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Analysis: Why docs. don't say sorry

By OLGA PIERCE, UPI Health Business Correspondent

WASHINGTON, Aug. 15 (UPI) -- The psychological difficulty of telling a patient about a medical error may do more to prevent physician disclosure than the litigious medical malpractice climate, a new study says.

"We think doctors' attitudes about disclosure come much more from the culture of medicine -- attitudes derived from training -- than the external malpractice environment," said Thomas Gallagher, associate professor of medicine at the University of Washington and lead author of a study appearing this week in the Archives of Internal Medicine.

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"At the moment, because they have so little guidance, physicians vary considerably in what they would say and often are not meeting patients' needs," he told United Press International.

Medical errors result in tens of thousands of deaths and tens of millions of dollars worth of additional costs to the American healthcare system each year, yet the Institute of Medicine has estimated that as few as five percent of these mistakes go reported.

Doctors and politicians have pointed to the lawsuit-happy legal system, but, according to the study, the difficulty of looking a patient in the eye and telling them they have been harmed may be a bigger factor.

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In the survey of 2,637 physicians in the United States and Canada, 98 percent supported disclosing serious errors to patients and 78 percent supported disclosing minor errors, but when they were presented with four scenarios of common physician errors they were much more divided about what to say.

Only 42 percent would use the word "error," 56 percent would mention the adverse event but not the error, 50 percent would give the patient specific information about what the error was and 13 percent would not reveal any details not requested by the patient.

Contrasted with what patients want -- an admission of error, information about the health ramifications, steps to taken to prevent repetition of the same mistake, and an apology -- this disconnect indicates a need for changes in the way doctors talk about mistakes, Gallagher said.

"This points out how early we are as a profession in the area of transparency. The vast majority of doctors haven't had any training in disclosure, and these conversations are really difficult."

The study also calls into question the role of malpractice lawsuits in preventing disclosure to patients.

It confirmed the conventional wisdom that doctors who are more concerned about being sued are less likely to give patients information about medical errors that could be used against them. But that also holds true in Canada, the survey found, where the ability of patients to sue their doctors is much more limited and doctors are sued one-fifth as often.

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"If you took the Canadian malpractice environment and magically transported it to the (United States), it would not make a big difference for patient disclosure," Gallagher said.

A more fruitful approach, he said, is to develop guidelines -- like those currently being discussed by the National Quality Forum -- to help doctors know what to say to patients when they make a mistake.

Some states have also passed laws allowing doctors to apologize without admitting legal liability, which helps, he said. "An apology is an important part of disclosure. It's clear that patients really value an apology."

Doctors also need help conveying errors that are due to more of a system breakdown than individual mistakes, Gallagher said. One example in the study involved an insulin overdose that resulted from sloppy physician handwriting, which should have been caught by pharmacy and hospital safeguards.

Patients need to hear someone take responsibility in such a case, but it is not fair for them to leave thinking the physician is entirely to blame, he noted.

Eventually -- similar to strides made in the last 30 years in telling patients bad health news -- the medical profession will get better at letting patients know a mistake has been made, Gallagher said. And when it does, it could actually reduce the number of malpractice lawsuits.

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Malpractice insurance companies that have experimented with early disclosure, apology and compensation policies have saved money, although no far-reaching studies have been done on the subject.

And while in some cases, disclosure of an error a patient may not have noticed on his own could precipitate a lawsuit, "overall there is a good business case to be made for disclosure," he said.

In the end, malpractice savings will be far eclipsed by the benefits to patients who have better information about their health and may experience fewer errors as a result of more open conversations within the medical profession, he added.

The good news from the study is that 94 percent of doctors said they would definitely or probably disclose an error, Cecil Wilson, board chair of the American Medical Association (AMA), told UPI.

"Patients deserve to know, and the AMA supports that," he said, "but in practice, disclosure may not be as frequent and complete as it should be."

More training and information would be helpful to doctors because "like anything else, it's always helpful to know how to go about it, especially in an area with so many emotions and concerns," he said.

But the threat of lawsuits should not be discounted as a major factor in determining how much physicians feel they are able to tell their patients, Wilson said, and that will require a legislative fix.

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"Our perception is that fear of medical liability litigation is one of the major deterrents," he said.

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