Patients and families often observe a serious problem with care during hospitalization.
In a study of more than 10,000 patients at eight hospitals, 49% indicated they had experienced a problem during hospitalization, according to results published in the March 2019 The BMJ Quality & Safety. In another study, published in the October 2016 Patient Education and Counseling, 32 of 70 (46%) surrogate decision makers of critically ill patients reported that they believed something went wrong that could have been prevented, resulting in harm.
When patients report breakdowns in care, the typical response from hospital staff is transforming from an old-fashioned “deny-and-defend” approach to a much more open dialogue of transparency and disclosure, said Thomas H. Gallagher, MD, MACP, coauthor of the former study and associate chair of patient care quality, safety, and value in the department of medicine at the University of Washington (UW) in Seattle.
Hospitalists who want to take the modern approach should get comfortable with the difficult act of apologizing, he said. “Hospitalists need to understand that we've arrived at an era of much greater openness with patients about things that have not gone well, that if there's a problem, they should take the initiative, let the patient know what happened, and apologize.”
When thinking about the concept of apologizing for breakdowns in care, keep in mind that, more often than not, these scenarios don't necessarily involve egregious medical errors.
“You don't have to have committed a fatal or terrible error. I think sometimes people think of medical errors, and they think you cut the wrong leg off,” said Kimberly A. Fisher, MD, MSc, an associate professor of medicine at the University of Massachusetts Medical School and a pulmonary and critical care medicine physician at UMass Memorial Medical Center, both in Worcester, Mass.
In fact, a more likely example of a breakdown in care would be that the patient's family members are frustrated because they haven't gotten answers to their questions, they waited for 12 hours in the ED, or the patient's lunch was cold when it arrived, she said. “I don't think you can be a hospitalist and get through rounds on any one day without hearing about at least one of those things.”
To assess the impact of an apology for these ordinary problems, Dr. Fisher led a randomized survey that gave 1,188 U.S. adults a hypothetical vignette of three care breakdowns: a slow response to the call bell, a rude aide, and unanswered questions. The survey asked participants to imagine they spoke up about the problem and then randomized them to different responses: a clinician offering a full apology, a limited apology, or “what we considered to not really be an apology, which is something along the lines of, ‘Well, I'm sorry if you think that happened,’” said Dr. Fisher.
Nearly three times as many participants who received a full apology said they would recommend the hospital than those receiving no apology, according to results published in the April 2020 The BMJ Quality & Safety. Of note, while the full apology included an expression of regret and empathy, an offer to remediate the immediate concern, and a commitment to taking steps to prevent a recurrence of the breakdown, it did not include an acknowledgment of responsibility.
“Sometimes bedside providers don't know what to say when patients do report problems. . . . The provider may not feel like they have any control over them or that they're not responsible for them, and oftentimes that's true, but you can still give an effective apology,” Dr. Fisher said.
Although a sincere apology can make patients less angry, there's no guarantee that there won't be any downside for the physician, especially if a situation is dire, noted Kathleen Mazor, EdD, senior author of the study and professor of medicine at University of Massachusetts Medical School.
“Certainly, for somebody who has irreparable harm, simply saying you're sorry is not enough,” she said. “But pretending that nothing went wrong or pretending that it was unavoidable when it clearly was definitely makes things worse and can cause people to pursue legal action.”
Hospitalist Aaron C. Hamilton, MD, MBA, FACP, associate chief quality officer at Cleveland Clinic, said he's seen the benefits of apologizing firsthand and believes that hospitalists should become more comfortable with the practice. While some may wonder whether apologizing for problems that are out of their control will place more risk on the organization, he said these conversations build trusting relationships that heal.
“Apologizing and having open communications and managing a clinical risk program are not mutually exclusive. In fact, they're complementary,” he said. “It's almost this paradox where, when we're honest with our communication, no matter how small the disclosure, outcomes actually tend to be better.”
Even discussions around more serious error disclosures can have beneficial effects. “Our research has shown that the vast majority of times, physicians report that when they have these conversations, they feel like the conversation went well, they were able to share the information that they wanted with the patient, and at the end, they felt relieved,” said Dr. Gallagher. “So these conversations can go well, but they require a little bit of planning and preparation.”
The best way to apologize
First and foremost, when offering an apology, sit down with the patient and family and listen, Dr. Hamilton recommended. This can neutralize even the most hostile environments.
“I've gone into rooms where it's like the dreaded room: The patient's lying in bed, and you've got the family members, and they're all standing up and they're ready to confront you as you walk in the door. It's this army, right?” he said. “And as soon as I pull out my seat and sit down, it kind of sets an expectation: I'm going to sit down, I'm going to listen, I have time for you. And you can see people change their body language, and then all of a sudden, they're looking for a place to sit down.”
While this practice may look different with COVID-19 infection protocols, it's still important to sit eye-to-eye when possible, especially for error disclosures, Dr. Hamilton said. “There have been opportunities to leverage virtual health and engaging patients and family more, but in the end, if you're the primary person responsible for that patient at the hospital, you don your [personal protective equipment], you go in the room, you see the patient, you sit down, and you have the conversation you need to have,” he said.
Be sure to allow enough time for these conversations, which take about 15 to 20 minutes when concise and effective, Dr. Hamilton said. “I always create a little extra space around that [conversation] and even think about what it might look like to have somebody cover my pager for 15 minutes,” he said. “Most of us are fortunate to be in a team environment where that might be possible.”
In general, the better the apology, the less time it takes, Dr. Hamilton added. “In my experience, when you have a conversation and you're trying to apologize, but you don't really apologize, you start making excuses or you start explaining a lot and you're not listening,” he said. “Often, what families and patients will do is prolong that conversation because they're not getting what they want, which is a straight apology, ownership, accountability, and a commitment to learn and improve.”
It's also important to find the right words to authentically express your apology, which vary by physician and by situation, Dr. Hamilton said. “These are hard conversations, but you have to find the words that are authentic to you,” he said. “If you're just going in and it feels like a scripted thing, like ‘I was told I have to say I'm sorry’ or ‘I have to apologize,’ patients and families pick up on that pretty quickly.”
A good apology includes both an explanation of what happened and recognition of how it affected the patient, Dr. Mazor said. “When things go wrong, they have an impact on people, and sometimes it's a minor inconvenience, sometimes it's significant harm, but I think it feels disrespectful when the impact of the small or large event isn't appreciated.”
Many times, patients aren't necessarily looking for a solution to the problem, added Dr. Gallagher, who is also professor of medicine and of bioethics and humanities at UW and director of the UW Medicine Center for Scholarship in Patient Care Quality and Safety.
In the case of a long wait in the ED before admission, “The patient's not expecting the physician to somehow miraculously solve that problem but, at a minimum, to just acknowledge that that must have been really upsetting,” he said. “‘You weren't feeling well, you were in a lot of pain, and then you had to wait an extra-long period of time in the emergency room. I'm really sorry that happened to you.’”
Like anything, the act of apology tends to become more natural with practice. “I think practicing apology in situations where it's fairly safe is a good idea, like if you're late or in situations where you're certainly not going to be sued,” said Dr. Mazor. “You can get used to acknowledging that things aren't exactly as you wish they were.”
For more serious conversations involving error disclosures, it's important to first understand the approach that's endorsed in your organization, Dr. Hamilton said. “I always ask that people consider their local milieu before they dive into these conversations . . . whether it's engaging with quality or clinical risk or ombudsman or patient experience or the law department.”
At Cleveland Clinic, he has physicians practice apologizing during roleplaying exercises. “Under situations where there's high stress or maybe your patient or family members are really upset, we get amygdala hijack and we'll be off our center. So having an idea and getting some practice in really helps,” Dr. Hamilton said, adding that each apology provides an opportunity to learn.
One final practice hospitalists can consider is asking patients or families what ideas they might have to prevent these problems from happening in the future, Dr. Hamilton said. “I think the crucial task is empathizing with patients and families and finding a way to weave it in that this is an opportunity for us to learn and to improve and to ensure that this doesn't happen again in the future to them or to other patients,” he said.