A discussion about a medical error must be carefully structured.

AAOS Now

Published 5/1/2010
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Aaron Lazare, MD

The apology dynamic

Meeting the needs of the offended party is key in making an apology

During the past 15 years, public and private apologies have increased, as has the body of literature on the application of apologies in various aspects of life. The importance of apologies in medical practice, a more recent phenomenon, was stimulated by the Institute of Medicine’s 1999 publication of To Err is Human and the requirement by The Joint Commission (previously the Joint Commission on Accreditation of Healthcare Organizations or JCAHO) that hospitals inform patients of medical errors.

Little has been written, however, on the apology process itself, particularly the psychological needs of the offended party and how an effective apology meets these needs. Such an understanding can provide a framework for teaching a physician, nurse, or student the fundamentals of offering a meaningful apology.

Most authors—with minor variations—have described the process of apologizing as consisting of acknowledging the offense, offering an explanation, expressing remorse, and offering reparation. I believe that this analysis, although accurate, requires elaboration to enhance the communication of more effective apologies.

I call the traditional perspective of the apology process “The Content of the Apology.” The two additional perspectives that are crucial to the success of the apology—the goals and the framework(s) (Table 1)—address the commonly overlooked needs of offended parties. Failure in any one of these three domains can render the apology ineffective or even counterproductive.

Goals of the apology
The apology process has the following five interrelated goals or outcomes:

  1. Restoring dignity and power
    Patients who have been offended want their dignity and power restored; they do not want to be disrespected, humiliated, or disempowered. Patients may experience humiliation or disrespect when they believe the doctor is withholding important information, lying to them, speaking in a condescending manner, failing to listen attentively, cutting them short, or avoiding them. Patients report feeling respected and their dignity restored by the demeanor of the physician and empowered when their misfortune leads to positive changes in procedures.
  2. Regaining trust
    Following an untoward incident, patients want an apology that they perceive as sincere and genuine and that assures them that the doctor can be trusted to make things right.
  3. Feeling cared for
    Patients want to feel cared for, that they are more than an object that needs to be fixed.
  4. Extending empathy and understanding
    Patients want to feel that their doctors are empathic, that they understand how the patient feels.
  5. Letting go
    Patients want to let go of the hostile feelings and ruminations that consume them. Although not often thought of as integral to the apology process, unless these goals are achieved, apologies are likely to fail.

Content of the apology
The content, which is traditionally regarded as the core of the apology process, must include the following:

  • An acknowledgement of the offense by the offender (physician) with a clear description of the harm done, including the nature of suffering of the patient, an acknowledgment that the patient was not at fault, and an acknowledgment between physician and patient of shared values, what is right and wrong. The issues of fault and values when implicit and obvious to both parties may not need discussion.
  • An explanation of why and how the offense occurred.
  • An expression of remorse by the offender and a deep regret about what happened.
  • An offer of reparation for damages, be it verbal, financial, or otherwise.

Framework(s) of the apology
I use the word framework to describe who is present for the apology discussion, where the apology takes place, when the apology takes place, and the nature of emotional interaction.

Who should be present: The patient—if physically and mentally able—is certainly one of the principals. Family members or friends may be selected by the patient, or with the patient’s consent, according to what they can contribute to the patient’s well being. On the professional side, the attending physician is often the principal. Nurse(s), other staff, and hospital administration need to be considered, depending on their importance to the situation at hand and hospital policy.

The setting of the discussion: If the patient is able to leave the bed, a room that affords privacy and offers comfortable amenities is preferable. Cell phones and other devices should be turned off; distractions and interruptions should be avoided.

The timing of the apology: Formal and complete apologies should be withheld until the presence and nature of the offense or mistake are clear. A generally overlooked but important aspect of timing is the suggestion by the physician for follow-up meetings to track the patient’s progress and listen to concerns that have not previously been verbalized. After a traumatic event that warrants an apology, the offended party will likely become aware, hours or days after the initial discussion, of other issues he/she wishes to discuss.

The nature of the interaction: It is important that the patient has the opportunity for catharsis, verbalizing feelings about the event and the physician. Otherwise, the patient will feel the communication is unsatisfactory and incomplete.

The need for a dialogue: Also important is that the doctor and patient have a dialogue. A rapid monologue by the doctor that prevents interruption by the patient will leave the patient dissatisfied. The patient will have concerns, worries, questions, and feelings that, if unexpressed, can mask distress and deprive the physician of a more complete understanding of the patient’s needs. A dialogue allows the physician and patient to react to each other.

Integrating the healing forces
The above compendium of healing mechanisms in apologies may seem mechanical or unnecessarily cumbersome for clinical practice. They are, in fact, rarely applied in totality in any given apology. In practice, each apology has its own unique healing requirements for effectiveness. It takes skill to listen, observe, recognize, and address the cognitive and emotional needs of a particular patient.

An analogous situation is the physician’s challenge to determine the nature of a patient’s medical problem in the initial examination. The physician rarely conducts a “complete” examination. Based on the patient’s symptoms and a focused history, an experienced physician can determine what additional history needs to be elicited, the degree of completeness of the physical examination, and what—if any—laboratory tests are indicated. The initial examination does not have to be “complete.” It has to be strategic. So too are the decisions about offering an apology. Not every aspect listed in this analysis must be addressed; an experienced clinician will recognize those needed for an effective apology.

The following examples illustrate how a failure to address any one of the three categories can be enough to undermine the effectiveness of the apology:

  • If the patient does not believe that the physician is genuine, sincere, caring, and respectful, it will be very difficult for the other healing mechanisms to overcome the ill will that is generated.
  • Of the content issues, the physician should be most concerned with properly acknowledging and taking responsibility for the offense. Often, an offender is so uneasy about admitting an offense (a mistake) that he or she offers a half-hearted acknowledgement and conditional statements such as “if I caused any trouble,” or uses the passive voice such as “mistakes were made,” or says “I am sorry” without acknowledging responsibility.
  • If the framework issues—the timing, the principals, the setting, or the catharsis/dialogue—are not addressed, the effectiveness of the apology could be compromised. The discussion will not be productive, and the goals of the apology will not be met.

Learning to apologize
In summary, an effective educational model would give the clinician (physician, nurse, and student) the opportunity to understand, practice, and master each individual aspect of the apology. Ultimately, these skills would be integrated to deliver an apology that effectively addresses the unique needs of the patient.

Additional References:

  1. Aaron Lazare, MD, is professor of psychiatry at the University of Massachusetts Medical School in Worcester, Mass., and the author of On Apology, Oxford University Press, 2004.
  2. Berlinger N: After Harm: Medical error and the ethics of forgiveness. Johns Hopkins University Press, 2005.
  3. Gallagher TH, Garbutt JM, Waterman AD, Flum DR, et al: Choosing your words carefully: How physicians would disclose harmful errors to patients. Arch Intern Med 2006;166:1585-1593.
  4. Gallagher TH, Studdert D, Levinson W: Disclosing harmful medical errors to patients. N Engl J Med 2007;356:2713-2719.
  5. Joint Commission on Accreditation of Healthcare Organizations, Standard RI.1.2.2, 1 July 2001.
  6. Kohn KT, Corrigan JM, Donaldson MS: To Err is Human: Building a Safer Health System. Washington, DC, National Academy Press, 1999.
  7. Lazare A: On Apology. Oxford University Press, 2004.
  8. Lazare A: Apology in medical practice: An emerging clinical skill. JAMA 2006;296:1401-1404.
  9. Lazare A: The healing forces of apology in medical practice and beyond. DePaul Law Review 2008;57:251-265.
  10. Leape L: Understanding The Power of Apology: How Saying “I’m Sorry” helps heal patients and Caregivers. Focus on Patient Safety: A Newsletter from the National Patient Safety Foundation 2004;8:1-3.
  11. Mazor KM, Simon SR, Yood RA, et al: Health plan members’ views about disclosure of medical errors. Ann Intern Med 2004;140:409-418.
  12. Shapiro J: Taking the mistakes out of medicine: Minnesota Children’s remakes its culture in the name of safety. US News Online, July 17, 2000.
  13. Wojcieszak D, Saxton JW, Finkelstein MM: Sorry Works! Disclosure, Apology, and Relationships Prevent Medical Malpractice Claims. Author House, 2007.
  14. Woods MS: Healing words: The power of apology in medicine. Doctors in Touch. 2007.