By Dennis J. Boyle, MD
Understanding the impact can help improve patient safety
Errors are all too frequent in medicine. The 1999 Institute of Medicine (IOM) report, To Err is Human: Building a Safer Health System estimated that as many as 98,000 deaths occur in U.S. hospitals each year as a result of iatrogenic error or injury. The IOM report strongly suggested that physicians recognize, prevent, and properly disclose clinical errors.
Whenever a medical error occurs, the involved physicians struggle with the aftermath. In 1984, for example, David Hilfiker, MD, a family practitioner and obstetrician misdiagnosed a viable pregnancy as a miscarriage and performed a dilation and curettage procedure. The thought that his patient had lost her child due to his error left him feeling both guilty and angry.
Writing in the New England Journal of Medicine, Dr. Hilfiker recalled this and other situations and discussed his own issues in dealing with such a serious event. He talked to the family about the error, but he did not share his anger or guilt nor did he ask for their forgiveness, believing that it would be wrong for him to share his burden with the grieving couple. However, he noted that “a physician is even less prepared to deal with his mistakes than the average person,” and called for “permission” for doctors to admit errors and share them with patients.
Since then, physicians and others in the healthcare system have learned much about the value of disclosing medical errors. While most of the attention typically (and appropriately) focuses on disclosing the error and addressing the concerns of the patient, the emotions triggered in a healthcare professional when an error occurs are often overlooked. All too often, physicians deal with these emotions in isolation.
The impact on physicians
In 2007, a survey of physicians in the United States and Canada focused on the emotional impact of medical errors. More than 3,000 physicians from multiple specialties participated. The following are among the key findings:
- 61 percent reported anxiety about future errors
- 44 percent reported a loss of confidence
- 42 percent reported sleeping difficulties
- 42 percent reported reduced job satisfaction
- 13 percent reported harm to their reputations
Neither specialty nor nationality seemed to influence the emotional impact of errors, suggesting that this issue affects all care settings. The study also found that even near-misses caused substantial emotional suffering for medical professionals.
Among those more likely to experience adverse emotional effects after an error were physicians who were dissatisfied with how their disclosure of serious error went. These dissatisfied physicians were also more likely to perceive themselves to be at an elevated risk for lawsuits, spend more than 75 percent of their time in clinical practice, and be female.
Other studies have suggested that errors can increase the physician’s risk of depression, substance abuse, and suicide. For some providers, the lingering emotional impact of an error can lead to disabling psychiatric symptoms such as posttraumatic stress disorder.
In a prospective, longitudinal study of residents, self-perceived errors were associated with reduced quality of life, increased burnout, and depression. Interestingly, those who experienced burnout reported increased rates of errors in subsequent months. This finding suggests a cycle in which errors and negative emotions beget each other.
What physicians need
It’s important to understand the needs and coping habits physicians have after an error occurs. A survey of family physicians identified the following four needs:
- The opportunity to talk to someone (cited by 63 percent of respondents)
- Reaffirmation of their competence (cited by 59 percent)
- Validation of their decision-making process (cited by 48 percent)
- Reassurance of their self-worth (cited by 30 percent)
To promote emotional healing, physicians may need to disclose the error to the patient and study the error for lessons learned. This requires that the discussion be safe and open.
The process of medical education can sometimes lead residents to develop coping mechanisms that are maladaptive. Traditionally, medical students are gradually socialized to expect perfection in themselves and others. Although accepting responsibility for errors is an important step, maladaptive coping mechanisms can evolve into a persistent reliance on isolation and silence.
At one extreme, some providers cope with errors by leaving the practice of medicine entirely. At the other end of the spectrum, physicians may become unnecessarily cautious in subsequent encounters, resulting in the overuse of tests and procedures (which in turn can lead to increased healthcare costs and harm to patients).
Some physicians may develop constructive coping strategies that do not depend on support from others within the healthcare community. Generally, physicians have not developed such strategies and desire more support from colleagues and institutions.
The emotional impact on individual physicians may eventually limit the success of healthcare organizations and the satisfaction of employees, medical staff, and even patients. As the patient safety movement continues to promote transparency in health care, addressing the emotional impact of errors should become a more accepted and recognized component of quality improvement initiatives.
Helping physicians deal with the emotional aspects of a medical error can help make medicine safer for everyone. Altering coping mechanism patterns will require a shift in both the medical culture and the habits of individual
Physicians can adopt the following mantra for self-care after an error: You need to recognize, forgive, repent, and finally, remember.
This mantra addresses both the healing aspect and the constructive changes that should occur after medical errors. A number of programs already exist to help deal with medical errors, including the following:
- Schwartz Center Rounds—These multidisciplinary forums are being adopted by many institutions. They enable caregivers to discuss the emotional and social issues that arise in caring for patients.
- Hospital employee assistance programs (EAP), physician support groups, and psychotherapy—Although used in a variety of settings, these programs may also be considered to address the four needs physicians have after a medical error.
- Physician health programs—Several physician health programs designed to help physicians deal with these issues can be found; state medical societies or medical liability insurers may be able to put physicians in contact with one.
- Individual therapy with a mental health professional—This should be the cornerstone of treatment for physicians in distress about a medical error.
Regardless of which model proves successful for an individual physician, the first step is awareness of the widespread impact of such events and how difficult coping might be for the provider.
Dennis J. Boyle, MD, is a physician risk manager for COPIC, a medical liability company. He can be reached at firstname.lastname@example.org
- Hilfiker D: Facing our mistakes. N Engl J Med 1984;310(2):118-122.
- Waterman AD, Garbutt J, Hazel E, et al: The emotional impact of medical errors on practicing physicians in the United States and Canada. Jt Comm J Qual Patient Saf 2007;33(8): 467–476.
- White AA, Waterman AD, McCotter P, Boyle DJ, Gallagher TH: Supporting health care workers after medical error: Considerations for health care leaders. J Clin Outcomes Manage 2008;15(5):240-247.
- Shanafelt TD, Bradley KA, Wipf JE, Black AL: Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. 2002;136(5):358-367.
- Newman MC: The emotional impact of mistakes on family physicians. Arch Fam Med 1996;5(2):71–75.
- Wu AW, Folkman S, McPhee SJ, Lo B: How house officers cope with their mistakes. West J Med 1993;159(5): 565–569.kj.