Like everybody else, doctors make mistakes, but fellow physicians can be hesitant to call them out.
The medical community acknowledges its duty for open discussion when mistakes occur, but according to a new report in The New England Journal of Medicine (NEJM), “Talking With Patients About Other Clinicians’ Errors,” patients are too often left in the dark.
As part of its coverage for the NEJM report, ProPublica held an expert panel Google chat on Nov. 11 to discuss why doctors keep quiet when they see fellow doctors fumble.
The report’s lead author, Dr. Thomas Gallagher, an internist and professor at the University of Washington School of Medicine, has spent several years researching the medical community’s response to mistakes. Gallagher said that, behind the silence, doctors are confused about what to do, and afraid about what might happen.
“It’s awkward I think for a variety of reasons. Doctors wonder what happens in cases where they weren’t directly involved in the error. They worry about having an awkward and uncomfortable conversation with a colleague about a potential error. They worry about lawsuits. They worry about losing business relationships,” said Gallagher.
Helen Haskell—who became a patient safety advocate after her 15-year-old son died from a medical error in 2000—said doctors who don’t speak out are “extremely common,” and patients pay the price.
“I think there are a lot of problems with failure to provide follow-up care from doctors who don’t want to be involved with someone else’s mistakes. Oftentimes when there is any iatrogenic harm, you get patients who are bounced from one doctor to another trying to find care,” she said.
Iatrogenic effect is preventable harm resulting from medical treatment or advice to patients. A health care provider or institution may cause iatrogenic harm.
Risking Professional Ruin
Dr. Brant Mittler, a cardiologist and medical malpractice attorney in San Antonio, Texas, said physicians who call out a mistake put their colleagues in a tough situation and risk being ostracized by the rest of the medical community.
“Doctors basically have no rights when an action is brought against them in the name of quality. Their ability to challenge those things in court is virtually zero. So doctors are afraid. Their professional reputations are on the line,” said Mittler.
“The threat of that professional ruin is enough I think to keep doctors from confronting other colleagues, particularly when those colleagues are aligned with large powerful groups.”
Mittler told the story of a Texas physician who reported bad care. The patient filed a lawsuit against the negligent doctor, but the whistle-blower was reported to the board for unethical behavior.
“He was exonerated but only after having to hire attorneys at a great cost and a lot of professional aggravation,” Mittler said.
Getting Doctors Talking
The panel agreed the bottom line was improving communication. They called for medical school, residency, and fellowship training to get doctors more comfortable discussing error, at least with colleagues.
Better communication skills, however, provide only part of the solution. Gallagher said doctors must still struggle with the consequences of speaking out.
“I think physicians endorse the general principles, they just lack confidence in what people would call just cultures—this notion that if they report an event it will be handled appropriately, fairly, and not in an unduly punitive fashion,” he said.
Hospitals throughout the country have confronted the issue with various strategies. Gallagher mentioned University of Michigan, Stanford, Medstar, and others that have established programs designed to encourage transparency and early reporting of mistakes.
The NEJM report found that some of the best peer review is done outside the organization, because it strips away the defensiveness and politics that characterizes a typical review process.
Mittler suggested medical mediators—individuals trained to facilitate a conversation about a medical error with no stake in either side—as a strategy to encourage more doctors to come forward. He said that as someone who sues doctors and hospitals for malpractice, he sees a lot of room for more constructive discussions.
Settling disputes by medical mediators is inherently less confrontational than a trial, and the settlements that result are often smaller. Despite the benefits, medical mediation has only been adopted in a few states.
Mittler proposed a plan for San Antonio hospitals a few years ago, but they all turned him down. He believes that hospitals just don’t want to give up their dominance in the peer review process.
“They went back to their find the bad apple process, which I think a lot of the times impairs open discussions,” he said.
