Here's the situation: Your 55-year-old wife has just had a stroke and lies recovering in a hospital bed. She's been seeing an internist for many years for type 2 diabetes, hypertension and, more recently, heart palpitations.
What you don't know is that behind the scenes the hospital neurologist is chewing her lip. Having looked through your wife's medical record, she's found two electrocardiograms from your wife's past visits to that primary care physician that clearly showed atrial fibrillation. A-fib is a potentially serious but treatable disruption of the heart's pumping rhythm that is known to increase the risk of stroke. Your wife's doctor, however, interpreted those chart squiggles as normal, reassured her that the arrhythmia was probably due to anxiety, and advised her to go home and relax.
Question: Would you want to be told of the neurologist's concerns? More to the point, would your wife … who, after all, is the patient … would she want to be told about the internist's misreadings, with the implication that earlier therapy might well have spared her the debilitating stroke?
When that scenario was described in the New England Journal of Medicine last October, more than a third of the physician readers who responded to an online poll said they would not have informed your wife of the other doctor's mistakes. To be sure, 22 percent allowed that they would clue in the hospital's peer-review committee. But 13 percent said they would keep mum altogether about their compeer's lapses.
Fear and Complexity
To Thomas Gallagher, M.D., those figures are disappointing but no surprise. "They're consistent with other research we've done," he says. "Physicians support the general concept that it's important to be open and honest with patients [about errors], but when it comes to specific cases they hesitate to share."
Gallagher, a general internist and professor of medicine and bioethics at the University of Washington School of Medicine, was the lead author of the NEJM article in which that fictional neurologist's dilemma was described. Titled "Talking with Patients about Other Clinicians' Errors," the paper acknowledged that there are many persuasive reasons physicians argue themselves out of performing what almost all agree in principle is an ethical duty. Some of their rationalizations are relatively honorable, some a bit less so.
Among the latter, and the most common, is simply fear. What if I blow the whistle on a colleague and nobody in the institutional chain of command will back me? What if he plots revenge? What if all it does is alienate me from the rest of the team and the medical staff? What if it earns me the reputation of being a troublemaker? What if in calling attention to another doctor's mistake I'm exposing her to severe and perhaps disproportionate internal sanctions, to discipline or license revocation by the state medical board, possibly to a malpractice lawsuit?
"It is not ill will," observes Jo Shapiro, M.D., of Brigham and Women's Hospital in Boston, "to think, ‘I don't want to bring harm to my colleague.'"
"In practice," wrote Gallagher and his coauthors (who included Shapiro), "fear of how a colleague will react, along with strong cultural norms around loyalty, solidarity and ‘tattling'" may deter doctors from voicing concern that a fellow clinician committed an error that needs to be disclosed to the patient.
"There is a natural reluctance," they continued, "to risk acquiring an unfavorable reputation with colleagues, disrupting relationships among and within care teams, or harming one's institution. Power differentials, including those associated with seniority, sex and race; previous relationships with colleagues; interprofessional and other cultural differences; and, in some cases, dependence on colleagues for referrals all create complicated interpersonal dynamics. Pragmatically, time constraints and coordinating meetings with multiple clinicians pose additional barriers."
Further complicating the issue, they noted, is the fact that "potential errors exist on a broad spectrum ranging from clinical decisions that are ‘not what I would have done' but are within the standard of care to blatant errors that might even suggest a problem of professional competence or proficiency."
Obviously, say the authors, the best way to resolve those uncertainties and come to agreement on how to proceed is for both parties to sit down together — the physician who spotted what looks like a medical error and the clinician responsible — and talk the situation through.
The Right Thing to Do
That's what the neurologist in the parable tried. After seeking two second opinions from cardiologists who confirmed that they also saw unmistakable evidence of atrial fibrillation in your wife's earlier electrocardiograms, she met with the internist, a well-respected senior figure in the local medical community and a major source of referrals to the hospital. When she suggested he'd missed the mark, and that your wife should be told, he reacted indignantly. He said he had an old test machine in his office, he was familiar with its quirks, and he stood by his original readings. They were absolutely correct, he maintained. He demanded that the neurologist turn over all further care of your wife to him.
How would you feel if the neurologist were to comply? If she didn't relay her doubts to anyone? If, more to the point, she didn't reveal what she'd found to your wife or you?
Arguments for disclosure of errors that have harmed or may harm patients are often grounded in the Golden Rule: "If the patient were you, doctor, would you want to know?"
That's a good question, allows Shapiro. But it's not the fundamental question. (After all, you might be able to cook up some circumstances in which you think you would not want to know, in which knowing wouldn't change the course of your treatment or would only make you feel helpless, bitter or vengeful.) No, says Shapiro, "The first question I always ask a physician when I'm doing disclosure coaching is: ‘Forgetting your fears and concerns, what do you think is the right thing to do?' And almost always, after a moment of reflection, the answer is: ‘The patient should be told.'"
Shapiro, an associate professor at Harvard Medical School and chief of the division of otolaryngology at Brigham and Women's Hospital, has headed the hospital's Center for Professionalism and Peer Support for the past five years. It's a model program for maintaining clinical staff morale and bolstering interpersonal competencies, and it features a service that is being offered by a growing number of U.S. hospitals (and, perhaps surprisingly, by malpractice insurers): "disclosure coaching."
Admission of error does not come easily to professionals whose guiding principle is "first, do no harm." ("The emotions I mostly hear when I'm doing peer support," says Shapiro, "are sorrow, guilt, shame.") Allegations of error by a colleague are equally fraught. And how should the news be broken to the patient? That takes tact and skill.
This is where a disclosure coach like Shapiro comes in. She's been trained to help the clinicians involved work out what went awry and why, and agree on who can most appropriately communicate the information to the patient — truthfully, clearly, empathetically, apologetically, with promise of follow-up but without excuses, speculation or finger-pointing.
What's not negotiable, says Shapiro, except in cases so rare she won't suggest an example — and which always involve second-opinion review by an unbiased expert, she stresses — is that the patient must be told.
According to some studies, a blanket institutional disclosure/apology policy like Brigham and Women's (it's the law in some states) actually reduces malpractice litigation risk. Lawsuits are "always a realistic concern," acknowledges Shapiro. "But we're not doing this because it's going to help us or hurt us. It's the moral thing to do, even if it's the most inconvenient and stressful and risky. The [patient's] right to know supersedes the possible adverse consequences [to the clinician or the institution].
"We've worked to create a culture of safety," she adds. "We can only get better as professionals and as an institution by learning from our mistakes, including learning from our near misses. Most of the disclosure coaching I do involves errors in which it's not exactly clear why things went wrong, and multiple people are involved. The point is not shaming and blaming. We don't punish as an institution. But," she admits, "not everyone knows that yet."
Only by changing the culture of health care from one of Draconian zero-tolerance coupled with Mafia-like omertà — an internal code of silence enforced by shunning and retaliation — only then can this nation's shocking death rate from medical errors be reduced, declares John Nance, a former pilot and aviation analyst turned patient safety evangelist.
Indeed, in the 14 years since the Institute of Medicine famously estimated that almost 100,000 patients die annually in the United States from preventable mistakes in their hospital care, the toll has only risen, he points out. According to a more recent study by NASA scientist John James, published last September in the Journal of Patient Safety, the verifiable harm is at least twice as great — and doubles again if misdiagnoses and underreporting are factored in.
Safety experts often point to the aviation industry as a model to be emulated by health care. As late as the 1980s, says Nance, cover-ups were common when pilots realized they were flying at the wrong altitude, had goofed in their fuel planning, had crossed another plane's flight path dangerously close or had made a landing approach too low — "mistakes no one other than the crew would have known about." Don't tell was the rule — until an accident gave the game away.
It's different now. Pilots report every departure from safe practice they've committed or observed, says Nance — because they know the consequences will be far worse for them if they don't. And informing on a colleague is a duty that need not mean ruining his or her career. Inadvertent errors will not be punished unless they become a pattern. Risky behavior will be corrected by coaching and minimal discipline. Drinking before climbing into the cockpit, for example, a significant problem until the 1970s, according to Nance, will now, whether self-admitted or reported by another member of the crew, earn a pilot only a trip to rehabilitation. Once. "Do it again," he notes, "and you're gone."
"It's like going back to Parenthood 101," Nance suggests. "I'd rather hear it from you. Otherwise it'll go harder on you." But that also means the copilot who failed to report the captain with whiskey on his breath is in deep trouble as well. "The change has been marvelous!" Nance exclaims. And that, he argues, is how it should work in health care.
"When you have a hospital or a health care system with an enlightened chief medical officer, one who really is part of the C-suite," he declares, "then there's going to be a peer review system in place that works. So let's say we find that Doctor X has been a problem, and you, Doctor Y, said nothing about it. Well, then, we're going to have to question whether you're right for this place!"
A concept that has gained currency among health care institutions is that of the "just culture." It's a pervasive organizational ethos based on openness and fairness, in which staff actively look for risks, freely report errors and hazards, and profit from adverse experience by improving system safety and making safe choices. Occasional inadvertent mistakes are accepted as inevitable — human error — and are dealt with by consoling the people involved and correcting the faulty processes, procedures, training or designs that contributed. Risky behaviors — actions taken by choice because the potential for harm is not recognized or is disregarded — are managed through coaching in situational awareness and realignment of incentives. Only reckless behavior merits punitive action.
Back on earth, notes Gallagher, more than half of nearly 600,000 doctors, nurses, pharmacists and other health care professionals surveyed at more than 1,110 hospitals nationwide in a 2012 Agency for Healthcare Research and Quality study said they believe (as reported in American Medical News) that "their organizations are still more interested in punishing missteps and enforcing hierarchy than in encouraging open communication and using adverse-event reports to learn what's gone wrong."
"It's critical that we strengthen the way our institutions approach just cultures," comments Gallagher. "Senior leaders have to set the example. Adequate distinctions have to be made between individual errors and systems errors."
That's the goal at Brigham & Women's, declares Shapiro. There, over the past two years, she and her colleagues have talked more than 100 distressed clinicians through the aftermath of adverse events. Perhaps a fifth of them involved harm to patients that required disclosure coaching.
Ironically, inculcation of a just culture mentality means that an organization's reported error rate will soar. At the University of Illinois Medical Center in Chicago, where a policy of investigating and disclosing adverse events to patients and offering them appropriate compensation was established in 2005, the annual number of safety incidents flagged by staffers rose from 2,000 in 2005 to 9,000 in 2011.
Had care worsened? Almost surely not. In 2005, a year after the hospital adopted its policy, 14 percent of the clinical staff admitted they'd hesitate to report an unanticipated adverse event to the hospital's safety and risk management department. In 2011, as the nonpunitive promise gained credence, only 3 percent said they'd still be reluctant.
"Although colleague-to-colleague discussions should be the starting point for exploring potential errors, institutions are ultimately responsible for ensuring that high-quality disclosure conversations occur with patients [too], regardless of which clinicians were involved in the event," wrote Gallagher and his co-authors in the NEJM.
And in fact, he concludes hopefully, "We're making slow headway. That's the exciting thing. We're at the end of the beginning."
David Ollier Weber is a principal of The Kila Springs Group in Placerville, Calif., and a regular contributor to H&HN Daily.