2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

Onclogists’ Difficulties in Facing and
Disclosing Medical Errors: Suggestions for
the Clinic
Overview: Along with improved safety measures and changes
in the culture of medicine, communication is key to reducing
the effect of medical errors and to easing the medical,
psychologic, and existential burdens they impose on all parties.
Disclosure demonstrates respect for patients’ autonomy
and promotes patient’s involvement in informed decision
making about ways to correct or alleviate the effects of the
error. It also enhances oncologists’ integrity and helps restore
trust in the patient-doctor relationship.
Because of the complexity of cancer treatments and the
uncertainty regarding outcomes in oncology, oncologists may
rationalize nondisclosure as a way to avoid adding to the
physical and existential suffering of their patients. Although
there is broad agreement among professional and regulatory
bodies, as well as medical ethicists, that physicians should
disclose errors to patients—and physicians largely support
IN RECENT years, research on the incidence and causes
of error in medicine has led to calls for change in policy
and practice. 1-2 Increasing attention has been paid to the
role that appropriate communication plays in preventing
and managing errors, not only at the medical level, but also
with regard to the emotional and psychologic aftermath of
error for patients, family members and physicians. The
limited research that has been conducted on the psychologic
consequences of medical errors on physicians shows that
they experience a wide range of emotions and thoughts—
from guilt, feelings of inadequacy, anguish, shame (even to
the point of leaving the profession) to excessive caution
toward other patients following the medical error. 3 Most of
what we know on this subject, however, comes from narrative
accounts of physicians who have been brave enough to
share with readers their experiences of committing or witnessing
a medical error—the first starting with Dr. David
Hilfiker in The New England Journal of Medicine in 1984. 4
Communication about medical errors is key to easing the
burden of errors on all parties with respect to all medical,
psychologic, and existential dimensions. Given the lifethreatening
nature of their illnesses and their dependence
on their oncologists, patients with cancer can be especially
hurt both physically and emotionally when errors or suspected
errors occur. Oncologists who carry the emotional
and psychologic burdens of caring for seriously ill patients
over long periods of time can also be deeply affected by their
own mistakes. 5 Proper disclosure, including a sincere apology,
is the first step to restore trust in the patient-doctor
relationship. It should be part of the immediate management
of errors and of dealing with their long-term aftermaths.
Disclosure of Medical Errors and the
Patient-Doctor Relationship
There is broad agreement among professional and regulatory
bodies and medical ethicists that physicians should
disclose errors to their patients. 2,6,7 Empirical studies show
that most patients want to be informed in detail about
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By Antonella Surbone, MD, PhD
disclosure of error to patients—studies show discrepancy
between physicians’ responses to hypothetical clinical scenarios
of truth telling about medical errors and actual practices
of withholding or tempering the truth. Among common
reasons for avoiding disclosure are risk of malpractice lawsuits,
fear of being exposed as incompetent, and feeling
shame before patients and colleagues.
Proper disclosure, however, including a sincere apology,
should be part of the management of errors and of their
long-term aftermaths. In disclosing medical errors, it is essential
for oncologists to pay equal attention to the medical
and the emotional aspects of the information they are giving
and the reaction that it elicits in patients and families. Specific
communication skills regarding disclosure of medical errors
can be learned.
medical errors that occur during their care, even when they
do not lead to a negative outcome. 8 Disclosure demonstrates
respect for patients’ autonomy and promotes their informed
decision making about ways to correct or alleviate the effects
of the error. 5,7
Physicians largely support disclosure of error to patients,
but there is discrepancy between responses to hypothetical
clinical scenarios of medical errors, in which doctors support
disclosure, and practice, in which they often do not provide
full disclosure. 9 Among common reasons for avoiding
disclosure are fear of malpractice lawsuits or of being
exposed as incompetent, as well as feelings of shame before
colleagues. 9-13 A pivotal study comparing 1,404 surgeons
and general physicians practicing in Canada to 1,233 practicing
in the United States showed that, even in a different
medical-malpractice environment, a misleading culture of
medicine that privileges technical perfectionism and success
rates over the humanist aspect of care in medical school,
rather than fear of being sued, is the prime deterrent to full
disclosure. 14,15 These attitudes toward the medical profession
are mostly transmitted through hidden curricula, which
push doctors away from talking about their mistakes for fear
of peer judgment or of punishment by senior staff.
Retrospective studies suggest that patients and family
members often sue because of doctors’ silence following
adverse events and the accompanying sense that they have
no other recourse for gaining respect, acknowledgment, and
satisfaction. 16 By contrast, patients’ and families’ reasons
not to sue after medical errors are far less known.
From the Department of Medicine, New York University Medical School, New York, NY.
Authors’ disclosures of potential conflicts of interest are found at the end of this article.
Address reprint requests Antonella Surbone, MD, PhD, New York University Medical
School, 5550 First Avenue, RBCD516, New York, NY 10016; e-mail: antonella.surbone@
gmail.com.
© 2012 by American Society of Clinical Oncology.
1092-9118/10/1-10