Wednesday, December 20, 2006

Clinical innovations, apologies, Twenty Clinical Innovations for Building Patient-Doctor Trust: Seventh in a Series

Offering Apologies and Reconciling Differences to Avoid Misunderstandings and Malpractice Risks

In this series of blogs, I have sought to spell out ways to innovate to build trust between hospitals, doctors, and patients. This is not easy in the current environment Health costs are rising. To cut costs, hospitals and doctors are rushing patients through their facilities and offices. In this rush, with too little time to think things through, mistakes and misunderstandings occur.

These problems can partially be compensated for through more information, better patient education, clearer communications, and concentrated public relations efforts. But adverse events will still happen and lead to mistrust.

Two ways of dealing with mistakes and misunderstanding are through reconciliation and apologies.

I’m a fan of the Truth and Reconciliation Commission, put together in South Africa at the end of Apartheid to heal racial wounds. Victims of violence could come forth to testify, and perpetrators of violence could ask for amnesty. By and large, this commission worked and succeeded in creating a climate of trust to help make South Africa a workable democracy.

In America in the malpractice arena, a similar idea has surfaced in the form of a joint effort between Common Good, a charitable organization formed by Philip K. Howard and the Harvard School of Public Health. Backers of the Common Good concept advocate specialized health courts to hear alleged victims of malpractice and testimony of perceived malpractice perpetrators.

I became interested in how to resolve differences and create trust between litigants when I interviewed Leonard Marcus, PhD., in 1999 for Physician Executive Magazine, Marcus anticipated adverse impacts of managed care. When patients and doctors lose control of their medical care, he reasoned, conflicts would become more common. Marcus sought an alternative to litigation for people involved in such conflicts. Marcus believes conflict is not necessarily negative -- it can be used constructively to focus attention on how to effect system improvement. Unfortunately, as he stated in my interview , "...people can get so caught up in the conflict that they can't even see the costs of escalation and the potential benefits of resolution."

In a May 18, 2005 front page piece in the Wall Street Journal, Rachel Zimmerman reported on a new strategy of the malpractice industry – doctors owning up to mistakes and apologizing. The industry found that contrite apologies by doctors avoided costly settlements. The article “Malpractice Insurers Find Owning Up to Errors Soothes Patient Anger“ described how apologies sometimes worked better than the usual “defend and deny” approach.

Insurers and hospital lawyers have long discouraged doctors from apologizing to patients for fear that apologies might fuel lawsuits. But now, some hospitals are urging doctors to fully disclose errors to patients. Consultants are being hired to give seminars on how to deliver lawsuit-deflecting apologies. Medical schools are giving courses on how to apologize for errors. And two states, Oregon and Colorado, have passed laws saying doctors’ apologies can’t be used against them in court. This is not to say that a strategy of “To err is human, to forgive divine” works in all circumstances. It is still wise to consult a lawyer before offering an apology, particularly for grievous errors.

It is, however, a good policy for institutions and doctors to train employees to offer apologies for common complaints. In their book “I’m Sorry to Health to Hear That..” Real Life Responses to Patients’ 101 Most Common Complaints (rL-Solutions, 2006), Susan Keane Baker and Leslie Bank have turned apologizing into an art form. Ms. Baker works with health care organizations to improve service quality, and Ms. Bank is Director of Customer Service at Montefiore Medical Center in the Bronx, a large multi-hospital system. Baker and Bank recognize that when complaints and service failures are directly addressed, the result is less litigious, more satisfied, cooperative and supportive patients and families Here are a few examples of what they recommend.


Complaint: You lost my paperwork and as a result, you’re saying I can’t be seen today?

Response: I’m sorry that happened. Let me see how we can fix this right away. Who is your doctor?


Complaint: My room hasn’t been cleaned in days. No one has emptied my wastebasket, and no one has changed my linens. What kind of place is this?

Response: I’m sorry. Let’s start by changing your linens right away. Would you like me to get an extra wastebasket for you? Let’s make a checklist of the things needing attention so we can fix it all.

Service Quality

Complaint: It takes forever for anyone to answer my call bell.

Response: I’m sorry to hear that. I know that while you’re waiting, every minute seems like an hour. What can I do for you right now?

Quality of Care

Complaint: I’m in pain and nobody cares The doctor doesn’t believe me about my pain.

Response: I’m sorry you’re in a lot of pain. I’ll contact your doctor right away. First, please tell me on a scale of 1 to 10, 10 being the worst, how much pain are you feeling right now? OK, I’ll be back with an update for you within five minutes.


Complaint: I can’t read my discharge instructions. I can’t read what the doctor wrote.

Response. I’m sorry. Let me call the doctor and ask for a printed copy. It shouldn’t take long.


Complaint: This bill might as well be written in Greek. How the heck am I supposed to know what I owe?

Response; I’m sorry. I’ll be happy t help you. I can walk you through the entire statement, or just point out the “amount due now” section.

This discussion of reconciliation and apologies reminds me two rules Dr. Neil Baum, a urologist in New Orleans, imposes on himself and his staff in his practice.

Rule #1 . The patient is always right.

Rule #2. If you think the patient is wrong, re-read Rule #1.