Lawsuit fears aren't reason for docs' silence on errors

Even now, more than 30 years later, Dr. Eric Larson finds it difficult to talk about a mistake he made as a young resident doctor in Boston: He tapped into a patient's artery when the needle should have gone into a vein.

His patient suddenly became very sick. She subsequently recovered, though, and never knew what Larson had done.

"In those days, it was unthinkable to tell the patient what had happened," recalled Larson, a former medical director of the University of Washington Medical Center who now heads Group Health's Center for Health Studies in Seattle.

As debates over medical malpractice raged in Washington and across the country, many doctors have blamed a litigious system in the United States for discouraging doctors from openly admitting mistakes to patients. Those same doctors have held up the Canadian system, which drastically limits liability and discourages lawsuits, as a model.

But it turns out that it's not the risk of lawsuits that zips doctors' lips but rather the "culture of medicine" itself, say leading researchers on the subject.

Canadian doctors are just as reluctant to fess up to mistakes, said Dr. Thomas Gallagher, a University of Washington internal-medicine physician and co-author of two studies published Monday in the Archives of Internal Medicine. They are the first to compare attitudes about error disclosure among doctors in the two countries.

Disclosing medical errors


In one study comparing attitudes of doctors in the United States with those of their Canadian counterparts, the doctors were given scenarios involving medical errors and offered choices about what they would say to patients. One set of scenarios was purposely selected as errors that would seem apparent to the patient, while another set was chosen as errors patients likely wouldn't find out about unless they were told. Surgeons were given a surgical scenario, while general medical doctors were given a nonsurgical scenario.

Errors viewed as more apparent

Surgeon: A surgeon leaves a sponge inside a patient during surgery, requiring a second operation to remove it.

General: A doctor carelessly writes an order for insulin, resulting in a hospital patient's overdose. The patient becomes unconscious, has to be resuscitated and transferred to intensive care.

Errors viewed as less apparent

Surgeon: A surgeon damages a patient's bile duct while using an unfamiliar new medical device. To repair the bile duct, the surgeon has to make the surgery into a more extensive procedure. The surgeon had warned the patient earlier that a more invasive surgery might be required.

General: A doctor forgets to check lab results to rule out a common but easily controlled side effect of a new drug that he gave to a patient with high blood pressure. The patient experiences a life-threatening irregular heartbeat, has to go to an emergency room to have his heart shocked back into rhythm and is hospitalized.

Source: "Choosing your Words Carefully: How Physicians Would Disclose Harmful Medical Errors to Patients," Thomas Gallagher, M.D., et al, Archives of Internal Medicine, Aug. 14.

In fact, Canadian and U.S. doctors' attitudes about disclosure were "very, very similar," Gallagher said. "Even in settings where doctors worry less about malpractice, disclosure is still difficult for doctors."

The studies surveyed 1,404 surgeons and general practioners throughout Canada and 1,233 surgeons and general practitioners in Washington and Missouri, states that have been labeled by tort-reform campaigners as being in a "crisis" because of a lack of affordable liability insurance.

Canadian doctors pay less for malpractice insurance and are much less likely to be sued. Cases are heard by judges, not juries. Damages for pain and suffering are capped. Punitive damages are rare. And if patients lose their lawsuits, they have to pay the doctors' legal bills.

Doctors in both countries were significantly less likely to disclose a serious error to patients if it was unlikely the patients would discover the error on their own. And doctors' thoughts on how likely they were to be sued didn't affect their decisions to disclose errors.

Disclosure, sort of

The results strongly suggest that the medical-malpractice environment, long believed by many doctors to be the "root of all evil," is not the prime deterrent to doctors' disclosing errors, Gallagher said.

"If you were to take the Canadian malpractice environment and transport it to the United States, we wouldn't expect it to make a big difference in doctors' willingness to disclose errors."

In addition to the study that directly compared Canadian and U.S. doctors' attitudes about disclosure, a companion study looked at how doctors would disclose an error.

Gallagher and Larson, with other authors, asked doctors to read and react to specific medical-error scenarios, such as a surgeon leaving a sponge inside a patient, to zero in on how doctors do — or don't — disclose.

The vast majority agreed that the error scenario they received was serious and that the doctor was responsible.

But more than half of the doctors said they would mention the "adverse event" but not say that it had resulted from their error. And only one-third said they would explicitly apologize.

Surgeons expressed more intent to disclose errors than general-medicine physicians.

But when they detailed how they would respond, the study found that the surgeons actually disclosed less.

Overall, 19 percent of surgeons said they would use the word "error," compared with 58 percent of the other doctors. And the surgeons indicated they would explicitly apologize half as often.

"Code of silence" is risky

Other studies have found that patients want specific information when doctors make a mistake.

They want to know what the error was, why it happened, how it will affect their health and how the doctor plans to make sure it doesn't happen again, Gallagher said.

"For patients, it's really important that a lesson was learned from this error," he said.

But disclosure is also crucial to improving patient safety, advocates such as Larson say.

"This code of silence, this conspiracy of silence does not work for reducing errors," Larson said. "What we know now is it does nobody any good to bury a mistake or cover up a mistake; you can't correct what led to the mistake unless you deal with it explicitly."

But if it isn't the legal medical-malpractice environment that keeps doctors quiet, what does?

Larson and Gallagher say they believe the main culprit is a "culture of medicine," which starts in medical school and instills a "culture of perfectionism" that doesn't train doctors to talk about mistakes.

Still, Gallagher predicts that will change: "We're just at the beginning of a culture change to greater transparency in medicine," he said.

Carol M. Ostrom: 206-464-2249 or costrom@seattletimes.com