterinary practice. Like most veterinarians, Dr. Samuelson is not blessed with a lineup of professionals in other areas who never make mistakes, although many do quality work most of the time. Suppose that one day Dr. Samuelson takes her car to the local garage she has patronized for years and recommended to others. The novice mechanic determines that her right front tire needs to be replaced, and she accepts his recommendation. The next day while driving in heavy traffic on a multi-lane highway, she suddenly senses a disturbing vibration from the right front end of her car. With as much luck as skill, she literally wrestles the car to the side of the road, hitting a guard rail in the process. Once she regains her composure, she has the car towed to the garage.
The owner of the garage immediately notices that three of the lug nuts are missing from the wheel and the remaining ones are loose. He then murmurs sympathetically, “I understand how upset you feel at this time,” and offers to write up an estimate on how much it will cost to repair the damage.
What responses could Dr. Samuelson make under these circumstances? One would be to accept that the looseness of the front wheel and resultant damage to her car was just one of those things that happens, and she should be grateful for the mechanic’s sympathy. Another would be to expect the mechanic to a) acknowledge responsibility for the error, and b) repair the damage caused by it at no charge. If she considers b) as the appropriate response, any reluctance on the garage owner’s part to agree might then lead Dr. Samuelson to contact her lawyer and perhaps seek punitive damages in addition to payment for everything else.
However, while most veterinarians immediately recognize the need for other professionals to acknowledge their mistakes, nothing strikes fear in the hearts of many practitioners more than the idea of doing so themselves. Past columns have noted how a lack of communication skills, more than a lack of medical knowledge, may result in malpractice suits. But as with most discussions on the subject, the primary focus is on quality communication to avoid such mistakes.
Like so many others, I did not feel comfortable discussing the long-standing “Admit no wrong” tradition that has dominated human and veterinary medicine for years. However, lately there has been a trend in human medicine that advocates radical changes in how clinicians address medical mistakes when they occur. Because of this, it seems reasonable to ponder these recommendations as they might benefit veterinary practitioners, too.
This trend is discussed by Dr. Lucien Leape, adjunct professor of health and policy at the Harvard School of Public Health, in an article titled “Disclose, Apologize, Explain.”(1) This mass media recap of more scholarly treatises on the subject is cited because, aside from reflecting other articles accurately, it also points out that this approach is going mainstream. Once the public becomes aware of what an increasing number of medical professionals consider the ideal way to deal with medical errors, they will expect the same response from their medical professionals. It seems reasonable to surmise that because veterinary medicine has long capitalized on its similarity to human medicine, some people will have the same expectations of their veterinarian.
Dr. Leape notes that in a recent survey of several thousand physicians who were presented with scenarios in which obvious errors occurred, only 42% said they would inform the patient or patient’s representatives of the errors. An even smaller percentage (37%) said they would offer any information on how they intended to prevent such errors from recurring. Dr. Leape gives 2 reasons for this unwillingness to share information on errors. The 1st reason is that physicians are human and no human likes to admit that he or she has made a mistake, especially one that has caused harm. The 2nd reason is that physicians erroneously believe that his or her patients expect them to be infallible, although Dr. Leape made no mention of the paternalistic nature of medical education fueling this clinician and public expectation.
Interestingly, Dr. Leape also does not mention the critical f-word — fear — at this time. Nonetheless, he does give the 4 essential steps in addressing medical errors. These steps, identified by a coalition of 14 hospitals associated with Harvard Medical School, warrant consideration by the veterinary profession.
- Tell the patient and family what happened, providing all known facts.
- Take responsibility. For veterinarians who own the practice, this means that the “buck stops with you,” even if the error was committed by someone on your staff. Most certainly, any subordinates also should accept responsibility for their roles, but the ultimate responsibility still rests with the owner.
- Apologize at once.Interestingly, Dr. Leape begins to get fuzzy here, referring to offering a “true” apology later if an investigation indicates that injury was caused by the error. This seems to imply a certain “untrueness” of the initial apology. He also notes that “Compassion diffuses anger and begins to restore trust.” However, if any “compassionate” apologies come across as lame platitudes, they could backfire. It is far better to apologize upfront for what is known at the time and then follow up with an equally sincere and more detailed apology as the details of the mistake become known. In other words, don’t cover up.
- Explain what will be done differently in the future. Most people who experience losses as a result of medical errors naturally seek comfort of some sort. For most, their only consolation may come from the knowledge that changes will be made to ensure that no one else need go through what they did. Consequently, providing them with this assurance can help them with any healing process.
At the close of the article, Dr. Leape finally mentions fear of malpractice suits as the “elephant in the room” for most clinicians. Like others, he then points out that experience proves that the “Above all, admit no wrong” approach is bad advice.
Since the United States Department of Veterans Affairs began a program of disclosure, apology, and early financial compensation in the 1990s, the number of malpractice suits has been dramatically reduced. Similar programs run by physician insurers in Colorado and at the University of Michigan are yielding equally positive results.
This leads to the addition of a 5th point that Dr. Leape only implied — early financial compensation. Although it may strike some as sound fiscal management to charge a client for all the medical services needed to rectify a medical error or otherwise deal with its consequences (including euthanasia), most clients see this as the ultimate slap in face by an utterly uncompassionate, as well as incompetent, practitioner. For those who would argue that they did the work and deserved to be paid for it, it may be wise to run a quick cost-benefit analysis. While it might appear that this approach works in the short run, in the long run the cost of a lawsuit triggered by what the client considers the practitioner’s crass insensitivity or even just the loss of business as the client spreads the word about the practitioner’s response may cost far more.