Physicians hurt when patients hurt

S. Jay Jayasankar, MD; Sara Nadelman, MPH; and Jo Shapiro, MD

“It feels like the ground has fallen from underneath your feet and your breath has been stolen—you’ve made a medical error. Is there any way to undo it?” That was the reaction of David Ring, MD, to an adverse event he experienced. As physicians, we likely will or have already experienced similar emotions at some point in our careers. We often feel intense concern and empathy for the patient, even if no error is involved.

Personal involvement in an adverse event that harmed a patient can be a demoralizing experience. As outlined by Dennis J. Boyle, MD, a physician risk manager for COPIC, a medical liability company, physicians can lose their confidence and become anxious about future errors; they need reaffirmation of their competence and validation of their decision making.

How do we, as physicians, deal with the feelings of shame and guilt that haunt us after a patient is harmed? Shame is “an emotional reaction to the experience of failing to live up to one’s image of oneself,” wrote Aaron Lazare, MD, in his 2005 book On Apology. For 20 years, shame kept Danielle Ofrey, MD, from talking openly about an error that had occurred during her residency. She identifies shame and resultant inability to admit to error as a key obstacle to improving patient safety.

These feelings are compounded by fear, anger, and isolation. The effects on a team that experiences an adverse event can be far reaching if they are not dealt with appropriately. David Hilfiker, MD, writing in The New England Journal of Medicine, said, “Although patients are the first and obvious victims of medical mistakes, doctors are wounded by the same errors.” He adds, “A physician is even less prepared to deal with his mistakes than the average person.”

Being involved in a serious adverse event can shake a physician’s confidence and that of his or her team. Emotionally impaired physicians are more likely to behave unprofessionally and experience burnout that can lead to patient safety risks and medical errors.

In Dr. Ring’s case, he apologized to the patient and family for the aforementioned error, alerted hospital administration, and performed corrective surgery. He adds, “And how was I handled? Brilliantly. Within minutes of completing the second procedure, operating room leadership was there to console and support me. The next day when we debriefed as a team, I tearfully apologized. ‘I blew it,’ I said. And our vice president of quality and safety at the hospital responded, ‘We all blew it.’”

Not everyone has the supportive environment that Dr. Ring describes. Underreporting near misses and mistakes to hospital leadership, the patient, and the patient’s family is a serious problem. Understanding why mistakes occur cannot happen unless the culture promotes safe reporting. At Brigham and Women’s Hospital (BWH), a peer support program and a disclosure and apology program (co-sponsored by Risk Management and CRICO, the liability carrier for Harvard physicians) helped to change the culture.

The BWH Center for Professionalism and Peer Support
At BWH, the innovative Center for Professionalism and Peer Support (CPPS) was developed to provide clinician education programs, guidance, and support. Staff involvement was widespread and included the Center’s Director, Anthony Whittemore, MD (chief medical officer [CMO] emeritus), Stanley Ashley, MD, (CMO), and representatives from a cross section of hospital departments from medical, surgical, graduate medical education, and nursing staff to compliance, risk management, and patient and family relations.

Realizing that physicians need peer support in a variety of situations, we created the first physician-to-physician peer support program to address several dimensions of physician needs, including after an adverse event. The Peer Support Program evolved from research showing that physicians want to be supported in times of crisis by other physicians more than any other group. Physicians rarely access support from nonphysicians, and they are unwilling to share their emotional distress in front of other groups.

The Peer Support Program reflects the intention of a March 2006 consensus paper, “When Things Go Wrong – Responding to Adverse Events,” which was developed and endorsed by all Harvard teaching hospitals and the CRICO Risk Management Foundation (CRICO/RMF). Through one-to-one and group peer support, clinicians can help each other in difficult situations and strengthen the community of trust at BWH. Since 2009, the CPPS, in close collaboration with the Employee Assistance Program (EAP), has trained a network of more than 40 physician peer supporters to reach out to their colleagues and help them deal with serious events. In addition, when something goes wrong anywhere in the hospital involving multiple healthcare team members, group peer support led by EAP and a clinician supporter is available for the team. The group peer support was established several years ago by Janet Barnes, JD, RN; Rick Van Pelt, MD; and many other BWH leaders.

BWH offers multiple resources for patients who have experienced harm, including Patient Family Relations, Social Services, Chaplaincy, and Medically Induced Trauma Support Services (MITSS). Nationally, other types of support programs range from expressive writing interventions (Johns Hopkins Hospital) to cross-disciplinary peer support (Kaiser Permanente and University of Missouri Health System).

Disclosure and apology
The emotional toll of medical errors on the patient, family, care team, and institution is enormous. Specific skills and support are required to have a positive disclosure and apology meeting. An effective apology is essential for a continued physician-patient relationship. The key elements of a successful apology include its goals, content, and framework.

CRICO/RMF and the Institute for Professionalism and Ethical Practice partnered with the BWH CPPS to train disclosure coaches. BWH gives every provider 24/7 access to a trained disclosure coach. To raise institutional awareness of the importance of disclosure and apology, the CPPS director gives a series of grand rounds throughout the institution.

Defendant support
The possible ill effects on clinicians named in a lawsuit include depression, loss of self-confidence, practicing defensive medicine, and, in some cases, leaving the profession altogether. Many physicians consider being a defendant in a lawsuit as an attack on their personal and professional integrity.

To mitigate such effects, BWH has a Defendant Support outreach program. The CPPS is notified by Risk Management when a complaint is filed. The CPPS director and the CMO send the clinician(s) a letter that includes information about the Defendant Support Program and lists senior physicians who have been through the litigation process and are available to provide support. This simple communication provides immediate and significant relief for the affected clinician.

Summary
Knowing that physicians find more comfort and support from peers, BWH developed several clinician support programs, including peer support, defendant support, and disclosure and apology coaching. The CPPS is highly collaborative and receives a high volume of referrals for its various programs.

S. Jay Jayasankar, MD, has served on the AAOS Medical Liability Committee; he can be reached at Jaymd@massmed.org

Sara Nadelman, MPH, is the Project Manager at the BWH CPPS; Jo Shapiro, MD, is Chief of the Division of Otolaryngology at BWH and Director of the BWH Center for Professionalism and Peer Support.

Editor’s Note: Articles labeled Orthopaedic Risk Manager are presented by the Medical Liability Committee under the direction of contributing editor David H. Sohn, MD.

Articles are provided for general information and are not legal advice; for legal advice, consult a qualified professional.

Email your comments to feedback-orm@aaos.org or contact this issue’s contributors directly.

References

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