By Thomas H. Gallagher, MD, MACP, Professor and Associate Chair, Department of Medicine, University of Washington. Executive Director, Collaborative for Accountability and Improvement
Do you tell a patient about another clinician’s medical error?
I am fortunate to come from a family of physicians: my grandfather was a solo practice pediatrician, my father was a primary care geriatrician in a two-physician office, and my daughter is in the middle of her third year of medical school. Appreciation of medicine as a noble profession whose members are called to serve the interests of their patients runs deep in our family, as it does for every other physician with whom I have interacted. Yet all physicians periodically encounter dilemmas in which reliance on abstract concepts of professionalism seem inadequate to guide our behavior.
As I began my research program exploring how to communicate with patients about errors two decades ago, I encountered just such a challenge. After every presentation, a physician would come up and tell me they were getting more comfortable with the need to communicate with patients about errors they had made. But faced with situations in which they were aware of a colleague’s error, they felt much less confident about what to say and to whom.
I decided to ask my father, who prized the outstanding care he provided to his patients along with his relationships with his colleagues, whether he had ever told a patient about another physician’s error. After a long pause, he said that there had been one situation in which his patient was seeing a specialist in a neighboring town who had an excellent bedside manner, but on several occasions had prescribed medications that were not indicated for that patient. My father concluded he had to say something to the patient. During one of his daily rounding visits with that patient in the hospital, my father said, “You know, there’s another heart specialist near where you live that I really like.” The patient looked a little confused, and my dad moved on to another topic of conversation. The patient was left to try to connect the dots: Why would Dr. Gallagher have said that? Should I think about seeing a different heart specialist?
There are myriad situations in which physicians might become aware of a colleague’s mistake. Why had my father, a highly respected and deeply principled community physician, only had one such conversation with a patient over his career? And why had he chosen to share his concerns with the patient in such an oblique manner?
Physicians should approach conversations with patients about other clinicians’ errors with caution for multiple good reasons. One of the most compelling concerns to many physicians is their belief that professionalism calls on them to treat their colleagues with the upmost respect and refrain from speaking ill of them to others, especially to that physician’s patients. Physicians’ deep commitment to their colleagues should come as no surprise. Even the Hippocratic Oath begins by articulating physicians’ duties of loyalty to their colleagues before any mention of obligations to our patients.
This traditional understanding of medical professionalism focuses heavily on the beliefs and character of individual physicians. A physician’s personal commitment to the values of the profession matters deeply and is a core element of what makes medicine special. However, the model of professionalism that made sense when my father and grandfather were practicing could use some updating.
For example, there is ample evidence that these commitments are insufficient to guide our actions when faced with challenging dilemmas, such as responding to a colleague whose quality of care is lacking or who may be suffering from impairment.1
A 2010 survey found that of physicians who said they were aware of a colleague who was incompetent, one-third had not reported the colleague to the relevant authority.
Physicians have the same natural human impulses as non-physicians to keep uncomfortable information to themselves and avoid situations potentially involving conflict or confrontation. Unfortunately, in the absence of effective communication about quality of care concerns, patients are left without the necessary information to make good decisions about their ongoing care, and efforts to support a physician who is struggling to provide effective care are impeded, putting their other patients at risk.
New approaches to understanding medical professionalism focus more on physicians’ behaviors than on their beliefs and situate these individual behaviors within the context of a broader system intended to facilitate appropriate responses to challenging situations.2 One example of an institutional structure designed to support physicians faced with concerns about potential errors are Communication and Resolution Programs (CRPs), such as Constellation’s HEAL model.
By providing a variety of tools and resources to help physicians communicate around quality of care concerns, coupled with strong institutional policies supporting transparency, CRPs enable physicians to turn their desire to behave professionally into effective action.
How to respond to a clinician colleague’s error
More detailed guidance is also available to support physicians who wonder how to respond when they become aware of a colleague’s error. We assembled a group of experts to develop recommendations for approaching this difficult situation, which included3:
- Patients and families come first. Concerns about alienating a colleague should not interfere with a patient’s right to know about harmful errors that have happened in their care.
- Explore, don’t ignore. Physicians should always begin the process by communicating directly with the physician who they think may have made the error, approaching the conversation through the lens of curiosity rather than accusation and assuming they do not have all the relevant facts.
- Institutions should lead. High-functioning CRPs such as HEAL ensure that patients are informed about harmful errors in their care, regardless of which clinicians were involved in the event. Institutional leadership is especially important when the potential error occurred at a different organization, or when the clinicians involved cannot reach consensus about what happened and whether to tell the patient.
My hope is that as my daughter and her classmates prepare to join us as medical colleagues, it will be in the context of a more modern understanding of what professionalism requires along with the tools, resources, and institutional supports to appropriately balance transparency with patients and strong commitments to our colleagues.
Doing better after harm events: The HEAL Prepare Toolkit
Sign in to ConstellationMutual.com to access the HEAL Prepare Toolkit found in Risk Resources.
Constellation’s HEAL program provides healing benefits for care teams and their organizations because we truly believe that what’s good for care teams is good for business.
- DesRoches CM, Rao SR, Fromson JA, et al. Physicians’ perceptions, preparedness for reporting, and experiences related to impaired and incompetent colleagues. JAMA 2010;304:187-93.
- Levinson W, Ginsburg S, Hafferty F. Understanding Medical Professionalism: McGraw-Hill Education; 2014.
- Gallagher TH, Mello MM, Levinson W, et al. Talking with patients about other clinicians’ errors. N Engl J Med 2013;369:1752-7.
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