Interacting with the Medical Humanities

Unit 8Section 5 Exercise 20Medical Uncertainty & ErrorApologizing: Practical Considerations

The following is a book review/interview, profiling a book in which Dr Michael Woods recounts the trauma of being sued for malpractice. The topic is apology. As you read the review, try to name the different functions of apologizing, as enumerated by the book's author, Michael Woods. The book's title is Healing Words: The Power of Apology in Medicine

"Healing Words: The Power of 'I'm Sorry' in Medical Practice", by Doug Kaufman, January 24, 2007

"My introduction to trial law began with 45 minutes of opening arguments in which the plaintiff's counsel derided me for incompetence as well as disregard for truth and patient welfare," Dr Woods wrote in "A Case of Failing to Say I'm Sorry," chapter 2 of the book. "He told jurors that I had committed fraud and breached my duty as a physician. He didn't merely question my character, he annihilated it. By the end of the opening arguments, my head was reeling."
"I believe ... that we should be doing this because it's the right thing to do, not because it's going to lower our liability."
–Dr Michael Woods
After 2 weeks of "intense legal debate," Dr Woods won the case. But, as he wrote in "Healing Words," he won the battle but felt "as if I'd lost the war. The emotional trauma of the ordeal lingered long after the case was closed.
Dr Woods, who performs general surgery at St. Vincent Regional Medical Center in Santa Fe, NM, said the lawsuit did influence his decision to write a book about the power of apology. But, he added, apologizing when appropriate should be a part of every doctor's repertoire.
"It's what I tell physicians all the time—'Nobody needs to sue me to make me feel bad about a bad outcome.' Every physician, or provider at least, understands that," he said. "I think many, if not most, providers, when they have a bad outcome, have this desire to be honest and to apologize to the patient for what they're going through.

"When I was in that position, once that claim letter was actually filed, the first thing that happened was my malpractice insurance company called me and said, 'Under no circumstance do you ever speak to this woman again without legal counsel present.'"

Chuckling, he added, "I think I recall even calling my attorney, who was hired by the insurer, and saying, 'Gee, can't I just call her and tell her I'm sorry?'"

The answer, he said, was an emphatic "No." After his case, Dr Woods had the opportunity to think about what he could have done differently with the patient and what apologizing would have accomplished. He realized he had never witnessed an attending physician apologizing to a patient.

"I just thought that was an incredibly odd thing," he said.

In addition to the legal ramifications feared by insurers, the reluctance to apologize, Dr Woods said, also may stem from doctors being taught to strive for perfection.

"It's a combination of both," he said. "Certainly there's been a very, very healthy dose of the dysfunctional culture of medicine that starts, really, from day 1 in medical school—the concept that we're trained to make the right decision all the time. That certainly can lead to a perfectionist attitude, if you will.

"If confronted with a situation where a physician has been involved with a patient who's had a bad outcome, the attitude can often be, 'Why should I apologize? I made all the right decisions.' In other words, 'Bad things happen, and it wasn't really my fault. Why should I apologize?' Whether that is or isn't true regarding fault.

"The point is, apology isn't about causality," Dr Woods said. "Apology is about empathy, and understanding what the patient is going through and feeling badly for that. It's not about, 'Gee, I'm sorry I caused this.'" Increasingly, he said, this is making sense to physicians.

"The apology itself, which I consider to be the front-end piece of maintaining the relationship and open communication, does not require any sort of admission of guilt," he said. "Even if there's a direct causal relationship on the part of the physician."

....Facing a malpractice lawsuit has impacted the way Dr Woods deals with patients and co-workers.

"What this has done for me, quite frankly, is [prompt me to] apologize freely and openly on a near daily basis," he said. "That's part of what the book talks about. I think what we need to focus on in healthcare is not just apologizing when there's a bad outcome, but apologizing for even the tiniest little thing that can affect the relationship."

Whether apologizing to a patient for being late or to an office nurse for being snippy after a late night, "apology is about respect for the other individual," Dr Woods said. It's also important, he said, to adopt a conciliatory tone as a matter of habit because of what it says about the doctor's caring attitude. "Patients are passive observers of behavior in the environment of care—in the clinics and the hospitals," he said.

If an atmosphere of respect and apology is fostered, even for seemingly inconsequential matters, it becomes clear the provider really does care.

"When they have a really bad problem happen, and there really is a very bad outcome—whether the physician causes it or not—[if] the physician goes in and says, 'Gee, I'm really sorry that this happened. I know it's not what you expected. It's not what I expected either,' it's credible. Because they've seen that that is the way people behave within that organization."

If a physician doesn't make that kind of a positive caring environment a regular practice, apologies after bad outcomes will likely seem insincere....

In chapter 1, "Reclaiming Good Medicine," Dr Woods cites a reference from an Archives of Internal Medicine article that said, "Data indicate that the likelihood of a lawsuit falls by 50% when an apology is offered and the details of the medical error are disclosed immediately."

"The data," Dr Woods said, "seems to be suggesting that it's actually far greater than [50%]. ... [The insurance] program called the three Rs [regret, responsibility, and remedy,] has shown dramatic reductions in claims being filed in the group of people where they've had this process utilized. The number of patients who go through that process [of the three Rs] who actually end up filing claims is just a handful. It was essentially nothing, compared to the standard approach to this problem."

In Healing Words, Dr Woods has expanded the three Rs to five—the original regret, responsibility and remedy, plus recognition (of when an apology is needed) and remain (engaged, meaning don't just issue a quick apology and then disappear).

"Apology and disclosure isn't a one-time event, where you run in, say you're sorry, tell them what you thought and then, because of your conflict-avoidant personality, you never see them again," Dr Woods said. "Apology and disclosure is a continuum. Conflict avoidance, which is actually very, very common in our profession, will negate all of the other benefits of apology and disclosure. So if you do it and disengage, you're still going to have a fairly angry group of people who feel like the physician has abandoned them. ... That actually is something that has a fair amount of data behind it."

Apology and disclosure, and an honest, open relationship with patients, will make a difference.

"What we're going to find is," he said, "by getting physicians focused on the relationship and getting support from insurers and hospitals in terms of providing training and education as it relates to 'how do you disclose,' as well as the willingness to potentially ante up a few costs that the patients incur, you're going to see far fewer [lawsuits] than the numbers currently quoted."

Respect and communication are essential, but "nothing works all the time," Dr Woods said....

"... I've become convincd,... that the major driver of medical malpractice [lawsuits] is not a litigious society, it is not physician ineptitude, it's anger," he said. "It's patient anger at not being provided with the information that they feel they need, and/or a sense that the physician is not respectful of them."

"I believe, and I'm speaking from a very physician-centric viewpoint, that we should be doing this because it's the right thing to do, not because it's going to lower our liability."

"Healing Words: The Power of Apology in Medicine, Second Edition," is $25 and is published by Joint Commission Resources (JCR), an affiliate of Joint Commission on Accreditation of Healthcare Organizations. To order, call JCR customer service toll-free at 877-223-6866 8 a.m. to 8 p.m. CT, or go to the www.jcrinc.com Web site. Use order code HWPM-07.

Study Questions

1. Apply some of the considerations in this review to Frank Huyler’s Bee Sting. Does Huyler accomplish the feats of apology as outlined in this summary? APply the '5 R's mentioned above to Huyler's story or to an example from your own experience or imagination.

2. Dr. Woods seems to be advocating a 'culture of apology.' What does that entail? Relate your answer to the following statement quoted in the book review above. “The point is apology isn’t about causality.”What prevents people from particpating in such a culture?

3. Give an interpretation of the following statment: "Apology and disclosure are of equal importance, but they accomplish something very different. Both have to happen in the aftermath of an unanticipated outcome."