LITTLE: A Field Without Apology

"I am sorry.” These are the words we want to hear when someone has done something wrong to us — especially if he or she has seriously hurt us. To face someone who refuses to acknowledge his or her mistakes, and the harm that was caused, compounds the original wrong and undermines any future trust we might hope to have in him or her.

Yet when physicians and hospitals commit errors, “I’m sorry” is often the last thing that patients hear. Medical mistakes are often not even disclosed to patients. Even — or especially — when those mistakes are deadly. The Institute of Medicine identifies medical error as the sixth leading cause of preventable death in the United States, killing an estimated 98,000 people each year.

There are many reasons that medical apologies are rare. Physicians feel ashamed and scared. They are often told to stay silent by medical lawyers trying to protect against liability risk. And they aren’t taught how to apologize, which isn’t easy to do when the people you hurt are the people you meant to help. Doctors are trained in many skills, like how to intubate a patient or how to calibrate medication dosing. But they are not trained in how to apologize.

This is a problem. Because if anything is certain in medicine, it is this: Every doctor will make mistakes that end up harming someone. Not because they are incompetent or don’t care, but because they are caring for so many. Even the best doctors, like the best cab drivers, will cause an accident some day, for the simple reason that they are out there day after day, logging mile after mile, and humans aren’t perfect.

More than that, many doctors work in hospitals or clinical settings that are woefully underequipped in basic quality control. As Atul Gawande, a physician who has long advocated admitting to errors in medicine, has pointed out, quality control systems common to other industries, from aviation to the restaurant industry, have evaded the medical profession. Whatever the root causes of medical error, though, apology needs to become a critical part of its aftermath.

Change is coming. Thirty-six states now have laws that encourage medical apology by offering some form of protection for those who engage in it, usually by insuring that the apology itself cannot be used against the physician if a suit is brought. Such laws are a critical step forward.

But the real change has to be a cultural one. Apology needs to be seen as a sign of caring, not a sign of weakness. If airlines can apologize when a flight has been delayed, doctors should be able to apologize when a surgery goes awry.

In the meantime, it turns out that good apologies are also good business. Hospitals across the country who have moved from deny-and-defend stances to policies endorsing early apology and restitution have found dramatic reductions in lawsuit payouts. One hospital system in Michigan saw its lawsuit payoffs decrease by 60 percent after instituting a policy that mandated immediate reporting of error, trained practitioners in communication and medical apology and supported practitioners who did apologize.

They are also good for health care practitioners. As Lucian Leape — a physician who has been at the vanguard of advocacy for disclosure and apology in medicine — has argued, a culture that precludes physicians from apologizing can be traumatizing for health care practitioners, whom he calls the “second victims” of medical error. He cites the critical repair that can come from acknowledging one’s mistakes, expressing remorse and helping to mitigate harm or offer reparations. Allowing room for true remorse, it turns out, can be healing to both sides of the medical encounter. And healing is what medicine is all about.

Maggie Little, Ph.D., is director of the Kennedy Institute of Ethics and an associate professor in the philosophy department. ENGAGING BIOETHICS appears every other Friday.