Hospitals study when to apologize to patients
Harvard Medical School's major teaching hospitals are considering adopting a sweeping disclosure policy that would establish detailed procedures for physicians to openly acknowledge medical errors and other bad results to their patients, and provide for training in apologizing.
A group of physicians, patients, and executives from the hospitals, led by Dr. Lucian Leape, a national specialist on patient safety, began drafting the policy last year. In recent months, the group circulated a 50-page first draft among hospital leaders, who responded favorably to its broad goals but have suggested numerous revisions, which the group is now implementing.
If Harvard's largest teaching hospitals -- Massachusetts General Hospital, Brigham and Women's Hospital, Beth Israel Deaconess Medical Center, Dana-Farber Cancer Institute, and Children's Hospital Boston -- adopt the policy, it would create a uniform response across the Harvard system to some of medicine's most difficult situations. The Harvard hospitals also would join a growing number of US medical centers and malpractice insurers that are embracing immediate and open disclosure and apology to patients when medical care goes wrong.
''I'm trying to get all the Harvard hospitals to adopt the policy," said Leape, a professor at the Harvard School of Public Health. ''The time has come to be open with our patients."
The policy states that patients should be compensated for expenses related to medical injuries, said doctors who have read it. But those involved in the project said they don't believe they can work out soon an agreement about who should pay such expenses, and which expenses are covered, so the group plans to leave out those details until after further discussions.
The Harvard hospitals, as do most hospitals, already have their own policies on dealing with unanticipated medical outcomes. The Joint Commission on Accreditation of Healthcare Organizations, a national group that reviews and accredits hospitals, requires hospital caregivers to tell patients about the most serious of these situations, but doesn't spell out requirements beyond that.
In Boston, Dana-Farber has one of the most detailed disclosure policies, and requires doctors to apologize for errors. But the ingredients of the Harvard hospitals' policies vary tremendously. And implementation of the policies and training is spotty, said Robert Hanscom, director of loss prevention for the Risk Management Foundation, which insures Harvard hospital doctors.
''We have some hospitals that have moved forward very progressively, but we've seen a couple of cases recently where there's been a real hesitancy on the part of providers to have that conversation with patients. It should happen within hours. We've seen delays of several days," said Hanscom, who is a member of Leape's group.
Leape and other physicians developing the policy said disclosure is ''the right thing to do," but there also is growing belief among malpractice insurers that such disclosure and open expression of sympathy and remorse could head off malpractice lawsuits in a system reeling from skyrocketing premiums.
''Doctors worry that if they talk to the patient, they're more likely to be sued," Hanscom said. ''Our feeling is just the opposite. It's the shutting down that angers patients. We've heard from patients in this situation that everyone almost shuns them."
Colorado's largest malpractice insurer, COPIC, for example, has enrolled 1,800 physicians in a disclosure program under which they immediately express remorse to patients when medical care goes wrong and describe in detail what happened. The insurer compensates patients for related expenses, including insurance deductibles for follow-up medical care; lost time at work; and baby sitters, said Dr. Jerome Buckley, who helped develop the program. Patients cannot participate in the program if they have filed a lawsuit, but they do not waive their right to sue later, he said.
Cases in which an obvious error occurred, such as a surgeon amputating the wrong leg, do not qualify for this program, Buckley said, because they must by law be reported to regulatory boards and investigated through traditional channels. But it does cover cases where patients experience a known potential complication or poor outcome, or when it's unclear that a bad outcome was caused by a physician's error.
Since 2000, COPIC has reimbursed more than 400 patients an average $5,300 each for bad medical outcomes, or a total of about $2 million.
Buckley said malpractice claims against these 1,800 doctors have dropped 50 percent since 2000, while the cost of settling these doctors' claims has fallen 23 percent. The University of Michigan Health System has cut claims in half and reduced settlements to $1.25 million from $3 million a year since developing a disclosure policy in 2002, said Richard Boothman, chief risk officer.
Last month, Buckley flew to Boston to speak to Risk Management Foundation executives as part of development of the proposed Harvard policy, and to executives from ProMutual Group, the state's largest malpractice insurer.
Leape said he did not want to discuss his proposal in detail until it's final.
But doctors who have reviewed it said that it addresses all aspects of a poor medical outcome: the impact on the patient and family; the impact on doctors and nurses; training for caregivers in handling these events, including immediate response teams that would provide immediate guidance on talking to patients and families; and the investigation of such events and making changes to prevent future problems.
''Yes, we're recommending that doctors say they're sorry," said Dr. Thomas Delbanco, of Beth Israel Deaconess and a member of Leape's group. ''Be a human being. Don't just say it; mean it."
The policy would require approval from the hospitals' top executives and in some cases trustees. ''A lot of details need to be worked out before we could sign off on it," said Dr. Britain Nicholson, Mass. General's chief medical officer. ''This would dramatically expand on our policy."
Nicholson and leaders at other hospitals said they want language clarified. For example, many bad outcomes are not errors; they are known but rare complications. Do doctors apologize in these cases? Should patients be compensated financially?
''If I am doing a colonoscopy and there is a perforation at a weak area in the bowel wall, a physician would take umbrage if he or she had to say 'I am sorry I made this error,' " said Nicholson.
He said doctors who reviewed the policy also want the section on support for physicians and nurses involved in medical mishaps expanded; possibilities are allowing these doctors paid time off and expanded counseling and mental health benefits.
Nicholson said that at Mass. General disclosure of medical errors is routine. But he said whether a doctor explicitly expresses remorse varies. ''Part of it depends on when you went through training," he said. ''Fifteen to 20 years ago coming through medical school and residency, we were implicitly, if not explicitly, told, 'Don't ever admit a mistake,' because it will come back to haunt you if you get sued." 