Two articles appear in the American Medical News, a publication of the American Medical Association, which discuss the issue of doctors apologizing for errors and the broader issue of forgiveness.

New Laws Let Doctors Say 'I'm sorry' for Medical Mistakes

The first article was written by Linda O. Prager. Below is a summary of some of the main points:

• Legal changes in a handful of states may make it easier for physicians to apologize for an unintended outcome without fear of it being later used against them in court.

• Legislatures and courts increasingly are protecting statements or other "benevolent gestures" expressing sympathy from being admitted as evidence of liability in medical malpractice and other accident cases.

• "It boggles the mind that you even need laws like this, " states Dr. Paul Barach, MD, now a safety researcher and incoming assistant professor of intensive care and cardiac anesthesia at the University of Chicago.

• Liability and patient safety experts said broader adoption of such laws could reduce both lawsuits and medical errors, since research suggests physicians' apologies can be powerful tools in fending off suits.

One study found almost a quarter of suits were prompted by patients' realization that physicians had failed to be completely honest or had intentionally misled them when a mishap occurred. More than a third of British patients participating in another study said they wouldn't have sued if they'd been offered a full explanation and apology.

• Even if a suit can't be prevented, apologies can reduce animosity enough to speed a settlement, maintains Dr. Jonathan R. Cohen, PhD, an expert on negotiation, dispute resolution and evidence at the University of Florida's law school.

• In the view of Leonard J. Marcus, PhD, director of the Harvard Program for Health Care Negotiation and Conflict Resolution, apologies are one of three prongs essential to successfully negotiating a health care dispute. His "three prongs" are:

  • An apology
  • A full explanation of what happened
  • To know that whatever happened to them or their family member won't happen to anyone else.

The Veterans Affairs Medical Center in Lexington, Ky., which once had among the highest malpractice claims totals in the VA system, is now in the bottom quartile after incorporating direct and quick apologies to patients into its refined risk-management approach. Any patient harmed by a medical error is immediately informed and offered an apology by the chief of staff. When risk management determines the hospital or its employees caused a patient injury, a fair settlement offer is made. Cases now typically are settled quickly, likely at considerably less cost than if a drawn-out fight had occurred.

• "Being straight" with patients still can carry high risks in states without admissibility limits on apologies, noted Martin J. Hatlie, president of the Partnership for Patient Safety.

• In California, where apologies, but not specific admissions of fault, are protected, there's a fine line for doctors to walk. "The problem many doctors have is finding the distinction between expressing sorrow and admitting fault," said Ron Neupauer, vice president of Medical Underwriters of California.

• Although he's hopeful the new law will encourage physicians to be more forthcoming with expressions of sympathy, he doubts it will significantly cut litigation costs.

• According to the report, "Being able to acknowledge when bad things happen is a critical first step in implementing changes to prevent recurrence. And it can free up health care institutions to pursue the systematic changes needed to minimize errors."

Additionally, "Where people can freely admit their errors and take responsibility for them, the organization becomes better at preventing errors," Dr. Cohen said.

Broadening the role of forgiveness in medicine

The second article was written by Vida Foubister and below are some of the highlights:

• "We are fallible," said Albert W. Wu, MD, MPH, associate professor of health policy and management and internal medicine at Johns Hopkins University, Baltimore.

• "Medicine is an error-ridden exercise, and we're going to make mistakes."

• "Forgiveness is an important element in practicing compassionate medicine" said Dr. Wu.

• Physician self-forgiveness and forgiveness among physicians and their colleagues can improve the health care environment and, as a result, the care rendered to patients.

"This area of psychological and spiritual intervention is essentially untapped," said Porter Storey, MD, medical director of the Hospice at the Texas Medical Center and a pain and symptom management consultant at the M.D. Anderson Cancer Center in Houston. "It can dramatically improve a lot of parameters in patients much more effectively than expensive medications, and it has essentially no bad side effects."

• In the 20 years Dr. Storey has been caring for dying patients, he has noticed that those who are able to let go of some past anger and hurt experience a dramatic reduction in anxiety and distress. This observation led him to begin investigating the ability of a counseling intervention to increase forgiveness as well as patients' sense of hope and overall quality of life.

• "You have much more control over your feelings than you do over the behavior of someone else," said Dr. Storey, who is on the faculty at the Baylor College of Medicine in Houston. "Even in situations where reconciliation is impossible, forgiveness is possible and the benefits can be very impressive."

• Charlotte vanOyen Witvliet, PhD, from Hope College in Holland, Mich., has demonstrated that unforgiving thoughts increase sympathetic nervous system arousal, heart rate and blood pressure. According to her research, "it's the cumulative effects of being forgiving that may buffer and even enhance health over time."

• According to by the Campaign for Forgiveness Research (LOOK FOR URL), a nonprofit group, as of 1998, there were about 60 scientific articles published on the topic of the beneficial effects of forgiveness.

• "Empathy is a form of forgiveness, and it doesn't say, 'Well, let's just forget about it,' "explained Stephen P. Bogdewic, PhD, vice chairman of family medicine and assistant dean for primary care education at Indiana University School of Medicine in Indianapolis. "It says, 'Let's forgive, but let's learn and become better.' "

Physicians also need to be more upfront with patients and make an effort to involve them in the decision-making process. "Both the forgiveness of patients and our forgiving ourselves and our colleagues is a necessary part of coming to a more realistic view of our profession," Dr. Wu said.

American Medical News August 21, 2000