"I’m sorry” is one of the most-used phrases in any language. Most of us don’t think twice about offering an apology when we unintentionally bump into a stranger on the sidewalk. However, when we have made a medical mistake, which most of us have in our medical careers, apologies seem to get stuck in our throats and become difficult or impossible to articulate.
We begin learning detachment early in our medical training. The problem is compounded by the stress of declining reimbursements and increasing overhead costs, giving us less time to bond with our patients. In addition, we are often reluctant to engage our patients in honest, open dialogue.
Moreover, our malpractice insurers tell us that an apology might be interpreted as an admission of fault or negligence that could make defense difficult if the patient files a lawsuit.
The Importance of Communication
Assuming an inverse relationship between a lawsuit and communication with the patient, the likelihood of being sued decreases significantly as communication between physician and patient increases.
The physicians demonstrate good communication skills when they ask the patients questions, encourage them to talk about their feelings, use humor when appropriate, and educate patients about what to expect during treatment.
Physicians with enhanced communication skills spend about 3 minutes more with their patients than those who have been sued. Another fact that is worth noting is that when an apology is offered, and the details of the medical error are disclosed in a timely fashion, the likelihood of a lawsuit decreases by 50%.(1)
Is it surprising that with the current time constraints on surgeons who send a resident, nurse, or medical assistant to the patient’s bedside to obtain the consent for surgery, there is a potential lawsuit if the outcome is less than anticipated?
How can we effectively apologize without admitting guilt or wrongdoing? An authentic apology is one that is heartfelt and driven by true regret or remorse. Five reasons to consider an apology are:
To show the patients you respect them.
To accept responsibility for the situation.
To demonstrate that you care how the patient feels.
To express your empathy.
To dissipate a patient’s anger.
Patients want to know what happened and why it happened, how the problem or error will affect their health in the short and long term, what is being done to correct the problem, who will be responsible for the cost of the error or complication, what has been learned, and what the physician is doing to avoid this happening again.
Expressing the Apology
The first step in apologizing is admitting to yourself that there has been a mistake and that an apology is in order. Then, deliver the apology.
Whenever possible, offer the apology in person, face to face with the patient or family. The apology should take place in a quiet environment with no distractions. Give the apology your undivided attention. Any distraction or interruptions will negate its impact. Turn off your cell phone and inform your staff that you are not to be interrupted while you are with the patient. Sit near the patient with no barriers such as an exam table, desk, or computer between you.
Begin the conversation by stating that you are sorry. This means using “I” words and not pointing fingers or using “you.” Say, “I am sorry.” Do not follow the apology with “but”! Don’t make excuses or blame someone else.
Own the mistake. Show the patient that you’re willing to take responsibility. Admit something went wrong; anything else makes the apology ineffective.
Be honest and describe what happened. Use language that the patient understands. Consider using visuals to explain the issue or problem.
Acknowledge their hurt and suffering. Consider saying something like, “I know how this must make you feel, so before I continue, I would like to hear what you have to say.”
Stop talking. Listen to the patient without interruptions. Studies have indicated that a patient explaining their medical problem to a physician is typically interrupted by the physician after 16 seconds.(2 )Ideally, patients will share their feelings and forgive the doctor for the error. This forgiveness won’t occur if the doctor is frequently interrupting the patient.
Offer a plan of action. Offer to obtain another opinion or refer to another more experienced colleague. If there will be no charge, share that with the patient, who may have concerns about the finances associated with the follow-up care. Indicate that you will continue to be involved until a satisfactory solution is reached. This indicates that you will stay with the patient physically and emotionally.
Describe the error as a learning experience for you and your practice. Emphasize that you will make every effort to ensure that the situation does not happen to future patients and describe how you intend to do so.
Finally, reiterate your apology. Cycle back and repeat, “I’m really sorry this happened. I hope you will forgive me.” The patient may not forgive you right then, but if you were sincere and honest, the forgiveness might be forthcoming.
An Apology Scenario
A Hispanic patient with limited English proficiency had a ureteral stent placed following shock wave lithotripsy for a kidney stone. The patient didn’t return for follow-up. A year later, the patient returned. The stent had been encrusted with calcium deposits, making it impossible to retrieve through a simple cystoscopy. The patient required additional open surgery to remove the stent.
The urologist requested a translator to facilitate communication with the patient and met with the patient and one of his family members in the doctor’s private consultation room. It was the end of the day, and most of the staff had left. The urologist turned off his cell phone and told the remaining staff he did not want to be interrupted. Chairs were arranged for the patient, his wife, the translator, and the doctor, all on the same side of the doctor’s desk.
The doctor begins, “Nice to see you and meet some of your family. Thanks for coming in so we might discuss what has happened to you.
“We placed a tube between your kidney and your bladder for the purpose of preventing any blockage with fragments of the small stones after that machine we used to break up the stone in your kidney. This tube was to be removed in two weeks. Our office tried to reach you, but we weren’t successful in locating you or a family member.
“I take full responsibility for not trying harder to find you and to remove the tube.
“Because the tube remained for a longer period, we had to make an incision to remove the tube. I know that this caused you pain, discomfort, and loss of time from your work. I want you to know that I take full responsibility, and we are putting into place a plan to reach all patients who have this tube so they aren’t lost to follow-up.
“We have contacted your insurance company, and they have assured us, and we assure you, that the additional surgery will be covered and you will not have any additional out-of-pocket costs.
“Do you understand what happened and the explanation? Again, I am sorry that this happened to you. Do you have any questions?”
The patient asks a few questions about his kidney function and restrictions to protect his kidneys. The patient acknowledges an appreciation for the doctor, his staff, and all their care. He understands what happened and appreciates the honesty of the doctor. The doctor is silent and does not interrupt the patient’s response.
The doctor reiterates, “I’m really sorry this happened. I hope you will forgive me, and I want you to know that you are a terrific patient, and I appreciate the opportunity to take care of you. If you ever have any questions or concerns, please call me any time.”
Conclusion
Mistakes are not only devastating for patients, but also damaging to the physician. An apology by the physician demonstrates understanding, compassion, and empathy. It is an opportunity to preserve the doctor-patient relationship. Doctors who admit responsibility and apologize are less likely to be involved in litigation.
References
Dahan S, Ducard D, Caeymaex L. Apology in Cases of Medical Error Disclosure: Thoughts Based on a Preliminary Study. PloS One. 2017;12(7):e0181854.
Groopman, J. How Doctors Think. New York: Houghton Mifflin Harcourt;2008.