Wednesday, May 28, 2008

Saying you're sorry

The NY Times ran a story last week about a "full disclosure" policy some hospitals are implementing. Rather than trying to conceal the circumstances of medical errors or poor outcomes, hospitals and doctors at the University of Illinois-Chicago are disclosing all the details and even apologizing to patients. As a result, malpractice claims have dropped by half since the policy was instituted.

This correlates with what we already know about the likelihood of malpractice suits. A patient's decision to sue often has more to do with some deficit in the patient-physician relationship rather than with some perceived technical or diagnostic error. Doctors who are inattentive, who rush through office visits, who blame the patient for untoward outcomes are more likely to find themselves sitting in a courtroom. Listen to your patient. Be empathetic. Communicate from the beginning the risks and benefits of any scheduled procedure. These are the skills we as physicians need to cultivate.

I operated on a lady a few weeks ago for recurrent diverticulitis; she'd been hospitalized several times over the past year for recurrent attacks, and she had had an abscess drained percutaneously during the most recent attack. I had planned on performing a laparoscopic sigmoid colectomy. I told her that generally patients tolerate it well and are able to go home in 2-5 days time. Let's do it, she said.

Well the case was a disaster. I had to open. The colon was stuck to the uterus. There was pus in the pelvis and the inflammatory changes extended quite low down onto the distal rectum (usually diverticulitis is a disease of the sigmoid colon). The anastomosis ended up being just above the lower sphincter mechanism. I always get worried about low pelvic anastomoses, especially in the setting of acute inflammation. Consequently, I protected it by diverting her fecal stream with a loop ileostomy. So she ended up with a much bigger incision, an extended hospitalization, and a stoma (which will be reversed with another operation in 4-6 weeks). Understandably, she was initially quite disappointed. Not that I did anything wrong. I have no doubt that my intra-operative decision making was appropriate. But the outcome was unexpected.

As we neared discharge, she started to feel better and one morning she sort of opened up to me. Doctor, she said, I understand you did the right thing for me. I'm okay with the bag on a temporary basis. But I wish you would have been more forthcoming prior to the operation that something like this might have happened. You know, I signed up for several art shows this year (she paints in water colors and displays her work at shows all over the midwest) and those entry fees are non-refundable. I'm going to lose all that money. If I'd known that something like this was even possible, I would not have made any plans this summer.

Hell, I felt terrible. I told her I was sorry. In retrospect, looking at some of the old CT scans, maybe I ought to have anticipated a tougher case. She was right. And I told her that. I apologized and offered to write letters to the art shows on her behalf. As soon as the word "sorry" left my lips, I could almost detect a physical change sweeping over her. Her shoulders relaxed. She smiled warmly. The lines in her face smoothed out. She had heard what she needed to hear. It's OK, she said.

I think there is some merit in open communication and admitting culpability in adverse or unexpected outcomes. But it isn't a panacea. You have to be careful. I thought this article gives an interesting counterpoint to the NY Times story.


rlbates said...

The two articles together make it even harder to know how to walk that line of saying "I'm sorry." especially when you know you did the right thing for the patient, the situation, etc.

Sid Schwab said...

I'm glad there's now recognition that it's okay to say you're sorry. Earlier in my career, we heard just the opposite from lawyers and insurance carriers. It's no panacea, of course; there are those that will sue no matter what. But when it feels right, I think it is right.

Parenthetically, and recognizing I know zero about your specific case, when I planned resection on a diverticulitis patient who'd had an abscess drained, I always wanted to wait at least three months. The natural course of the disease doesn't always allow it, of course...

HMS said...

It takes character for a doctor to say "sorry" - patients often register that and whatever went wrong seems less sinister than before. Bravo, Doc.

Anonymous said...

Full disclosure and "sorry" may make all parties (most importantly the patient) feel better about the adverse outcome, but I recently read an article (maybe NEJM?) that came to the conclusion that extent of injury/disability is the single greatest predictor of whether a lawsuit will be filed. The article went on to almost entirely dismiss elements of the patient physician relationship as an indication of future litigation.

Thanks for the blog, I look forward to your postings.