When Doctors Admit Their Mistakes


One afternoon, I overheard a nurse asking another physician how she was feeling. The physician, a young woman known throughout the hospital for her cheery disposition and sunny bedside manner, looked ashen. She smiled weakly in response and insisted that nothing was wrong.

“She’s lying,” the nurse whispered to me as the doctor walked away. “She’s upset because risk management wouldn’t let her go to that patient’s funeral.”

That the optimistic young physician would grieve following a patient’s death hardly surprised anyone. We had all seen her go through the death of a patient before: she worked in a specialty where such loss was relatively common, yet she fearlessly continued to develop deep relationships with those she cared for. However, as the nurse so perceptively noted that afternoon, what was more difficult for her to bear this time was not the loss but the constraint imposed on the relationship afterward.

Her patient had died in the hospital a week earlier. In conversations in the hallways and clinics, other doctors and nurses combed through the facts of the event hoping to find some detail — a physiological oddity, an honest misunderstanding, even an error — that could help prevent the same thing from happening to our patients in the future.

But then rumors that the family was considering a lawsuit began to make the rounds. Soon afterward, administrators from risk management, the department of the hospital devoted to improving safety, began warning us not to talk about the case — not to one another, not to the news media and, most of all, not to the family. It was not hard to understand why under this new order of silence attending a patient’s funeral might be discouraged.

Several weeks later, I ran into my colleague once more and asked if she had heard anything about the patient’s family. “Yes,” she said lowering her voice. She pulled me over to a quiet end of the hallway and recounted a recent phone conversation with the patient’s mother. Then she took a deep breath and began grinning broadly. “I know the hospital and the lawyers and the other doctors might disagree with what I did, but I had to talk to the family,” she said. “I just couldn’t abandon them.”

Despite the best efforts of health care professionals, bad things can happen in hospitals. Up until more recently, when errors occurred, the scenario that played out was always the same. Clinicians, devastated but fearful of litigation, would shut down. Patients and their families, grieving but desperate to make sense of the event, would find that their doctors and nurses were no longer responsive or available. Eventually, the most important relationship in health care, that between patient and doctor, would cede to the most adversarial one, that between plaintiff and defendant.

In the late 1980s, one hospital system, the Veterans Affairs Medical Center in Lexington, Ky., decided to try another approach to medical mistakes. Doctors there eventually published a paper describing their ”humanistic risk management policy.” It included early review of the events that took place, full disclosure to patients of accidents or errors, fair compensation for injuries and ongoing attention to the relationship between clinicians and patients. And it appeared to decrease liability claims and costs.

Encouraged by these early results and by emerging data linking open disclosure with patient satisfaction, quality of care and improved overall safety, a few other intrepid health care systems across the country began to experiment with similar programs.

Few at the time could argue against the benefits to patients of open disclosure. But in the years since, one question has remained: are these policies also beneficial to physicians, many of whom are already struggling just to get their work done?

According to a study released this week in The Annals of Internal Medicine and the experience of one of the early-adopter institutions, the answer appears to be yes.

Since 2001, the University of Michigan Health System has handled patient injuries by initiating discussions with patients and families, conducting internal investigations and offering apologies with offers of compensation should those investigations reveal medical errors. To examine the repercussions of such an open disclosure with compensation policy, researchers analyzed the number of claims and lawsuits filed against the hospital system between 1995 and 2007, comparing data from before and after the policy took effect.

Contrary to fears that such transparency might worsen litigation, the researchers found that there were actually fewer lawsuits and claims after the hospital began its disclosure with compensation program. Moreover, the hospital system’s liability costs for lawsuits, patient compensation and legal fees dropped, and claims in general were resolved faster than ever before.

“Everybody worries that disclosure will lead to liability going through the roof,” said Dr. Allen Kachalia, lead author and an assistant professor of medicine at Harvard Medical School. “But here’s one institution that set up their disclosure program privately and independently, helped their patients avoid using the courts and tort system, and did not sustain the skyrocketing claims and costs that others might have predicted.”

The disclosure process at Michigan involves a series of meetings that take anywhere from a few weeks to more than a year to complete. Doctors, other involved clinicians and members of the hospital’s risk management department meet with the patient and family members to explain the events, offer assurances that the investigation will be timely and thorough, and promise that all will be done to prevent such a mistake from ever occurring again. While not all of the injuries investigated are due to errors, those that are result in compensation ranging from a simple formal apology to a check, mortgage payments and funding for named lectureships and memorials.

“When you break that paradigm of litigation and give patients the chance to understand the human element of the other side — of the doctor and what they are struggling with — you find that people are far more forgiving and understanding than has been typically assumed,” said Richard C. Boothman, one of the study’s authors and the medical center’s chief risk officer, who devised and carried out the disclosure program. “We have given patients no alternative but to sue, and then we use the fact that they sue to show how opportunistic and awful they are.”

While the study documents the financial bottom line, Mr. Boothman notes that there have been perhaps even more significant repercussions in the culture of the institution. When the program first started, for example, a majority of injury reports came from patient lawyers. “Today more than 75 percent of the time we learn of an incident from the clinicians or from the patients themselves almost as soon as it happens,” Mr. Boothman said.

That openness has in turn created an environment where patient safety and patient care, not avoidance of litigation, have become the priority.

“All this program does is give permission to doctors and other caregivers to do what’s important and what they want to do — take care of the patients and make sure the same error doesn’t ever happen again in the future,” Mr. Boothman said.

The study authors acknowledge that more research needs to be done examining the effect of disclosure with compensation policies on health care settings other than large academic medical centers like their own. Nonetheless, they believe that their experience has shown that openly discussing, admitting and even apologizing for medical errors is important not only for patients but also for doctors and the doctor-patient relationship itself.

“Everyone loathes litigation, but it’s the only alternative we’ve ever given anybody,” Mr. Boothman said. “Something is wrong if the only way we can address medical errors prevents human beings from understanding one another.”

He added: “There has to be an appreciation across the board that we are all in this together.”

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