Doctors’ responses to medical errors

Critical Reviews in Oncology/Hematology 52 (2004) 147–163

Doctors’ responses to medical errors

Michael Rowe∗

Department of Psychiatry, Yale School of Medicine, 205 Whitney Avenue, New Haven, CT 06511, USA

Accepted 25 June 2004

Contents

Abstract. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147

1. Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147

2. Professional principles and the legal context. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150

3. Doctors’ responses to medical error. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151

3.1. Research on doctors’ responses to medical error. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1513.2. Patient views of doctors’ responses to medical error. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152

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3.3. Physician narratives on medical error. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1533.3.1. Self-directed narratives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1533.3.2. Patient- or family-directed narratives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1543.3.3. Narratives on other doctors’ errors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1553.3.4. Narratives of uncertainty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156

4. Discussion and conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158

Reviewers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160

Acknowledgement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160

Biography. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163

bstract

Medical error has become a topic of much concern in recent years. Doctors’ responses to their own or others’ medical errors arecause openness or secrecy has an impact on efforts to reduce iatrogenic injury, on malpractice litigation, and on patient and doctoith care. This article reviews doctor’s responses to error within the context of contemporary medical care and considers themes

rom this review.2004 Elsevier Ireland Ltd. All rights reserved.

eywords:Medical error; Systemic error; Disclosure; Litigation; Medical uncertainty

. Introduction

Two decades ago, David Hilfiker’s story of medical er-or was published inThe New England Journal of Medicine.arb and Russ Daily, whose first two babies Dr. Hilfiker had

∗ Tel.: +1 203 624 0000x100; fax: +1 203 787 2605.E-mail address:[email protected].

delivered, came to him for a prenatal exam for their thAlthough Mrs. Daily showed typical signs of pregnancy,urine test came back negative. The next week the tesnegative again. Dr. Hilfiker, suspecting a miscarriage,sidered sending Mrs. Daily to Duluth for an ultrasound,Duluth was more than a hundred miles away from theral Minnesota town where they lived, the test was expenand the Dailys were people of modest means. Dr. Hilfi

040-8428/$ – see front matter © 2004 Elsevier Ireland Ltd. All rights reserved.oi:10.1016/j.critrevonc.2004.06.003

148 M. Rowe / Critical Reviews in Oncology/Hematology 52 (2004) 147–163

decided against the test, and told the Dailys he suspected amiscarriage.

On her next visit Mrs. Daily’s uterus was still enlarged,but her urine test came back negative again. Dr. Hilfiker toldher she had miscarried shortly before her first exam, and rec-ommended a dilation and curettage if she did not excrete thedead tissue soon. Two weeks later he scheduled the procedurewhen a fourth urine test came back negative and Mrs. Dailyhad not had her menses. Starting the procedure, Dr. Hilfikerwas surprised at the size of Mrs. Daily’s uterus, which seemedeven larger now than when he had examined her just two daysbefore. He was also surprised at the size and good conditionof the body parts he extracted. After stopping the procedure,which he was unable to complete, he told Mr. Daily of hisdifficulties in performing the procedure but did not reveal allhe suspected. Two days later the pathology report confirmedhis fear that he had aborted a live fetus. Hilfiker met with thecouple and confessed his error. He also admitted, in responseto Mr. Daily’s gentle, hesitant questioning, that an ultrasoundwould have confirmed the pregnancy.

In the second half of his article, Hilfiker focuses on prob-lems that doctors who commit a serious medical error mustconfront. Hilfiker wanted to talk to the Dailys again to con-vey his sorrow and ask for their forgiveness, but decided itwould be wrong for him to lay his burden on the grievingc kesw didw hisp alysisa houta owsi cuso ot onc tiong con-f thatw solu-t then

ale tors.T errort ent’sl nds kes.T , andf torsu tog theirc

tyy them t hasb im-p suresf pres-

sure for increased patient autonomy, and well-publicized in-stances of medical error[2–9]. The 1999 Institute of Medicine(IOM) report,ToErr isHuman, estimated that 44,000–98,000deaths occur in US hospitals each year as a result of iatro-genic injury. The report documents a wide range of safetyproblems in medical care and offers a number of recom-mendations for change, including establishment of a nationalcenter for patient safety and a combination of voluntary andmandatory reporting of adverse events[10–11]. Reports fromother industrialized nations, including the United Kingdomand Australia, have also highlighted the problem of medicalerror[12–13].

The IOM report draws heavily on previous research onmedical error in the United States. Investigators with the Har-vard Medical Practice Study reviewed over 30,000 dischargesfrom New York State hospitals in 1984. They concluded that3.7% of patients suffered a serious iatrogenic injury whichprolonged their hospital stay or resulted in disability or death,and that about a half of those injuries were caused by medi-cal error[14–15]. Researchers who conducted a population-based chart review of adverse events and negligent care inUtah and Colorado hospitals in 1992 found adverse eventsin 2.9% of all cases, with about 10% resulting in death[16].A 1995 study found frequent errors in drug administrationduring hospitalizations on medical and surgical units[17].O aved rs ora omicc

s ons oc-t ndi-v thinc placew ilt-i pen[ alsa rt oft therp

chedt ith-o fh ient,t thec thep -l iths pitalfl res,c d un-d ys g andi d po-t er ofp s that

ouple. He talked with other doctors, reviewing his mistaith them, but knew they were not being completely canith him, perhaps because they knew they might be inosition one day, or already had been. In any case, annd lesson learning, Hilfiker writes, are inadequate witddressing the emotional and spiritual turmoil that foll

n the wake of medical error. Doctors are trained to fon the details of the case and on their interventions, nonfronting their emotions when diagnosis and interveno awry. Case conferences and morbidity and mortality

erences are similarly geared toward details and optionsere missed. They leave no room for confession and ab

ion. Instead, doctors bury their feelings and move on toext case.

Hilfiker notes that the difficulties of dealing with medicrror are not limited to those that become clear to dochey also involve error that doctors never detect, and

hey do detect but never see in all its effects on the patiife. Overlaid on this fact, Hilfiker notes, are doctors’ aociety’s expectations that doctors will not make mistahus when they do they must be punished, judged guilty

orced to make restitution. Hilfiker contends that these facndermine doctors’ health and clinical work. “We needive ourselves permission to recognize our errors andonsequences,” he concludes[1].

If Hilfiker’s was a lone voice in the wilderness twenears ago, a chorus of voices both within and outsideedical profession has joined him. This renewed intereseen prompted by a confluence of factors—the qualityrovement and patient safety movements, market pres

or greater cost-effectiveness in healthcare, consumer

ther studies that preceded or followed the IOM report hocumented the incidence or observation of medical errodverse events in hospital care, at high human and econosts[18–22].

The most notable aspect of the IOM report is its focuystemic error. Individual errors result from deficits in dor’s skill or attentiveness, but in the systemic view the iidual doctor is one link in a chain of events that occur wiomplicated medical situations. These situations takeithin medical institutions that host “latent errors”—bu

n problems that are, in effect, accidents waiting to hap3,4,23–26]. Using Charles Perrow’s terminology, hospitre “tightly coupled” systems—decisions made in one pa

he system are likely to trigger or compound events in oarts of it[27].

Traditionally, hospital systems of care have been patogether as a set of related but individual units and wut special attention to patient safety[3,28]. The number oealth professionals involved in caring for any one pat

he size and complexity of healthcare institutions, andomplexities of patients’ medical problems contribute tootential for iatrogenic harm[26,29]. Other systemic prob

ems may include illegible doctors’ orders, medications wimilar names and dangerous drugs kept with the hosoor stock, lack of double checking for surgical procedurushing work schedules for residents and interns, anerstaffing on patient units[9,10,30,31]. In addition, the veruccesses of modern medicine, such as diagnostic testinncreased treatment options, carry with them increaseential for harm, since each new test adds to the numbossible interventions to be made and to the interaction

M. Rowe / Critical Reviews in Oncology/Hematology 52 (2004) 147–163 149

may occur among these interventions, thus providing newopportunities for error[29].

Researchers have distinguished “sharp end” errors, in-volving direct-care practitioners, from “dull end” errors, in-volving administrative decisions that constrain safety efforts[32]. Interpersonal relationships and communication playkey roles in team performance in surgery and among healthcare teams[33,34]. Ethnographers, with a street-level viewof medical care, have demonstrated the intricate patterns ofdecision-making on medical units and the continuous processof decision-making on intensive care units, where interven-tions arise in response to previous interventions and shapeanother set of interventions[35,36].

The systemic response to errors involves examining boththe individual partsandthe multiple links within the organi-zation. This, in turn, involves a shift away from post-accidentanalyses of individual error and toward designing processesof care that help detect error[10]. The shift in focus from indi-vidual to systemic error also involves a shift from blame andpunishment of individual physicians to learning and fixingsystemic problems through the use of computer technology,simplification and standardization of procedures, reduction inreliance on memory and the number of handoffs in a system,decentralization of decision making, and increased commu-nication both within and across disciplinary teams and lineso

’ ex-p ressa teresta ala JointC ns’( is-c themt cred-i ts toi rsa olicyw hada f thet re inp hen,w leftt -p nclu-s vedr butt s ab

or as renttO s ons andt afety[ om-

mendations to reduce error may be prohibitively expensive toimplement. He also challenges the IOM’s calculation of errorand death, pointing out that the New York and Colorado/Utahstudies on which the report based its calculations of deathfrom medical error distinguished between preventable andnon-preventable adverse events, while the IOM report com-bined both under the category of medical error[53]. (Others,however, claim the report may underestimate the extent ofmedical error, since it does not include injuries occurring af-ter discharge but related to the adverse hospital event[56]).Hofer and colleagues have questioned the IOM’s (and oth-ers’) definition of medical error and have pointed out thedifficulty in determining adverse outcomes and negligencein the care of patients with complicated medical problemsrequiring complicated interventions[57,58]. Charles Boskwrites that the IOM report sanitizes and rationalizes medicalerror, simplifying a complicated process that remains hiddenfrom a public which has jumped on the findings to demandimmediate improvement[59]. Clearly, though, the report hasopened up professional and public debate about medical errorand is likely to shape both for years to come.

The theme of this article is doctors’ responses to medicalerror considered within their professional, institutional, le-gal, and public contexts. The author’s review of the literaturefell into two main areas: (1) research literature on incidencea re re-g cur;a ountsa ludedM f theN rya ; andc asedo igh-s e re-s n inr terialb s orv dicale itedu lableo

er-r or canb ctiond asedm d toa ofr of aw h asp fromn andm thep time[ tableo edi-

f authority[3,8,37–47].Reactions to the IOM report far exceeded its authors

ectations. The report was widely cited in the American pnd generated considerable legislative and regulatory innd support[11,48]. Its influence at the level of institutionnd medical practice has been less dramatic. The USommission on Accreditation of Health Care Organizatio

JCAHO’s) 2001 revised policy requiring hospitals to dlose all unexpected outcomes to patients, and allowingo take corrective action rather than being placed on actation watch immediately, may encourage internal efforncrease patient safety[49]. A 2002 survey of risk managend residents, conducted six months after the JCAHO pas issued, revealed that the vast majority of hospitalspractice of disclosing harm to patients at least some o

ime and that board-approved policies for disclosure welace or in development at most. Still, decisions about what, and how disclosure should happen were mostly

o individual clinicians[50,51]. Analysis of a mail and telehone survey of US doctors to assess agreement with coions from the IOM report found that most doctors belieeduction of medical errors should be a national priority,hatall doctors saw the threat of malpractice litigation aarrier to the voluntary reporting the report calls for[52].

The IOM report has its critics. Some argue that a call fystem of voluntary reporting is unrealistic under the curort system for malpractice in the United States[6,53–55].thers point to financial pressures on hospitals to focuhort-term economic survival and leave safety behind,he absence of an effective consumer lobby for patient s3,8]. Troyen Brennan argues that many of the reports’ rec

nd types of error and conceptual and research literatuarding the contexts within which medical error may ocnd (2) research on, and physician or other narrative accbout, doctors’ responses to medical error. Sources incedline, the Literature, Arts, and Medicine database oew York University School of Medicine, and other librand online searches; reference sections of key articlesonsultation with experts in the field. Selections were bn one of more of the following factors: appearance in htandard scientific or professional journals; impact of thearch or theory on the field, as evidenced by its citatioelevant literature; and the author’s judgment that the marought important, insightful, or underrepresented findingiews to bear on the topic of doctors’ responses to merror. In general, work published before 1990 was not cnless the work was seminal or was one of the few avain a particular theme or aspect of the topic.

A working understanding and definition of “medicalor” is necessary. James Reason rites that all human erre categorized either as skill-based lapses, in which the aoes not go according to plan, or as rules- or knowledge-bistakes, in which the plan itself is flawed or not suitechieve the objective[60]. Others have offered a rangeelated definitions for medical error: unintentional userong approach or failure to carry out a correct approaclanned, a preventable adverse medical event resultingegligent or “honest” acts of commission or omission,edical action or inaction that has the potential to harmatient and that peers would have judged wrong at the

61–65]. Adverse events have been defined as prevenr ameliorable injuries occurring as a direct result of m


cal care, and as injuries caused by medical management thatprolong hospitalization or produce disability[56,66]. For thisarticle, error or possible error will be what the physician who“commits” or observes it perceives it to be, but the preced-ing definitions reflect the profession’s understanding of thesubject and thus shape doctors’ perceptions of error.

Before turning to those perceptions and responses, it willbe useful to review the stated expectations of the medical pro-fession regarding doctors’ responses to error and the contextof malpractice litigation within which doctors in the UnitedStates, and many other countries, practice medicine.

2. Professional principles and the legal context

The American Medical Association’s (AMA’s) 1957 Prin-ciples of Medical Ethics enjoins doctors to report accidents,injuries, or poor results stemming from medical treatment[67]. The AMA’s 2001 revised Principles states that physi-cians must be honest with patients and expose incompetentor unethical colleagues[68]. The Ethics Manual of the Amer-ican College of Doctors states that rules for truth telling fol-low from respect for patient autonomy[69]. Medical ethicistsstrongly support the principle of disclosing harm to patients[64,70–73]. Disclosure not only demonstrates respect for pa-tients’ autonomy in the abstract, but provides them with infor-mE t, doc-t med[ nd,u ntol thet ship[ althc blic,a

en-d ofes-s dicale ouldb andu so iansn stsa d howa tm t tom o hos-p , nott ther ure,i cat-i tices

cticea nd ag ual

doctor’s incompetence or carelessness. Malpractice awardscompensate injured persons and deter future error by assign-ing personal blame, thus encouraging better care or forcingincompetent doctors out of the profession[6,37,54,55,78].In addition, supporters of the current malpractice system ar-gue, tort reform to limits jury awards will not hold downinsurance premiums to doctors or protect patients from mal-practice[79,80].

Critics of the tort system for malpractice liability chargethat it fails to address the problem of medical error on sev-eral counts. First, only a small fraction of patients who areinjured by negligence file lawsuits[54,81]. Second, there islittle relationship between successful litigation and size ofaward and the degree to which negligent practice contributedto harm[54,61,82]. Third, there is no compelling evidenceof a relationship between lawsuits and subsequent improvedquality of care[6,54]. Fourth, those who are most in needof compensation for injury—the poor—have the fewest re-sources of time, money, and other support for pursuing litiga-tion [78]. Fifth, the current tort system for negligence inhibitsthe reduction of error that may come with open disclosure andanalysis of errors, because the prospect of litigation followingdisclosure is humiliating and career threatening for doctorsand can lead to huge losses for both doctors and medical in-stitutions[39,54,64,78,83,84]. In addition, as Lucian Leapeh g er-r willgw intoa

inw heiri ence,i -p ark,S -p pa-t temw sibil-i pingp par-e sidee ntt venti thatt usm ups,c faults il tod

der-w ingm ive-n ) top edia-t line

ation that may affect their future treatment decisions[64].ven when an error poses no present harm to the patien

ors should assume the patient would want to be infor62]. Hiding errors denies to the practice of medicine altimately, to all patients, the opportunity to turn error i

earning that could prevent future error. It also violatesrust that lies at the heart of the doctor–patient relation74]. At the organizational level, the mission of the heare institution is based in trust with patients and the pund failure to report error may undermine that trust[75].

Translation of principles into practice, however, is depent on the ways that doctors and other health care prionals interpret them. Robert Zussman writes that methics is primarily normative and that more attention she paid to how ideas of right and wrong are interpretedsed in everyday clinical practice[36]. Michael Devita pointut that medical codes of ethics lack the specificity cliniceed in order to find their way through conflicting interend versions of the truth about a given adverse event annd when to disclose it to patients[76]. Albert Wu writes thaany doctors interpret the AMA’s 1957 ethics statemenean they should report adverse events to superiors or tital quality assurance or risk management committees

o patients[64]. Admission of error to patients, then, isight thing to do, but there are daunting barriers to disclosncluding reluctance to admit error, concern about impling other practitioners, and fears of liability in a malpracuit [39,75,77].

The goals of malpractice litigation are to deter bad prand pay victims for losses. For malpractice attorneys aood segment of the public, injury is the result of individ

as observed, many doctors do not believe that reportinors will lead to their reduction, only that someone elseet caught and punished the next time around[85]. Sixth andorst of all, the tort system turns patients and doctorsdversaries[61].

Many in the US urge a move to a “no-fault” systemhich injured patients would have to prove only that t

njury was caused by medical management, not neglign order to be compensated[54,55,78]. Alternatives to malractice litigation have been in place for years in Denmweden, Finland, and New Zealand[55,78,86]. Some suporters argue that US doctors’ involvement in assisting

ients’ claims for compensation through a no-fault sysould be a natural extension of their therapeutic respon

ty to patients, comparable to the current practice of helatients with workers’ compensation claims or of helpingnts gain compensation for children who suffer seriousffects from vaccinations[55,87]. Regarding the argume

hat hospitals and doctors will have no incentive to prenjury if the threat of litigation is removed, some contendhe “liability incentive” can be maintained through varioeans—pooling risk among institutions or medical gro

ombining aspects of both malpractice litigation and no-ystems, and sanctioning doctors or institutions that faisclose errors leading to patient injury[6,54,88].

In the absence of wholesale reform, efforts are unay to improve the current litigious environment surroundedical error. These include the concept of medical forgess, involving doctors’ apologies (with legal protectionatients in the case of medical error; interest-based m

ion; institutional or physician–patient charters that out


specific approaches to medical error; patient representativeswho work with patients, doctors, and the hospital to keepcommunication lines open in the case of a medical error;training for physicians on disclosure of errors to patients;and humanistic risk management policies with swift reviewand fair compensation for injuries[11,37,70,76,89–95].

3. Doctors’ responses to medical error

Medical students are taught about the unacceptability oferror while, at the same time, they are learning about theinherent uncertainty of medicine and inevitability of errorin their early clinical work and observations[42,96–101].Terry Mizrachi writes that doctors-in-training learn how tocope with error through denying it—viewing the practice ofmedicine as an art with gray areas; discounting it—blamingthe hospital, superiors or subordinates, or the patient; and,when they can no longer deny or discount error, distancingit—concluding that all doctors’ make mistakes, but do thebest they can. Yet doubts remain, and their medical trainingdoes not help young doctors talk about them. Instead, theydefend themselves against their own medical errors by re-garding themselves as their own worst critics and thus thesole judges of the care they provide[102]. Bosk, who con-ducted an ethnographic study of surgical training, found thats taintya prac-t icale rat-e as ac s canb f thed tryh thats thei icidetc iansi tatusa rain-i ers[

d ina encea st nticalw eire tor’sh jus-t s.B z ar-g ectivea edgeo thek dif-f nts

about treatment decisions[110]. The “therapeutic privilege”of the doctor to withhold negative information from patientsin order to protect them from the effects of receiving badinformation, then, has increasingly come under scrutiny andcriticism in an era of patient autonomy[91].

Arthur Frank, referring mainly to chronic illness, contraststhe older, Parsonian version of the doctor–patient relation-ship, in which the patient played the sick role and was re-sponsible only for getting well, to that of the “post-colonialill person” who takes responsibility for the meaning of hisor her own illness[111,112]. Increasingly, patients are de-manding more equal partnerships and decision-making inthe doctor–patient relationship[91,113]. Bosk argues thatthe loss of physician charisma and movement toward a morecontractual physician–patient relationship is a source of theincrease in malpractice litigation in the United States[103].Many see the doctor–patient relationship as being threatenedby contemporary managed care with its market orientation,financial incentives for doctors that may lead patients to ques-tion their doctors’ motives and loyalties, short office visitsthat leave patients feeling rushed, and increased physiciancaseloads[114–120].

Even in an era of patient autonomy, people want to havecaring and respectful relationships with their doctors[121].They also see their medical experiences as entangled witht rs toao dur-i heird andh tapedp , thatv ortert

pa-t fort ee h hisd

J dy, I’dl sm hingb km ence,a sickm byl hare,a eingo atural[

3

s’ re-l ients

urgical residents learn about the management of uncernd error from their attending surgeons, who teach the

ice of moral competence, distinguishing among technrror, or errors of skill, judgmental errors, or errors of stgy, and normative, or moral errors—the failure to actonscientious physician. Technical and judgmental errore forgiven, but moral errors reflect upon the character ooctor-in-training[103]. Research on residents in psychiaas detailed the use of terminology and verbal ritualserve to diminish the significance of error and preserventegrity of the profession, especially in the case of a suhat might have been prevented[104,105]. Finally, identifi-ation with and loyalty to other physicians and physicn training and mutual awareness of the professions’ snd power, acquired both during and beyond medical t

ng, contribute to doctors’ reluctance to criticize their pe106–108].

Paul Starr writes that, in another era, doctors worke“quasi-ecclesiastic” atmosphere with near-total confidnd the awed respect of their patients[109]. Jay Katz write

hat, historically, doctors have seen their interests as ideith those of their patients. This view, combined with thsoteric knowledge and belief in the mystery of the docealing power (a belief their patients shared), provided

ification for not informing patients of their dire conditionut doctors’ and patients’ interests are not identical, Katues, since doctors can neither shed their medical perspnd its inevitable biases nor share their patients’ knowlf the meaning of illness within their lives. In addition,nowledge doctors need for diagnosis and treatment iserent from the knowledge they need to talk with patie

he issues of their everyday lives and want their doctottend to more than their biomedical needs[122,123]. Yet,ften patients do not communicate these issues directly

ng office visits. Instead, they hint at them, giving cues toctors may respond to. Surprisingly, Wendy Levinsoner colleagues found, in analyzing audiotaped and videoatient encounters of primary care doctors and surgeonsisits in which doctors responded to patient cues were shhan those in which they failed to respond[122].

Doctors may forget that caring and recognition of theient’s suffering can continue even when the opportunityreatment or cure has passed[124]. Anatole Broyard wrotloquently about the relationship he wanted to have witoctor:

ust as he orders blood tests and bone scans of my boike my doctor to scanme, to grope for my spirit as well a

y prostrate. Without some such recognition, I am notut my illness The doctor. . . doesn’t have to lie to the sican or give him false assurances: He himself, his presnd his will to reach the patient are the assurance thean needs. . . He has little to lose and everything to gain

etting the sick man into his heart. If he does, they can ss few others can, the wonder, terror, and exaltation of bn the edge of being, between the natural and the supern

125].

.1. Research on doctors’ responses to medical error

Research and reported experience attest to doctoructance to disclose medical error to superiors or pat


because of their fears of malpractice litigation, their highexpectations of themselves and the shame and sense of in-adequacy that error brings, or their ignorance of reportingprocedures[39,62,78,126,127]. In one study, house officersreported telling their attending doctors of serious medicalmistakes about half the time and patients or their familiesless than a quarter of the time[65]. In another, one-third ofdoctors, given a hypothetical situation in which a patient diedof a medication error, said they would provide less than fulldisclosure to family members[128]. In still another, onlyabout 60% of ophthalmologists said they would report anyand all complications during surgery, while more than 90%of patients said they would want to be informed[129].

Marilynn Rosenthal conducted in-depth interviews with100 surgeons and general practitioners in England and Swe-den. She concluded that shared uncertainty enhances doc-tors’ mutual identification with each other, leading to a mu-tual sympathy and tolerance for error and a sense that onlydoctors can judge fellow doctors. That judgment, at the raretimes it is set in motion, moves slowly, fitfully, and ineffec-tively [130]. Marc Newman conducted in-depth interviewswith family physicians to elicit both the emotional impactof what they regarded as their most memorable mistakes,and their responses to a hypothetical scenario concerning aphysician’s possible error. He found that the large majoritya f thatg Yet,w ctori ouldo na nerali rrors,o ofteni m-p ctorst nds,o ene ancet , theb ingf thep

ortyp hers’w icalt itedq intot sion,h sionss it,t

U is-tam mis-

take. . . the primary thing in my mind is,did I do at the timewhat appeared to be correct, you know, and if I didn’t give itone hundred percent, I’m mad at myself. I think the secondthing is. . . if there is that much uncertainty, that I’m worriedabout making a mistake, I get somebody else to look, too,you know, try and minimize the chance of making a mistake.But I think, you know,when a mistake does occur, I think itis something, you know, that you have to own up toand. . . ifI’ve made a mistake which is. . . a rational sort of a mistake,understandable. . . I don’t find it extremely difficult to copewith it or something like. . . like, do I lie awake nights? No[133a].

In Paget’s phenomenological approach, uncertainty andthe inevitability of error are notperceptionsbut reality forphysicians.Beingwrongis different from the external charac-terization ofbeing at fault; it is a direct experience of doctors’being-in-the-world, an intrinsic part of their work and pro-fession that brings with it the “anguish of clinical action” and“the moral ambiguity” of being a clinician[133b]. Actionsthemselves are not right or wrong, Paget contends. Instead,actionsbecomeright or wrong in retrospect as they unfoldover time in a process that she calls “a complex sorrow” ofaction going wrong[133c]. Because error is inevitable andcommon in medical practice, doctors must accept the possi-bility of error every time they make, or fail to make, a medical

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dmitted having made a mistake, and a large majority oroup had wanted someone to talk to about the error.hile they acknowledged the need for support of the do

n the hypothetical scenario, less than a third said they wffer that support unconditionally[131]. John Christensend colleagues conducted in-depth interviews with ge

nternists and medical sub specialists and found that er perceived errors, shook doctors’ self-confidence and

nvolved feelings of guilt, fear of being found out as incoetent, and fear of stigmatization by colleagues. Few do

alked about their mistakes to colleagues, family, or frier to their patients[132a]. Both Newman and Christensmphasize a few key themes underlying doctors’ reluct

o disclose error: the competitiveness of medical practiceelief in physician control and the difficulty acknowledg

allibility, and the taboo against “first, doing no harm” toatient.

Marianne Paget conducted in-depth interviews with fhysicians regarding errors they made or observed in otork, efforts they make to avoid them, and the psycholog

urmoil they experience in facing them. The following eduote from a physician interview provides a glimpse

he overlapping feelings and motivations of anguish, evaonesty and attempts at honesty that may be further evaense of inevitability of error, and difficulty of confrontinghat doctors experience:

sually, that’s. . . you know, I think, when you make a make or when I make a mistake in patient care. . . first ofll, I try not to, but it’s inevitable. You know, you’ve got toake mistakes. And, you know, when you do make a

,

intervention. Paget’s work conjures the image of the dowalking into a field of practice filled with mines that were nplanted deliberately, but grew there and are a natural pathe field. The physical risk, however, is to the body of thetient, not of the doctor, and thus the anguish that comes wthe doctor makes a mistake. This anguish is compoundethe fact that “no adequate language captures their wortheir conduct going awry with an even hand[133d].”

3.2. Patient views of doctors’ responses to medical erro

Studies consistently show that patients want toinformed of medical error or other adverse eve[129,134,135]. Ironically, given many doctors’ silence in thcase of error, research conducted with patients, family mbers, and malpractice attorneys suggests that patients mmore likely to sue when they arenot told about error thanwhen they are[28,134,135]. (While such research tells uwhat patients or family members think in retrospect orpothetically, it cannot tell us how they would respond if thhad beenorwereinformed of medical error[76,91].) Studiesconducted by Wendy Levinson, Thomas Gallagher, anders reveal that people sue not only because they wantcompensated for losses and suffering or to care for an injfamily member, but because they want to know what hpened and what will be done to prevent similar errors frhappening to other patients in the future, because theydeserted or devalued by doctors, or because they want thsponsible parties to be held accountable[77,123,136–139].Other studies, not associated with technical quality of c


but providing cautionary lessons in thecaring that is inex-tricably associated, for patients and families members, withmedicalcare, suggest that doctors who spend time educat-ing and communicating with their patients may be less likelyto be sued, and that unsolicited patient complaints are posi-tively associated with doctors’ risk management experience[140–142]. Finally, late or confusing bills or collection pro-cesses can serve as triggers for lawsuits, perhaps, as GeraldHickson observes, because they serve as a focal point for pa-tients’ or family members’ dissatisfaction with poor care ora poor outcome[143,144].

Patient or family member narratives often support find-ings such as those cited above. “Lawsuits are filed not justfor financial reasons,” writes Carol Levine of surgical mis-takes that occurred in her husband’s care after his automobileaccident, “but because people feel abandoned and aggrieved[87b].” Burt Feilich, an attorney, writes that lack of com-munication among doctors led a failure to schedule a timelycesarean section for his wife. The baby, in a breech position,died a few days after an emergency cesarean. The Feilich’srefrained from suing only because they knew no attorneywould accept the case with the limited compensation that anewborn’s death can bring[145]. Sandra Gilbert’s account ofher attempts to get answers about her husband’s death dur-ing routine prostate surgery illustrates how a “circling thew ead tot k toa w-s thersr witht hiss rayalw eath[ er-a of un-t eon’sh ssary,s ningc , il-l icala res

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(including one written by a nonphysician about a physician)can be placed, somewhat untidily, into four categories: self-directed narratives, patient- or family-directed narratives, ob-servations of other doctors’ errors, and narratives of uncer-tainty.

3.3.1. Self-directed narrativesOther doctors have followed David Hilfiker’s pioneering

account by writing about their own medical errors. In hisaccount of trying, and failing, to intubate a trauma victimand waiting too long to call for help, Atul Gawande takesone step further Paget’s insight that “being wrong” is a stateof experience, not an externally-bestowed attribute:

I felt a sense of shame like a burning ulcer. This was not guilt:guilt is what you feel when you have done something wrong.What I felt was shame: I was what was wrong[96b].

Surgeons, Gawande contends, have to be able to put a lidon such feeling or they will be unable to practice. On the otherhand, surgeons who find fault with everyone but themselvesand are confident they never make mistakes are even moredangerous than those who have trouble “moving on.”

A physician of this author’s (Rowe’s) acquaintance re-counted an early brush with possible error:

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agons” approach to catastrophic adverse events can lhe outcome—litigation—that doctors and hospitals seevoid [146]. Michael Rowe’s account of considering a lauit after his son’s death echoes those of Levine and oegarding the silence of doctors after a patients’ death,he added point that the sensitivity of many doctors whileon was fighting for his life exacerbated his sense of bethen those same doctors were silent after his son’s d

147–150]. Other patient narratives—of “failed” chemothpy that the patient later learned had been successful,

reatable cancer that proved to be treatable, and of a surgarsh recommendation of invasive, and possibly unneceurgery to a patient who had just learned of a life-threateondition—while not necessarily involving medical errorustrate the importance of responding to patients’ mednd emotional needs in critical- or potentially critical-caituations[151–153].

.3. Physician narratives on medical error

Anne Hawkins, a scholar of illness narratives,pathographies,” wrote more than a decade ago that weore narratives of doctors’ experiences to match thosatients:

e need more writing that conveys the main reality of whs to be a physician in today’s technological medical sys

nly when we hearboth the doctor’s and the patient’s voiill we have a medicine that is truly human[154].

A number of recent physician accounts answer thisnd many involve the issue of medical error. These narra

remember my first year as a pediatric resident. . .. I wasn call thirty-six hours on and twelve off for three yearould get calls in the middle of the night from nursesoctors about something that needed to be done. Once

o increase a medication for a child. I woke up in the mornn a panic. I couldn’t remember what I had said on the phthought I was going to die until I got there to figure ohat I had done. I had gradually convinced myself Ione something wrong until I was at the bedside and reahad not.

This physician’s uncertainty and panic were a direcponse to a loss of control due to lack of sleep, but hisight stand as a metaphor for the underlying lack of connd sense of possible error that doctors may carry wide-a

nto their next medical encounter.Ian Couper writes about his experience at a 280 bed

ospital in South Africa. As the attending doctor covell wards and with no specialists to call upon, he waited

ong to intervene with cesarean sections on two delivereek apart from each other. Both babies died. “At this poe writes about the second delivery, “I wanted to run a

o hide, to weep, to give up medicine—anything but goell that mother that her baby was dead[155a].” He tells theother of complications, but not of his mistake. He feltmurderer and wanted to leave medicine, but forced him

o go back to work, all the time questioning himself:

m I competent? How will I know whether or not I am coetent? Who will tell me when I am no longer competeow do I avoid making the same mistake over again[155b]?


He offers a litany of doctors’ responses to their guilt overbeing wrong—concealing or distorting the facts, blaming oth-ers, burying the feelings inside and becoming distant andcold, becoming the one local specialist in an obscure areaof medicine, and fleeing to nonclinical work. Like Hilfiker,he believes that working through error involves the spiritualwork of restitution and forgiveness, but that there is no placein modern medicine to undertake such work. Instead, doctorsexpect perfection of themselves and so, making a mistake ishumiliating. “If nobody is sharing mistakes,” he writes, “it re-inforces the concept either that mistakes do not happen or thatthe consequences of talking about them are terrible[156].”Couper makes the interesting observation that doctors’ inter-nal responses to error occur in relation to five entities—theself that questions one’s competence, other doctors who willassess one’s competence, patients who will render a moresweeping judgment of person and physician, regulatory agen-cies that can impose professional sanctions, and the law thatpatients or family members turn to for compensation.

3.3.2. Patient- or family-directed narrativesThe issue of disclosure to patients or family members is

one of the first that comes up in professional or lay discussionsof medical error. A number of recent physician narratives

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In my ear I can hear the admonitions of hospital lawyerscautioning me not to say too much. Don’t commit yourself,they might say. And I feel—what is it?—something like theshame of being caught doing something wrong. But in thecavity of that humiliation, finally exposed, I feel no desire towaffle or dodge. She deserves better than that[158].

He tells the woman that, yes, he might have prevented herhusband’s death. She leaves, but remains his patient, neveragain mentioning her husband. Eventually, she returns for herown screening sigmoidoscopy. Nathalie Robins, a journalistwho wrote a book on the Libby Zion-New York UniversityHospital malpractice case, writes about returning to the Ob-Gyn who had performed an unsuccessful amniocentesis dur-ing her previous pregnancy, causing her to miscarry. Robinsignored her friends’ advice to sue, she writes, because of herdoctors’ expressions of sorrow and solicitude following themiscarriage[9]. One can imagine that such absolution as wasoffered in these two cases may be both comforting and dis-comforting for doctors who are given a reminder, each timethey see their patient, of another patient’s death. Christensenand colleagues report on the extremes to which doctors’ guiltand repentance can lead:

Besides disclosure of the mistake to patient or family, physi-cians reported coping in other ways to reduce feelings ofg guilth fam-i iodo ingf

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uilt. One physician reported that his response to hisad been to become a kind of indentured servant to the

ly, attempting to expiate his “crime” over a prolonged perf time by spending more time with the family and reduc

ees[132b].

Michael Kovalchik provides a doctor–patient accorom a different perspective. A patient, Theo, is suing hpparently without cause, for Kovalchik’s secondary rolheo’s leg amputation following an infection that was colicated by his insulin-dependent diabetes. Two years

he litigation, Theo’s dialysis unit requests a transfer toalchik’s unit, located in Theo’s hometown. Kovalchik ovomes his anger at the thought of treating Theo and welcim to the unit. Theo, relieved, opens up to staff over time

alks about confronting his own death. Eventually, he dhe lawsuit:

hen he arrived for his next dialysis treatment, I askedhy. After reflecting for a moment, he sheepishly poinut that we had been “very good” to him. The fire inelly, born out of the loss of his leg, burned out. His anissipated, he could no longer maintain a lawsuit again

159].

One must bear in mind the possibility of subtle medoercion of such a vulnerable patient, but Kovalchik’s pbout a “relationship that bridged our differences” seems

aken here[159].Dan Shapiro, a psychologist who specializes in trea

octors, writes about a talented obstetrician in her mid-1ho began to lose her sense of competency after mi

address the decision to disclose and its consequences.Richard Boyte writes about caring for Casey, a six mon

old infant on mechanical ventilation after surgery to repaiheart defect. His condition has deteriorated with pneumosepsis, and kidney failure. Boyte, the pediatric critical caspecialist, thinks Casey is too fragile to tolerate placemof a central venous catheter which the pediatric nephrolohas requested so that he can start hemofiltration. Againsbetter instincts, Boyte decides to go ahead. Performingprocedure, he fails to use his stethoscope soon enougdetect that a clot in a chest tube has masked bleeding fropunctured artery. The baby dies. Boyte tells Casey’s pareof his error. They thank him for his efforts. He writes:

Why did I tell them so much? Was I seeking some forof absolution? Perhaps so, but I hope my true purposefull disclosure was, in the end, more honorable. They hentrusted me with their daughter’s life. I owed them the tru[157].

Wu has written that doctors are often relieved after admting a serious error, and find that patients or family membenot colleagues, may be the only people who can offer forginess[65]. Boyte’s placement of his own need for absolutioon a lower moral plane than that of telling the truth to Caseparents underlines the need, and the difficulty of asking,that absolution or forgiveness.

David Watts writes about a routine medical visit withpatient, the wife of a healthy 62-year-old man whose deathmight have prevented by ordering a screening sigmoidoscas part of a general check up. The woman asks if he cohave prevented her husband’s death:


evidence of late deceleration and waiting too long to per-form a C-section. The baby developed cerebral palsy, pos-sibly from oxygen deprivation due to the late deceleration,and the mother sued. At one point during the discovery pro-cess, the mother called the obstetrician, Dr. Sorvino, at home.Sorvino, remembering her attorney’s caution against havingcontact with the mother, hung up the phone. Shapiro describesSorvino’s sense of being a fraud, her leave from practiceand, eventually, her suicide attempt. Eventually, Dr. Sorvinomeets with the mother and her baby. The mother acknowl-edges Sorvino’s courage in meeting with her, but ends themeeting by saying she never wants to see her again. Even thiscontact, however, becomes a form of redemption for Sorvino.Referring to the time the mother had called her at home, shetells Shapiro, “The moment I hung up on Stacy. . . that wasthe end of my career[160].” A dramatic tension in Shapiro’snarrative—his own struggle over whether to intervene for fearthat Dr. Sorvino will attempt suicide or to honor her autonomyby accepting her reassurances that she will not—emphasizesthe theme of uncertainty that began the story, with Sorvinoholding off on performing a cesarean section because of herpatient’s wish to have a vaginal birth.

Frank Huyler, an emergency room physician, writes abouta man in his early thirties who comes in to the emergencyroom asking for antibiotics. The ER is particularly busy andH es,“ ght.Y ck.N atch[ ibi-o ex?H hate all.W hisb ylerm seet fromt st ath

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heels of his ungodlike error—magnify, rather than diminish,the sense of relief he conveys at his patient’s recovery and atbeing able to offer himself up to the man’s anger.

3.3.3. Narratives on other doctors’ errorsDoctors observe and respond to other doctors’ errors

through witnessing the medical event, direct observation andclose contact over time, and participation in malpractice liti-gation or regulatory oversight.

Neil Calman writes about his “indoctrination into the un-derworld of medical secrecy” after a 60-year-old patient diedwhen his potassium was not routinely monitored and wenttoo high after surgery[162a]. The attending surgeon leavesCalman, then a third year medical student, to comfort thefamily, after making clear that he does not want Calman totell the family about the error. Calman’s burden of secrecyis multiple, since he learns that the surgery preceding thepatient’s death was made necessary by an infection causedby one of a defective batch of cardiovascular catheters. Hisconflicts are multiple, too:

Should I tell his [the patient’s] family everything I knew? Orwas I as a doctor. . . committed to keeping the secrets thatlie beyond the patients’ and families grasp? Was I partiallyresponsible for the future survival of the wife, daughter, and

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uyler is correspondingly rushed. “After a while,” he writyou come to rely, more than anything else, on first siou walk into the room and you think, sick or not siot sick goes home as fast as possible. Sick, you w

161a].” Huyler asks the man if he is allergic to any anttics. Penicillin and erythromycin, the man says. And Kefle doesn’t think so. Huyler gives the Keflex, thinking tven if the man is allergic to it, the risk of reaction is smithin half an hour the man is in respiratory distress,

lood pressure falls, and he is minutes from death. Huanages to intubate and stabilize him. A month later, he

he man at another hospital, where he is recuperatinghe allergic reaction. The patient yells and shakes his fiim:

heard the anger in his voice, and as I looked at him, nods he accused me, humbling myself with an act of w

elt suddenly large and powerful, somehow proprietary. Iearly killed him, and then I had brought him back fromdge, I had caught his hand just as he fell into the empaces and held him there. His anger sustained me: it me was undamaged, it meant that he was safe, nearlygain.

I’m sorry this happened, Mr. Lopez.”

Easy for you to say,” he said, his eyes glittering.

e was so alive[161b].

The contradictory emotions of Huyler’s response toncounter—of his godlike power as a physician and his

o be punished for having to exercise those powers o

s

te

granddaughter Charlie had left behind?. . . Did the companythat made the catheters know that some of them had bcontaminated? Would lawsuits have forced them out of buness, making those devices unavailable to others who wobenefit? Would the hospital be forced to pay millions, erodithe services it was providing to other patients? Would doctbe afraid to assume the challenges of caring for criticallypatients like Charlie? Didn’t Charlie’s family deserve to bcompensated for the errors that caused their loss? Wouldbenefits to that one family outweigh the damage that cobe done to the physicians and the hospital[162b]?

Calman writes about how quickly he adapted to keepsecrets and about the obstacles to openness: the unspagreement among doctors that mistakes are an inevitableof practicing medicine, that doctors’ should discuss mistaonly of those they employ or supervise, and that lawsucause undue financial burden on doctors and hospitals, ddoctors’ attention and confidence, and lead to public humiation. Both law and medicine, Calman concludes, mustchanged in order to ensure just compensation to the injuand encourage disclosure of errors.

Richard Beach writes about deciding whether to repa friend and colleague, the director of the neonatal intsive care unit where Beach is an attending physician. Tcolleague repeatedly makes elemental errors such as nodering a chest X-ray after intubating a premature infaBeach’s story is illustrative of the competing and complloyalties—to patients, fellow doctors, the hospital, and tprofession—that doctors’ experience when they observemistakes of other doctors, and the ways in which clear


competence becomes cloudy when facing the prospect of re-porting a colleague. Medical students are not taught aboutphysician incompetence, Beach writes, “for such would im-ply the system doesn’t work[163].” He makes a distinctionbetween physicians who learn from their mistakes and thosewho repeat them with no attempt at correction or recognitionof the damage they have done. He concludes, ruefully, thathis colleague falls into the latter group. Eventually, he callsa regional director to inform him of the problem. This doc-tor downplays Beach’s concerns with a lecture on differentclinical approaches and management styles, and then callsthe colleague and tells him to settle his problems within hisown family. At the end of the story, Beach calls the stateboard to report his colleague, choosing the loyalty he owesto his patients over the loyalty he owes to a fellow doctor,but only after demonstrating how difficult such a real-worlddecision is for him, and how little help he has received fromhis profession to overcome his lesser loyalties.

Doctors’ testimony for plaintiffs in malpractice lawsuitsmay strain their relationships with colleagues in general, butpresumably carries less emotional burden than that involvedwith reporting a close colleague. The motivation to take onthe expert witness role, however, may emerge from personalexperience. Linda Peeno writes that she began testifying inmalpractice lawsuits after a stint conducting case reviewsf loyerp ungp g theo thate om-pB e de-p eatho rassfi thep quater be-c illances ederaA porte

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fare of the patient, even though the patient is not hers. In thelast case, Brass, at the furthest and most bureaucratic removefrom clinical practice, takes on the role of attending-at-largeand looks to national models to correct the practice of herstate’s medical institutions.

3.3.4. Narratives of uncertaintyUncertainty not only contributes to the chance of error

in medical practice, but to the difficulty, at times, of under-standing the cause of the error, whether the error led to a poorresult, or whether what looks like an error is an error in fact.

Danielle Ofri writes of possible error in a story that startswith a morbidity and mortality conference. Mr. H, a 31-year-old white male, had attempted suicide three years earlier byingesting a bottle of lye. His esophagus was destroyed, buta piece of colon was surgically inserted to replace it. Uponadmission Mr. H is nauseated, vomiting, and dizzy, but hislaboratory results are normal. Dr. Ofri performs a balloondilation to correct esophageal strictures. That evening, Mr.H rapidly develops hypotensivity, an elevated lactate level,and low blood pressure. Ofri describes a series of medicalinterventions and calls to several attendings who decline tocome in to see her failing patient. She examines an X-ray forsigns of a ruptured esophagus from the balloon procedure,but concludes that the line of clearing she sees on the X-rayi lon.O n theu did,i theb ist’sr thisfi tionh ep ing.M e ofc mpth wardt Mr.H r thats s:

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or a managed care organization. In one case, her empraised her for finding a contract exclusion to deny a yoatient an opportunity for a heart transplant, thus savinrganization US$ 500,000. Walking out of her officevening, she looked at a newly installed sculpture her cany had purchased at the cost of 3.8 million dollars[164].rass (a pseudonym), writes about her work with a statartment of health. Hospital X was being sued for the df baby in its emergency room. As she investigates, Bnds an unusual number of deaths in that hospital. Inrocess, she receives an education in the wholly inadeules governing the hiring of physicians in her state. Sheomes convinced that the state needs to develop a surveystem for serious adverse events analogous to the Fviation Agency system, which allows employees to rerrors or dangerous situations without penalty[165].

These narratives offer a wide range of doctors’ reaco other doctors’ errors. The doctors in the first two naives both describe the emotionally wrenching experief observing a colleague’s error, but from different pers

ives. The subtext of Calman’s reasoning and rationalizabout disclosure to the family is a young doctor’s shoc

he moral compromise he is offered in exchange, it seor full membership in the profession. Beach’s narrativehe other hand, conveys a strong sense of the emotionaf collegiality built up in day-to-day work and personal

ationships, and of the professional and personal disruhat, the reader surmises, will follow for him after “turnin” a colleague. In the third narrative, Peeno, whom somhe profession might regard as a renegade, retains her ids a physician through practicing her primary duty to the

l

s only a shadow from the surgically inserted piece of cofri goes home, and the patient dies that night. Back onit the next day, the chief resident tells her that the X-ray

n fact, show free air in Mr. H’s heart immediately afteralloon procedure. Ofri had failed to read the radiologeport, and the radiologist had failed to call her aboutnding. At the end of the story, however, further examinaas revealed that the X-ray didnotreveal free air, but only thiece of colon Ofri had originally concluded she was seer. H, it appears, died of micro-perforations from the piec

olon, in effect successfully completing the suicide attee started three years before. Ofri writes of her anger to

he attendings and their lack of collegiality or concern for. The critical care attending comes over and reminds hehe never explicitly asked him to come in. Ofri conclude

he room was shrinking around me fast. My eardrumsike they were about to implode from the pressure. My stch was in knots and the taste of vomit was in my mouuddenly had an overwhelming urge to disembowel somith my own bare hands.

ut I just didn’t know who[166a].

This story and a second from Ofri provide excellent cxamples of uncertainty in practice and the way in w

ncreased availability of diagnostic testing multiplies theortunity for error even as it gives doctors new tools to muccessful interventions. Ofri writes of being two monhort of finishing her residency and seeing a young woerced, who was admitted after visiting the ER with wppears to Ofri to be aseptic meningitis. This condition,


comments, should have prompted the ER doctors to sendMerced home with aspirin. Ofri’s examination yields no re-markable findings, but she asks Merced about travel, recentillnesses or vaccinations, and other possible sources of theheadaches and pins and needles feelings she complains ofhaving for a few minutes at a time. On a sudden inspira-tion or whim, Ofri decides to send her cerebrospinal fluid fora Lyme titre. The next morning, Merced exhibits the bizarrebehavior— lying on the floor with her clothes off, hair askew,babbling and disoriented—that the ER doctors had observedwhen she came in the day before. Thirty minutes later sheis fine. A neurologist diagnoses a temporal lobe seizure andMerced is treated and released.

A week later, the Lyme disease titre comes back positiveand Ofri is the toast of the unit for diagnosing a condition sorare in an urban hospital. Another week later, though, Mercedis admitted to the ER with a headache and is dead withinhours. A second Lyme disease test comes back negative. Thecause of Merced’s death is a mystery, and Ofri ends her res-idency humbled. She writes of wanting to go to Merced’schildren to apologize for her and her profession’s shortcom-ings, false pride, and failure, yet also writes that standingwith the family in the ER after Merced’s death was her mostauthentic experience as a doctor. There, she was a person,not only a physician or scientist, who “wanted to be in thiss mine[ edh vedo ndinga d liti-g ss ofw

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imagine her head teeming with small thoughts, and the mo-tion of her hands, her eyes, alive in the world, going out intoit, entering it, decade after decade ahead[161c].

From the perspective of moment-to-moment, high-intensity clinical practice, heads on the coin of uncertaintyis the instinct, or luck, to catch an error of omission or com-mission just before it happens, and perhaps save the patient’slife. Tails, which Ofri experienced in Merced’s case afterthinking she had caught heads, represents the wrong hunchor the failure to have the right one, and suggests that the in-stinct which doctors draw on in the face of uncertainty maybe right only about half the time, thus compounding the un-certainty of clinical work.

John Lantos, a pediatrician at the University of Chicago,writes of his own encounters with error:

I’ve made quite a few mistakes in my time. They come backto haunt me late at night. Missing a diagnosis, prescribing awrong drug, botching a procedure. Sometimes, patients havedied as a result of my mistakes. Other times, my mistakes haveincreased their suffering. When they come back to me, late atnight, I hold court in my mind, replaying events, wonderingwhether they were honest mistakes, forgivable mistakes, orif not, how I can go on[167a].

One of his mistakes occurred when he was a resident cov-e italh has ah edyo re-fl . Hec rug.H t thatV yearsb able.T . Heg in ani etherh forea icew e un-c( )i

A nty.S fectm s de-r tillo er-s icals

ts int andh of ther ctors

acred zone that was alive with real feelings, theirs and166b].” Ofri touches on the “horrible sanctity” and sanctifiorror” that family members’ may experience after a lone’s unexpected downturn and death. Such understand acknowledgement might undercut the bitterness anation that sometimes follows a poor outcome, regardlehether there is negligent care[148].Huyler writes about seeing a two-year-old girl in the em

ency room. The father says nothing is wrong; the moays the child is acting strange. Huyler’s examinationhe girl’s behavior are normal. “They’re Medicaid,” a triaurse tells him, implying that the parents are trying toomething for free. About to leave the room, he asks iirl could have got into someone’s medications. Toge

he parents and Huyler conclude that the girl, who hadith her grandmother, must have found one of her oral hlycemics on the floor. Ingesting the pill, which likely wouave killed her without Huyler’s intervention of IV sugar ahospital stay, had caused her bizarre behavior, but sheen given a sucker before coming in to the hospital, andad temporarily masked the effects of the pill. Huyler eis story with a dual image of the healthy girl he has sand the one who would have died had he sent her home

he ER:

s I watched the girl skip and jump around us, the pain oeedle forgotten already, I felt sick, cold and damp, terry what I had almost missed. One question, an afterthohat was all it had been.

rom time to time I think about her. I imagine her playn parks, jumping on the couch, shrieking in the bathtu

ring the NICU. A three-month old baby with congeneart disease and two previous open-heart operationseart rate of 300 beats/min. Lantos tries the NICU remf dunking the baby’s face in ice water to stimulate theex that causes heart rate to slow down. It does not workonsiders giving the baby a dose of Verapamil, a new de has not read the recent case reports which suggeserapamil can cause cardiac arrest in newborns. Twoefore, Lantos writes, the drug would not have been availwo years later, no one was using it on babies anymoreives a dose. The baby’s heart rate goes from 300 to 0

nstant, and he dies. Afterwards, Lantos wondered whe should have known, or should have called for help becting, or should have tried dunking the baby’s face inater again. His account provides an object lesson in thertainty of clinical practice about which Renee Fox wrotealbeit in reference to medicalresearchwith human subjectsn the 1950s:

ll physicians are confronted with problems of uncertaiome of these result from their own incomplete or imperastery of available medical knowledge and skills; other

ive from limitations in current medical knowledge; and sthers grow out of difficulties in distinguishing between ponal ignorance or ineptitude and the limitations of medcience[168].

A thought might occur to readers of these accounhe original that they are the product of highly sensitiveonest physicians and not necessarily representativeesponses of physicians at large. No doubt there are do


who, by dint of temperament or practice in denial, have fewerconflicting thoughts and emotions after committing their ownerrors, or have even convinced themselves that they do notmake mistakes. Yet in-depth research by Paget and otherssuggests that, while the authors cited here are unusually ar-ticulate, their stories are more likely to be representative ofthe average physician’s response to error than they are to beidiosyncratic. Another possible caveat is that these stories puttoo much weight on dramatic cases of error or possible errorand not enough on the day-to-day mishaps, mistakes, and sys-temic problems that vex medical practice today. There is truthin this, too, yet many of these stories convey aspects of thecomplexity of modern medical care and the small compro-mises that may erode good care. Danielle Ofri, for example,wants to confront the attendings who refused to come in tosee Mr. H, but holds back because she still has to work withthem. Frank Huyler’s stories take place against a backdropof sniffling children in the ER waiting room and of humanpettiness, as in the nurses whispered, “They’re Medicaid”diagnosis of the apparent good health of a child who has in-gested oral hypoglemics. Richard Beach’s story of reportinghis friend takes place within the context of that doctor’s pasterrors, large and small, and is punctuated by change-of-dutysmall talk between doctors that is part of the normal disasterof NICU medical practice.

ts areb e re-c ar-r oto s-s care,i herea h ac im-p t theirp nar-r n tol thatt wella gs forp dingt

4

act.I hysi-c uallypa uro-s clesa oro d thatd sw in

scientific journals began in the late 1920s with the use ofthe scientific methods in medical education and the growingthreat of malpractice suits[170].

Merilee Kerr argues that current blame-laden and individ-ualistic responses to medical error in the United States can betraced to the early influence of Calvinism, with its strict divi-sions between good and evil acts and persons[171]. ArthurKleinman writes of a tendency in 20th Century American so-ciety to transform the messy but timeless realities of humanlife and suffering into practical problems that can be managedby technological means, rather than as open-ended questionsabout timeless moral issues. His comments on cancer as anaffront to our sense of predictability and control over our livesmight be paraphrased to make medical error an affront to ournotion of unending medical progress[172]. Renee Fox tracesan increased danger of iatrogenic harm from medications andtreatments to advances in biomedical knowledge starting inthe 1940s that led to an increased ability to diagnose, treat,and prevent disease. She also notes that medicine’s abilityto cure disease and prolong life had the boomerang effect ofdecreasing tolerance for uncertainty[173a].

Although doctors, researchers, and other observers dif-fer on the magnitude of the problem of medical error andthe relative contributions of system versus individual error,there is consensus that medical error is a significant issue inc at them rs toc liti-g ragesd rdingd ls areo taintya nota mu-n pa-t pe-c sureo sup-p theirm t-t s int tweenm fectt ssiblee

usta n tos awayf orderi louso rs ind ruci-a withw eversm e face

Perhaps a more important issue is why these accouneing written now, beyond the encouragement they haveived from doctors like Hilfiker or students of medical native like Hawkins. What functions might they fulfill, nnly for their individual writers but for the medical profeion as a whole during a time of rapid change in healthn doctor’s roles, and in doctor–patient relationships? Tre a number of possibilities, in addition to their fit witonfessional age: an effort to correct the public’s growingression of doctors as arrogant and unconcerned abouatients’ welfare, a plea for mercy for physicians, or aative wing of medicine that wants the medical professioook more closely at itself, and to change. It may also behese accounts, which often are written for the public ass for other doctors, both reflect and are creating openinhysician–patient and physician-public dialogues regar

he future of the doctor–patient relationship.

. Discussion and conclusion

Medical silence on medical error is an historical artifn earlier times, the origin of disease was mysterious. Pians had few tools to combat it, and the outcome, usoor, was seen as a sign from God[169]. In the late 19thnd early 20th Century mistakes in the new field of neurgery were routinely reported in popular journal artis an educational tool[170]. The concept of medical errnly emerged when progress in medicine demonstrateisease could be treated, and thus could bemis-treated aell [169]. The current practice of “burying” errors with

ontemporary health care. There is also consensus thedical profession does not adequately prepare docto

onfront error in their own practice, even aside from theious atmosphere that surrounds health care and discouiscussion of error with patients and colleagues. Regaoctor’s responses to medical error, numerous proposan the table: teaching doctors to accept error and uncernd using this knowledge as a tool for reducing error,n excuse for accepting it; teaching doctors better comication skills, including ways to disclose error to their

ients; developing written institutional procedures, with sific steps and assignment of responsibility, for disclof error to patients and family members; and providingort and counseling to doctors to help them cope withistakes[64,70,77,98,100,123]. In addition, more explicit a

ention should be paid to the impact of cultural differencehe relationships between doctors and patients, and beedical institutions and patient cultures, which may af

he course of treatment and the response to error, or porror, from all parties[174].

Examination of doctors’ responses to medical error mlso take into account the meaning of error in relatiotandard practice, as well as gradations in movementrom standard practice before the doctor crosses the bnto bad practice. Frank Huyler tells a story of a queruld woman who, after seeing him and many other doctoifferent hospitals and clinics across the country for excting pain when she is touched, is eventually diagnosedhat her neurosurgeon calls “the worst broken neck I’veeen in someone who wasn’t paralyzed or dead[161d].” Theissed diagnosis seems incredible, outrageous, on th


of it, yet is understandable in the narrative telling. That somany doctors missed it could be seen as an indictment of theprofession, but probably tells us more about habits of mindand perception (of old people whose bodily decay may bedisquieting to others, of “complainers”) that are common tophysicians and nonphysicians. Danielle Ofri has an instinctto check for Lyme Disease in Merced. The test comes backpositive, but apparently no one thinks to question whether theresult, for such a rare disease in an urban hospital, might bea false positive. But did belief that Merced had Lyme Dis-ease lead Ofri astray from the possibility of diagnosing herunderlying condition? And if so, did Ofri commit a medi-cal error? It is hard to say so. Such cases at the fringe ofmedical error help to put consideration of error into its livedcontext.

Attention to specific problems has the merit of allowingus to bring focused efforts and expertise to bear upon them,but may also cause us to lose sight of contextual factors[175]. In the case of medical error, one such factor is ac-cess to health care. Millions of people in the United Stateswho are uninsured or underinsured receive their health carein emergency rooms or clinics where they are unlikely tosee the same doctor on successive visits. These persons haveless opportunity to experience some forms of medical errorand more opportunity to experience those forms that stemf theirdD etsa n ofr enefitm ene-fi ts,e omis-s re toc arec -arti ale rtym oora rt

oc-t thosew inga e or-g d ofd hysi-c medic cultt nte-g aseda t tot oses icals eoryt dis-

closed their mistakes than if they hide them, each doctorwould still have to consider that he or she might be theone who tells the wrong patient and ends up in court. Ifthisfear could be allayed, the most humanistic doctor might betempted to confess to avoid litigation, even in cases where thepatient is severely harmed and deserves compensation. Fi-nally, if a form of no-fault care were instituted in the UnitedStates and other countries that rely on the tort system, thequality of the doctor–patient relationship that comes intoplay in resolution of most cases of medical error would re-main.

The health care encounter has profound overtones of hu-man relationship, human vulnerability, and the reality of ourfinal dissolution[179]. In place of the charisma of the hier-atic, paternalistic doctor, it may be that there is a charisma,or investment with grace, of the medical relationship andthe medical encounter. A merely contractual relationship orpartnership, much as it has to offer to correct physician dom-inance and lack of attention to patient choice, seems inad-equate without acknowledgement of the inherent drama ofboth relationship and encounter and their backdrop of mor-tality [175,180]. Renee Fox writes:

[H]ealth, illness, and medical care in our society, as in allothers, are integrally connected with some of the most el-emental and basic, and some of the most transcendent andu n ofh ysi-c ent,t fh livesa ent,a , our“ n-t aret d thep s ofm ain,s heirr

fulld andp andp nd se-c licita et ctorsm tner-s ther care,aP tiont sis ofo tion-s ss ofh

rom the haphazard nature of their access to care andoctors’ relative ignorance of their conditions[114,120,147].istribution of health care is an issue not only of who gccess to care and who does not, but of the allocatioesources between preventive and primary care that bany and high-cost, high-technology interventions that b

t few [113,176,177]. In addition, as Thomas Lee commenmphasis on patient safety does not address errors ofion such as failure to screen for colorectal cancer, failuontrol high blood pressure (a failure in which patientsomplicit), and failure to consistently provide state-of-thenterventions to patients[177]. Finally, discussion of medicrror does not attend to what David Hilfiker calls “poveedicine,” in which doctors cut corners in their care of pnd uninsured persons in order to providesomecare rathe

han none at all[178].Returning to medical error as used in this article, d

ors’ responses are a product of the temperaments ofho choose to go into the profession, of medical trainnd medical practice as taught and as practiced, of thanization and funding of health care, of the law, anoctor–patient relationships. If, as physicians and nonpians seem to agree, a change in doctors’ response toal error would help patients and doctors alike, it is diffio imagine that such a change will occur without an irated approach to all of the factors cited above. Increttention to doctor–patient communication might attrac

he profession students with greater “people skills,” but thkills must still be rewarded and nurtured during medchool and residency. If doctors were to accept the thhat their patients are less likely to sue them if they

-

ltimate aspects of the human condition. The conceptiouman beings, their birth, survival, and growth, their phal, emotional, and intellectual capacities and developmheir sexuality, aging, mortality and death. . . are core foci oealth, illness, and medicine, as are the quality of theirnd some of the significant forms of pain, suffering, accidndangstthat human beings experience. In this sensecoming in,” our “staying in,” and our “going out” are coinuously linked with our health, and with the medical chat we seek and receive. The experience of illness anractice of medicine also summon up critical problemeaning—fundamental questions about the “whys” of p

uffering, the limits of human life, and death, and about telations to evil, sin, and injustice[173b].

John Lantos, in arguing against the idea that faith inisclosure will help restore the public’s faith in medicineatients’ faith in their doctors, writes that “both doctorsatients have lost a sense of the profession as sacred aret. There is no room for mystery. Everything is to be expnd rational, measurable and assessable[167b].” Others argu

hat trust in medicine and between patients and their doust be restored through various means, including par

hip in decision making, renegotiated relationships withineality of the current systemic and economic system ofnd concern with character in the profession[113,181,182].erhaps an area for exploration that follows from atten

o medical error and doctors’ responses to it is a syntheur understanding of patient choice, doctor–patient relahips, and medical errors within the present-day busineealth care.


Reviewers

Dr. Lidia SCHAPIRA, Massachusetts General Hospital,Division of Hematology/Oncology, 100 Blossom Street, Cox640, Boston, Massachusetts MA 02114, USA.

Antonella SURBONE, MD, PhD, FACP, “Ethics in Oncol-ogy” Subject Editor of CROH, New York University CancerCenter, Division of Medical Oncology, New York NY 10016,USA.

Dr. Pieter H.M. DE MULDER, University Hospital Ni-jmegen, Department of Medical Oncology, P.O. box 9101,NL-6500 HB Nijmegen, The Netherlands.

Acknowledgement

The author thanks James Fleming Jr. for editorial assis-tance.

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iography

Michael Rowe, Ph.D., M.P.A., is an Associate Clinicrofessor of Sociology in the Yale School of Medicine,artment of Psychiatry and Institution for Social and P

cy Studies. His scholarly and research interests incoctor–patient relationships, high-intensity medical cnd the social and institutional contexts of medical ce also conducts research in the areas of homelessneental illness and community-based public mental he

are for persons with serious mental illness.

Doctors’ responses to medical errors

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