By Ron Hartung
Physicians are human. Try as they might, they’ll never be error-free. A group of Florida State alumni, faculty members and other experts spent two hours April 14 discussing medical mistakes and the difficult doctor-patient conversations that sometimes follow.
The participants had different ideas about exactly when those conversations were necessary. Everyone agreed, though, on the importance of minimizing mistakes and maintaining a trusting doctor-patient relationship.
The session was “Avoiding and Reacting to Medical Errors: Legal and Ethical Issues,” offered during the College of Medicine’s alumni reunion. The moderator was Marshall Kapp, J.D., MPH, director of Florida State’s Center for Innovative Collaboration in Medicine and Law. He presented a hypothetical medical case to five panelists: Don Hinkle, J.D., who handles medical-malpractice cases; Keith Ingram, M.D., an anesthesiologist; Linda Keen, R.N., J.D., an attorney with significant experience as a risk manager; Jacqueline Lloyd, M.D., professor in the Department of Geriatrics; and Michael Nair-Collins, Ph.D., the in-house philosopher for the Department of Medical Humanities and Social Sciences.
In the hypothetical case, a patient using a PCA pump after surgery had a brief adverse reaction to morphine. Afterward, it came to light that he’d had a similar reaction four years earlier. The panelists came up with a long list of questions the hospital should explore and agreed that the primary goal was not to find fault but to find the root cause, to keep the error from recurring.
They did not reach consensus, however, on precisely when an error warrants informing the risk manager and the patient. At least one panelist thought only permanent damage to the patient should trigger such conversations. The phrase “No harm, no foul” came up often.
But as Lloyd said, “Who’s defining harm and foul?” What may seem like no big deal to the doctor, she said, might be a very big deal to the patient.
“These are issues of trust,” she said. “A lack of trust can significantly impair any future doctor-patient relationship.” That is one good reason to have these difficult conversations with a patient after an adverse outcome, even a minor one. The patient might say, “I have trust in this person because they play it straight with me when things don’t go right.”
Keen agreed. Detecting patterns of systemic failure, she said, requires having an accurate picture of errors that occur, and that requires openness.
That doesn’t mean blurting out “I made a mistake” before all questions have been answered, she noted. But a physician might tell a patient, “You just had a reaction to a medication. This is what we’ve figured out so far….”
For Nair-Collins, the answer is fairly simple: Follow ethical principles. Respect the family. Discuss medical errors, even if there were no catastrophic outcomes. An adverse reaction to morphine, for example, is important information for the patient to have before his next surgery.
Like other panelists, Nair-Collins stressed the importance of the doctor-patient relationship. The patient goes to a doctor who may be a complete stranger and allows that doctor to perform all sorts of invasive procedures he would never let anyone else do – simply because he trusts her training and title. He said physicians must respect and be worthy of that trust.
Ingram spoke for most people, physicians or otherwise, when he said it’s difficult to admit you made a mistake, especially in such a litigious society. Nair-Collins conceded that society unfairly expects doctors to fix everything and make no mistakes. But, he said, admitting mistakes is the right thing to do. Besides, he said, research suggests that disclosure does not increase a physician’s exposure to litigation or legal liability.
Hinkle confirmed that most of his medical-malpractice clients are angry that something unexpected happened and that the hospital doesn’t seem to care. Or they’re frustrated because they don’t have much information. An apology from the medical team doesn’t guarantee that the patient won’t sue, he said, but it certainly defuses the anger and changes the whole tenor of the discussion.
“I have noticed a decrease in ‘easy’ cases involving egregious, avoidable errors,” Hinkle said. “I hope it’s a trend. Hopefully, you’ll put me out of business.”