Doctor-Patient Bond Frays After Medical Mistake

People who care deeply for a patient affected by a medical mistake often shoulder their own level of guilt after the incident. "Family members, in particular, can feel extraordinary guilt," Delbanco said, and often berate themselves, thinking, " 'If I had done this, this wouldn't have happened,' 'If I had been there, I would have prevented it,' 'If only I had been more forceful, the doctor wouldn't have done this.' "

Such was the case for those close to a young man with sickle cell anemia, mentioned in theNEJMarticle. The unnamed patient received morphine while in the hospital -- despite a well-documented allergy to the painkiller. He slipped into kidney failure and coma soon after, and his sister said she felt as if she "failed her family in terms of 'I should have been there.' That's a guilt that everyone shares."

Doctors who acknowledge that a mistake has happened, and outline steps to prevent such mistakes going forward, can ease a lot of distress for themselves and the patient, experts say.

But, in many cases, physicians have "a lack of confidence in their communication skills -- they just aren't sure how to have these conversations," said Dr. Thomas Gallagher, associate professor of medicine at the University of Washington School of Medicine, in Seattle.

Gallagher said Delbanco's and Bell's article echoes the findings of studies he has led, which revealed profound differences in the ways doctors and patients communicated after a serious medical error.

But he also believes the landscape around medical errors is changing. Already, about 30 states have enacted so-called "I'm sorry" laws, which, to a certain degree, make a doctor's apology for an error inadmissible in a court of law.

That should help ease patient-doctor conversations. But Gallagher said many of these laws still "provide very little protection for clinicians. They allow you to say 'I'm sorry,' but they don't allow you to make any expression that a mistake happened or to admit liability."

And, he said, it's not entirely clear that admitting to mistakes always wards off a lawsuit. "It's not a magic bullet," Gallagher said. "There will clearly be some cases where disclosure is what precipitates a lawsuit."

So, work remains to be done in finding strategies that allow patients and doctors to remain close even after a mistake occurs.

For his part, Delbanco said he is currently screening his film for third-year students at Harvard Medical School -- at the request of the school's dean -- to help them become better physicians. "Traditionally, there's been little coaching in this area," he said. "That's changing."

His advice to patients: If a serious medical error occurs, "be very aggressive in asking for communication. Patients should not be afraid of opening their mouths." And if that communication is not forthcoming, "Ask why and with whom can they speak?" he said.

And a hasty "I'm sorry" from a physician may not always be adequate, Delbanco added.

"Apology only means something when you show what you are going to do for that person -- and for the next person," he said. "Otherwise, they are just words."

More information

There's more on preventing medical errors at the U.S. Agency for Healthcare Research and Quality.

SOURCES: Tom Delbanco, M.D., professor, general medicine and primary care, Harvard Medical School, and Beth Israel Deaconess Medical Center, Boston; Thomas Gallagher, M.D., associate professor, medicine, medical history and ethics, University of Washington School of Medicine, Seattle; Oct. 25, 2007,New England Journal of Medicine