It’s 1982, and in middle-school gyms across the country, among punch bowls and parental scrutiny, young girls and boys are slow-dancing with outstretched arms to a breathtaking song by the band Chicago. The song tells of the agonizing difficulty of apology, how despite the want and need to apologize, it is just too arduous.
Fast-forward 30 years, and it is hard to believe that cheesy No. 1 Billboard hit espoused the feelings that continue to haunt healthcare providers across the country: It’s hard for me to say I’m sorry.
Others Say It
If you look at the world around us, you see apology everywhere. Customer service representatives and customer-minded industries routinely let those words flow off their tongues with ease and grace.
While I was driving down the interstate last week, the number of traffic lanes shrunk from three to two to one. Anticipating widespread aggravation from weary travelers, the state transportation department deployed several large road signs every few miles; they read “WE APOLOGIZE FOR THE INCONVENIENCE … BEAR WITH US WHILE WE MAKE YOUR ROADS SMOOTHER AND SAFER.” Those simple messages made me feel like the congestion was not a senseless waste of time, that the state’s Department of Transportation was actually being strategic and thoughtful in their rationing of lanes during rush hour in the middle of the week.
Phone-based, customer-service departments figured out the simple apology a long time ago. While holding the line for a Lands’ End customer-service representative a few weeks ago, I heard, “We apologize for the delay. Your business is important to us. Please hold the line while we address callers ahead of you.” It validated for me that those phone representatives are not just sitting around eating lunch, completely ignoring my call, and that maybe there are others who procrastinated buying back-to-school backpacks until September—and just happened to call right before me.
I even got an apology at the dry cleaner. Amidst my last batch of clothes, my astute dry cleaner apparently found a very stubborn stain, which resisted all of their usual concoctions. It was on the back of a shirt and I probably would not have even noticed it was there. But nonetheless, they sent an apology tag, with a picture of a distraught butler who seemed to have struggled with that stain for hours.
Why Not Us?
So why is “sorry” so hard in healthcare? When things happen to patients, things that are inconvenient or downright dangerous, we have great difficulty in simply saying: “Hey, I am really sorry this happened to you,” or “I am so sorry you are still here. You must be really frustrated by our inefficiencies.”
I have the distinct pleasure of overseeing my hospital’s risk-management department for a few months. This means I get to see and hear what does and doesn’t happen to patients, which, at times, is misaligned with what should or shouldn’t happen to patients. When unanticipated events occur, the group launches into an investigation of what happened, why it happened, and the risk that it could happen again. After the initial dust settles and the facts are relayed from the care team to the risk-management team, the risk team always asks of those involved: “So what does the patient and their family know?” And we get a range of answers—some polished, some fumbled, some baffled.
The next question is: “Well, what should they know?” And that is always an easy question to answer. They should know the truth. Not just some of the truth, or half the truth, or a partial truth. Not what the care team thinks the patient “can handle.” They should just get the truth. To the best of the team’s ability, they should tell the patient:
- What (they think) happened;
- Why (they think) it happened;
- What it means for the patient; and
- What they are going to do to make it not happen again.
And then the patient (and family members) deserve an apology—sincere, compassionate, genuine. The apology should be the easy part, as most providers do not always know what happened, why it happened, or what they are going to do to prevent it from happening, but they usually truly do feel sorry that it happened at all.
Patients are unanimous in their desire to be informed if a medical error has occurred; focus groups have found that patients believe such information would enhance their trust in their physicians and would reassure them that they were receiving complete information. And they want an apology.1
But interestingly, many physicians believe that full disclosure with apology is not warranted or appropriate, and that the apology could erode patient trust, might scare the patient, and might increase the risk of legal liability.1
There is little evidence that disclosure is harmful or detrimental, and there is some evidence that it is beneficial to the medical industry (i.e. reduces claims and litigation costs). A study published in 2010 from the University of Michigan Health System found a disclosure-with-compensation program was associated with a 36% reduction in new claims, a 65% reduction in lawsuits, and a 59% reduction in total liability cost.2
I have witnessed this phenomenon from both sides. My mother, who has Alzheimer’s and lives in an assisted-living facility, recently was given twice the dose of her medications one morning. She was “given” her night medications by being placed in her room, which she has no recollection of (the staff are supposed to watch her take her medications). The next morning, she saw the medications and took them, then took another dose when the nurse came by to give her morning medications. It was not realized until she’d already taken the medications and the staff noticed the medicine cup from the night before. My mom said she felt a little weak and dizzy for a few hours, but nothing significant, and she fully recovered. Interestingly, my mom mentioned it in passing, but no one called to let us know a medication error had occurred. Although she was not harmed, it made us, her family, lose a little trust in the facility because we found out about it indirectly, without any acknowledgement or apology.
On the other side of the equation, I have witnessed countless numbers of patient events in which providers feel worried and uncomfortable about the effects of disclosure with apology on themselves and their patients.
The bottom line is, disclosure with apology is needed and appreciated by patients, and it is absolutely the right thing to do. So download that cheesy Chicago song to your iPod and practice saying (or singing) “I’m sorry.” If the butler with chemicals can do it, so can we.
Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at firstname.lastname@example.org.
- Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA. 2003;289(8):1001-1007.
- Kachalia A, Kaufman SR, Boothman R, et al. Liability claims and costs before and after implementation of a medical error disclosure program. Ann Intern Med. 2010;153(4):213-221.