There is a very clear code of ethics for the medical profession. Physicians and hospitals are supposed to fully disclose errors and adverse events. That is the policy of the Joint Commission which accredits and certifies roughly 21,000 health care organizations in the U.S. Many other health care organizations that protect the public have also endorsed full disclosure of medical mistakes or “serious unanticipated outcomes” (AHRQ-Agency for Healthcare Research and Quality, July, 2016). But research suggests that many physicians probably ignore these guidelines (BMJ Quality and Safety, Oct., 2016).
Testing Doctors for Truthfulness:
Researchers sent questionnaires to 630 primary care physicians who were working in HMOs in Georgia, Massachusetts and Washington. Roughly half (333) participated in the survey and about 300 responses were included in the analysis. Most were seasoned health professionals, having practiced medicine for over a decade.
The Two Vignettes:
Delayed Cancer Diagnosis:
Everyone who participated in the study received two hypothetical scenarios. In one, the primary care doctor was asked to imagine seeing a 45 year-old woman with high blood pressure that had been well controlled. This was a routine follow-up visit for her hypertension.
During the visit the patient noted that a lump in her left breast seemed larger than it was six months earlier when she was seen by a colleague at the clinic. He had examined her breast but had not ordered a mammogram. No additional breast exam had been scheduled.
“A subsequent breast biopsy revealed cancer, with 3 positive axillary nodes.” The woman should have received a scan much sooner, but the colleague missed several opportunities to follow up.
Care Coordination Breakdown:
In the second hypothetical case, a 65 year-old man with hypothyroidism was being treated for colon cancer. He contacted the clinic a few times to report that he was feeling fatigued and was dealing with bouts of diarrhea.
He was reassured by a nurse. The nurse brought his calls to your attention and to the oncologist who was treating him. Both you and the oncologist assumed the other physician was following his case closely. Neither you nor the oncologist followed up. The patient ended up in the emergency room because he passed out on the way to the hospital. His hematocrit was 16. A normal value should have been 42 to 54. Someone dropped the ball.
The Questions:
Doctors who participated in this survey were asked how likely they would:
- Apologize for the mishandling of the cases
- Explain the reasons for the delay and diagnostic screw-up
- Describe the cause of the mistakes
- Reveal plans to prevent such events from happening to other patients in the future
The Answers:
One of the authors, Dr. Douglas Roblin, was quoted by Newswise:
“The intent to disclose was not as frequent as we thought it might be…The two vignettes gave pretty consistent findings. The majority would not fully disclose, and we were hoping for full disclosure because that is the ethical expectation.”
Results of the survey:
The authors found:
“A majority of respondents would not be fully forthcoming in either situation, providing only a limited or no apology, limited or no explanation and limited or no information about the cause. For the delayed cancer diagnosis vignette, a majority would provide limited or no information about efforts to prevent recurrences…”
Discussion
“Our study shows that, despite all the attention over the past 14 years to the importance of open communication with patients following error, full disclosure remains elusive. Most physicians would provide only partial disclosure after either of the events studied here. When asked what they would tell the patient about the cause of the error, 77% of the physicians for the delayed diagnosis of cancer case, and 58% of the respondents for the care coordination breakdown case, would offer either no information or make vague references to ‘miscommunications’. More than half of the physicians in both cases reported they would not volunteer an apology or would offer only a vague expression of regret. This limited approach to disclosure by physicians in this study falls far short of patient expectations and national standards.”
The People’s Pharmacy Interpretation:
We are not entirely surprised by these results, but we are disappointed. Please keep in mind that this study involved hypothetical case reports. It was not asking physicians whether they had actually made a mistake and whether they would report it to the patient or family. This was all hypothetical. In other words, “doctor, would you disclose an error if your colleague missed an opportunity to diagnose breast cancer in a timely fashion?” The majority said no, they would not fully disclose medical mistakes or apologize.
We have to wonder what the actual disclosure rate would be if a doctor actually did make a serious mistake either in diagnosis or treatment. We suspect that the report card might be even worse.
Ethical Expectations:
Here is what doctors have been told repeatedly they should do after medical mistakes are discovered:
- Provide full disclosure of all harmful errors
- Apologize and accept responsibility for the medical mistakes
- Explain exactly what happened and why
- Commit to preventing such a mistake(s) from happening in the future to others
Error Discovery and Reporting:
A study published in the Journal of Patient Safety (Dec. 1, 2021) asked a question about how doctors report other doctors who were discovered to make medical mistakes. Here were the objectives of the research:
“Patient safety programs aim to improve transparency regarding medical errors, and there is broad consensus on how providers should communicate about their own errors. How providers should respond to other providers’ errors is less clear, especially when they occur outside the provider’s facility or system (intersystem medical error discovery [IMED]).”
By now you are probably not surprised to read their conclusions:
“Ethics codes provide little guidance on communication regarding IMED scenarios, and in some cases, the guidance is internally conflicting.”
Protect Yourself and Your Loved Ones:
Please forgive us for sharing a personal story. We lost someone we loved because of a series of medical mistakes at one of the country’s leading teaching hospitals. There was no disclosure of errors and no apology. Only after we discovered on our own that a number of medical mistakes had been made did hospital personnel provide additional details. Even then there was a reluctance to admit the hospital was at fault. We did not sue. We wanted to make sure no one else experienced similar errors. Sadly, this is not a message that has been welcomed. Are Medical Mistakes and Deaths Being Swept Under the Rug?
We did write a book to try to help others avoid the pain and anguish we went through. Here is a link to that publication should you wish to try to help family and friends avoid a similar tragedy. We provide lists of common errors, strategies for avoiding problems and ways you can prevent misdiagnoses. We hope this book will save lives.
Please share your own story in the comment section below.
