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JAMA: To Err Is Human, to Apologize Is Hard

  • 1.  JAMA: To Err Is Human, to Apologize Is Hard

    Posted 08-11-2021 12:00
      |   view attached
    Dear All,

    Please see the attached essay, "To Err Is Human, to Apologize Is Hard," from JAMA, published in late July. The writer, a general internist at MGH, went to medical school with a colleague of mine who forwarded the piece to me.

    Dr. Krakower's experience was/is wrenching and must make us humble about the limitations in contemporary medical culture of expressing an authentic apology. The language she and her husband hear about their son reminded me of the book "Mistakes Were Made ... But Not By Me."  Should this have happened in the Boston area, the gap between extraordinary local clinician-researchers who have been such important advocates of apology and the experience of this family is especially saddening. 

    This lack of apology led to a breach: "As physician-patients, we identified with our doctors many times along the way, but when our son slipped through the cracks, we found ourselves across a chasm from the clinicians we had trusted.  In the absence of an honest apology, there was no bridge across that divide, and we left these conversations feeling abandoned."

    I hope the essay might offer us an example and platform for discussion at the upcoming SIDM conference. And I hope this finds you all well.

    Best,
    Steve


    ------------------------------
    Stephen Martin
    University of Massachusetts
    ------------------------------


  • 2.  RE: JAMA: To Err Is Human, to Apologize Is Hard

    Posted 08-12-2021 12:49
    Can someone explain to me how Neurologist sends me to have MRI with contrast of Brain,Cervical,Theoretic, EMG,Blood work, due to a fall down stairs year 2017.My symptoms were; severe chronic debilitating pain in neck and back, tinnitus, numbness & tingling of upper & lower extremities, severe leg cramps,memory loss, brain fog.I refused to take pain pills because I did not want to mask the pain, wanted my spine to be fixed! Dr. sends me to another Dr. in the same facility that tells me he is going to perform an ablation of lumbar. Morning of procedure tells me he is only doing a diagnostic. Afterwards the nurse tells me that Dr. used my MRI of 2015 not resent MRI 2017. Continue to seek help, in 2019 orthopedic Dr. performs ACDF C4-C6, still no relief but getting worse. 2021 neurosurgeon performs ACDF C3-C7 discectomy C6, removal of existing hardware that did not fuse,plus screws were coming loose. No one ever told me that my procedure had never fused, even after post op and numerous X-rays and MRI's. I am thankful that I went to the Mayo Clinic in Jacksonville,FL. All staff, volunteer, doctors truly care and do everything the right way in order to provide quality of life, in which I now have! I am scheduled at for procedure called Intercept for my lumbar.

    ------------------------------
    Jamie Parker
    Home Management
    ------------------------------



  • 3.  RE: JAMA: To Err Is Human, to Apologize Is Hard

    Posted 08-12-2021 13:08
      |   view attached

    Thanks, Steve!

     

    I think this is a super-important topic. It tends to be handled differently depending on the medical specialty, and the practice setting.  So thanks for sending this terrific essay from JAMA, which I would never have seen otherwise.  I also found that book, "Mistakes were made... but not by me" to be inspirational. 

     

    I think that we all understand that mistakes are inevitable, even as we strive to find ways for reducing their frequency and impact.  Accordingly, we must learn more effective ways to deal with mistakes when they happen, including taking responsibility for them, apologizing for our errors, and making amends to the best extent possible.

     

    We in Radiology have a well-known error rate, of about 5%.  This means we often have cause for apology.  Despite this, the practice of apologizing when errors are identified is rather spotty throughout the field (it's better in big academic centers, but nearly absent in other settings).  The attached article was published in the #1 radiology journal back in 2019 as kind of a "call to action" for the field, written in the hope of making apology more a cornerstone of radiology practice.

     

    All the best,

     

    Mike

     

     

    Michael A. Bruno, M.D., M.S., F.A.C.R.  
    Professor of Radiology & Medicine

    Vice Chair for Quality & Patient Safety

    Chief, Division of Emergency Radiology

    Penn State Milton S. Hershey Medical Center
    ( (717) 531-8703  |  6 (717) 531-5737

    * mbruno@pennstatehealth.psu.edu  

    1571679014277

     

    _ _ _ _ _

     

    Dear All,

    Please see the attached essay, "To Err Is Human, to Apologize Is Hard," from JAMA, published in late July. The writer, a general internist at MGH, went to medical school with a colleague of mine who forwarded the piece to me.

    Dr. Krakower's experience was/is wrenching and must make us humble about the limitations in contemporary medical culture of expressing an authentic apology. The language she and her husband hear about their son reminded me of the book "Mistakes Were Made ... But Not By Me."  Should this have happened in the Boston area, the gap between extraordinary local clinician-researchers who have been such important advocates of apology and the experience of this family is especially saddening. 

    This lack of apology led to a breach: "As physician-patients, we identified with our doctors many times along the way, but when our son slipped through the cracks, we found ourselves across a chasm from the clinicians we had trusted.  In the absence of an honest apology, there was no bridge across that divide, and we left these conversations feeling abandoned."

    I hope the essay might offer us an example and platform for discussion at the upcoming SIDM conference. And I hope this finds you all well.

    Best,
    Steve


    ------------------------------
    Stephen Martin
    University of Massachusetts
    ------------------------------

     

     




    Attachment(s)



  • 4.  RE: JAMA: To Err Is Human, to Apologize Is Hard

    Posted 08-13-2021 18:57

    I really appreciate you bringing attention to this testimony in JAMA. Likewise, I never would have seen it. Apology is becoming more universally recognized as the appropriate response to medical error, but sadly it appears this is not always performed. Unfortunately, such omissions fester lasting pain to victims and families. 

    As a physician who sought out and performed a difficult apology to a patient and family following a particularly severe catastrophic event (unanticipated paraplegia), I can share that the experience was life-changing for me and continues to fuel my passion around diagnostic error and patient safety. Regardless of how awful I felt during the moment, I would not hesitate to perform this duty should it ever be needed again.



    ------------------------------
    David Ryon
    David Ryon
    ------------------------------



  • 5.  RE: JAMA: To Err Is Human, to Apologize Is Hard

    Posted 08-14-2021 21:41

    A troubling point in Dr Krakower's narrative is how only one of the involved physicians in this case was able to offer an authentic and appropriate apology.  This is not something that comes naturally to most physicians, and almost none will have any prior experience to call upon.  It seems like this would be an opportunity for healthcare organizations or large practices to have someone dedicated to work with clinicians involved in disclosable events to help them prepare what to say and how to say it.  There are definitely similarities to speaking with the press – it doesn't come naturally to most of us.  Some coaching is valuable, and many organizations already provide this service.

     

    Mark L Graber MD FACP

    Founder and President Emeritus, SIDM






  • 6.  RE: JAMA: To Err Is Human, to Apologize Is Hard

    Posted 08-15-2021 00:30

    Thanks Mark,

    Is there any data relating to court cases with apology and without apology?

    Rob Bell M.D.









  • 7.  RE: JAMA: To Err Is Human, to Apologize Is Hard

    Posted 08-15-2021 07:55
      |   view attached

    Rob –  The best study on this that I'm familiar with is the one from Kachalia et al – attached.  The findings here were in line with Rick Boothman's experience with his work on transparency and disclosure.  Not only is it the right thing to do, the likelihood of a suit does NOT increase. 

     

    Ilene Corina has made the point many times that what patients want is not financial gain – they want to know the truth, what actually happened, and an honest apology.

     

    Mark L Graber, MD FACP

    Founder and President Emeritus, SIDM






  • 8.  RE: JAMA: To Err Is Human, to Apologize Is Hard

    Posted 08-15-2021 13:23
    Thanks Mark,

    That sounds good

    The next questions are:

    What has happened to the specific error(s) made over time when CRPs were used?

    Have future patients in the hospital concerned benefited from past CRPs?

    Why aren’t all hospitals involved in such programs if there are patient/family benefits?

    And finally should we be focussing on big things to help patients.

    Could some annual SIDM goals if not present help.

    Rob




  • 9.  RE: JAMA: To Err Is Human, to Apologize Is Hard

    Posted 08-15-2021 16:54
    Thanks to Dr Martin for posting the article by Dr Krakower reporting on her family's experience with diagnostic errors and their tragic consequences. I suspect her observations about physicians, fallibility and apology are known at some level by all of us, yet when apology for our errors is indicated, we just can't muster the will or courage to do it.

    The question of how to deal with errors that lead to harm has largely been the province of risk managers, malpractice insurers and defense attorneys, where "deny and defend" has been the prevailing philosophy, and apology and acknowledgement of error has been viewed as sabotage of the malpractice defense effort which inevitably begins as soon at the first report of patient injury, whether through official channels like incident reports or informally through rumors and conversations in hallways and at lunch. 

    It has long been recognized that the adversarial nature of the tort process which is at the heart of our system of righting the wrongs that have resulted in harm to patients serves the interests of neither the victims of that harm nor the clinicians involved in the event, whether or not negligence was a factor. 

    For nearly 20 years, momentum has been building for Communication and Resolution Program models. AHRQ has been promoting a model called CANDOR (Communication AND Optimal Resolution - https://search.ahrq.gov/search?q=CANDOR) which claims ethical high ground and is patient-centered in emphasizing early disclosure, transparency and working toward a fair resolution, including compensation, for all the parties. Many states and regulators are encouraging these approaches, but adoption has been slow and resistance remains. 

    As Kachalia, et al, point out in their (limited) study, there were benefits from using a CRP approach such as no worsening of claims volume, no increase in overall costs and no longer resolution times, yet there is still reluctance by institutions, clinicians and defense attorneys to adopt such approaches. There are a number of reasons:

    Among them are: 

    1) the needed skills and approaches to effective communication in the setting of patient injury and harm differ depending whether or not the harm resulted from negligence;
    2) concerns (whether valid or not) over the impact of reports of payments to patients or families on the clinician's profile in the National Practitioner Data Bank;
    3) uncertainty on the parts of many defense attorneys who not convinced that the approach will be beneficial to institutions or practitioners, especially in the setting of potential negligence, and advise against it; 
    4) the interests of institutions and practitioners' in any given case may be divergent so agreement on an approach is not easily obtained.

    Several recent articles propose solutions to  the problems of acceptance and use of CRP approaches. Here is a good starting point:


    David

    David L Meyers, MD, MBE, FACEP





  • 10.  RE: JAMA: To Err Is Human, to Apologize Is Hard

    Posted 08-16-2021 11:23

    Thanks for sharing this story/article. One thing that resonates in Mark's comments is that apologizing for medical mistakes, especially those resulting from our own agency, doesn't come naturally. Why is it that I can apologize to my spouse for things I did that hurt her without "training or coaching" but I find that hard with patients? I suspect the answer lies in the nature of our relationship. My wife knows my fears, my failings, my idiosyncrasies and has built up a library of experiences where my intent and impact were not aligned – our relationship is one where the failures and successes are mutual. "Babe, I know you will make mistakes, so will I. But we'll get through." In contrast, the patient-physician relationship infrequently enjoys the same level of understanding of one another's unique individual experiences. More importantly, success is the societal expectation – there is little room for failure...

     

    ...Or so our society and the culture of medicine has taught us. But, I don't think this is entirely accurate. My experience suggests that our patients understand our human fallibility more than we give them credit.

     

    Shortly after finishing pediatric emergency fellowship, I cared for a toddler with a very rare inherited metabolic disorder (only a dozen or so reported cases). The family's metabolic doc called me in the ED to alert me of the impending presentation to the ED for vomiting, provided me a prescriptive list of tasks including special fluids, imaging and lab tests to be done immediately on arrival. All the orders were entered the moment the ED record was created in the EHR. What I didn't know was that I could start plain D10W while waiting for the specific fluids from pharmacy. After returning from radiology, I was passing by the patient's room when the nurse called out to me for help. The patient was apneic, pulseless and the monitor showed V-tach. Her K has shot up to >7. Fortunately, we achieved ROSC but the patient spent 5 days in the hospital, intubated for a weekend.

     

    I had not been coached on apologizing for something like this. I literally killed their child. Sheepishly, I walked numbly, to her ICU bedside. I checked in with the nurse; her lytes were stable. Mom and dad were at the bedside. I didn't call Risk, or my section chief. I just said, "I'm sorry, if I had gotten the D10 sooner, I don't think this would have happened. I'm sorry this happened. I am going to report this to our incident reporting system so I and the rest of the staff can learn."  The air in the room was leaden. Mom said nothing. The father, nearly exhausted by the night's events, said sternly like a father talking to his wayward adolescent. "I hope you've learned from this and it doesn't happen to anyone else's child." I knew I was dismissed.

     

    We physicians know how things like this linger. It lingered. I was frightened for my next shift. The imposter syndrome Dr. Krakower alluded to  shrouded every step. And then something worse happened. On again in the ED two weeks later the same metabolic attending called. The same patient was at home vomiting again. She was on the way. This time, I pre-registered her. I ordered all the appropriate fluids to the bedside including the D10W. I knew medically what to do. I didn't know socially what to do. I fully anticipated the parents walking in and saying, "Not him, anyone but him."  This time the patient arrested in the car on the way to the ED, unknown downtime. As the nurse wheeled the gurney down the hallway to the resuscitation bay, CPR in progress, mom's eyes and mine met. "Thank God you're here...you know exactly what to do."

     

    The next 20 minutes were a firestorm of epi, compressions, failed IO lines - the patient died.

     

    12 years on, I have shared this story with numerous trainees and colleagues in sessions on making mistakes in medicine and surviving. To apologize is hard when you have harmed someone who has entrusted their life to you. But, as Dr. Krakower points out, the only way to restore trust is an honest and sincere apology. However, we must also express contrition. Acknowledging our part in the patient's story and the commitment not just to an individual patient but to society in general that we will offer the penance (not self-flagellation and recrimination) of learning from the experience and strive to do better next time.

     

    I am forever thankful for the opportunity to apologize to that family, that they permitted me into their grief for a moment in the ICU to acknowledge my failure. And I am forever thankful for the grace and courage the second encounter afforded me. To recognize the immense restorative healing power of that apology.

     

    Be well.

     

    Jg

     

    Joe Grubenhoff, MD, MSCS (he/him/his) | Associate Professor of Pediatrics 

    Section of Emergency Medicine | University of Colorado

    Medical Director – Diagnostic Safety Program

    Children's Hospital Colorado

    joe.grubenhoff@childrenscolorado.org

    signature_829143088

    THIS IS QUALITY MANAGEMENT INFORMATION RELATING TO THE EVALUATION OR IMPROVEMENT OF HEALTH CARE SERVICES, AND IS PART OF A QUALITY MANAGEMENT PROGRAM AS DESCRIBED IN 42 U.S.C.A. 299 ET. SEQ.,  42 C.F.R. 3.206 ET. SEQ. AND C.R.S. 25-3-109(2). IT IS CONFIDENTIAL AND PROTECTED UNDER C.R.S. 25-3-109(1) AND –(3), 42 U.S.C.A. 299 ET. SEQ. AND 42 C.F.R. 3.206 ET. SEQ., AND IS TO BE USED FOR CHILDREN'S HOSPITAL COLORADO PURPOSES ONLY.

     






  • 11.  RE: JAMA: To Err Is Human, to Apologize Is Hard

    Posted 08-17-2021 08:57
    Joe Grubenhoff Good for you. Well done.

    What kind of physicians make mistakes?

    Are there common factors?

    Anything in the literature?

    Any clues from other disciplines?

    Has a detailed study/investigation ever been undertaken?

    Would knowing help?

    Rob Bell M.D.