When you screw up...

[healthscigrad8]

I'm curious, when you eventually screw up as a med student/resident/staff physician, when are you actually obligated to tell the patient, and how much do you disclose? From discussions I've had with a health care professional who works in an ICU, I hear that it's quite common to just say 'we came across some problems' instead of admitting a personal mistake (ex. accidentally cutting an artery in surgery). I understand that health care professionals (and hospital legal teams) are trying to cover their butts, but I'd like to know if there's a general guideline to approach disclosure of medical errors. I'd love some clarification, especially one that is med school interview-appropriate.

[Jochi1543]

The interview-appropriate response is to tell the patient the truth right away. In a real-life situation, I would probably consult a hospital lawyer/legal hotline first about how much you should disclose without prompting.

[aKGDH]

Actually Jochi I don't think it's as simple as that. I'm currently reading through Doing Right, and according to the author, telling the truth to a patient is only done if it will benefit the patient in some way. For example, if surgery is done and the surgeon accidentally leaves something inside the patient that does not belong but does not pose any danger to the patient's health, he does not need to tell the patient. The point is to prevent any unnecessary concern on the patient's part. However, if the situation is one in which the patient may be harmed if he is not made aware of the truth, the truth should be told, but tactfully such that the physician-patient relationship is not tarnished. Trust between the two should still be maintained in order to provide the patient with the best possible follow-ups.

 

I think the point is to always do what is best for the patient. I understand if the reality is a slightly different version, but it's what I would say if asked by an adcom and my admission chance riding on this question.

[intouch]

I'm not sure I agree with aKDGH... Its hard to envision a situation in which leaving an object inside someone would be attached to ZERO potential harm.

 

eg. a person's surgical pins are to be removed, and one fractures within the bone, leaving a tiny fragment behind. It would cause damage to retrieve that and the doctor is 100% certain that no problems would ever arise, so the decision is to leave it behind. The patient isn't informed "for his own good", because he/she has been prone to anxiety about surgery etc... Two years later, he is visiting France, and is in a car accident. The consulting physician orders an MRI and the piece tears through the skull, causing permanent brain damage.

 

A big "what if" situation for sure, but one that proper disclosure could have avoided.

 

My personal opinion is that almost everyone prefers to be told the truth about their own body (autonomy) and should be treated as an independent, intelligent decision maker if competent. Paternalism is outdated in almost every situation, and I think I would steer clear of a paternalistic attitude in an interview, even if you felt differently.

 

My answer to the OP's question would be to document the screw-up quickly and honestly, while I still remembered all of the details; then, if the problem posed no immediate threat, consult with my hospital's legal team as well as my superior, MAKING IT CLEAR to them that I would be disclosing my error shortly, and having in place the proper support for the patient when I decided to compassionately, apologetically, and openly admit my error. "Proper support" could mean no one, if the mistake was a simple and inconsequential, or the patient's family, a counsellor, my superior, etc if the mistake had serious consequences.

 

Just my two cents, I'm not an authority on anything here...

[terryann]

I agree with Jochi. I asked a surgeon, and his opinion was the same as Jochi's..I think you would be in more trouble legally, if you failed to tell the patient and hid the complication...usually some form of paper trail is there anyway, and patients and their lawyers have a right to their records and hospital records. It would not only be what the physican wrote but what the nurses etc wrote too...

[aKGDH]

What about a situation where a patient is dying of terminal cancer and there is little the hospital can do except ease pain? If the patient would like to know his prognosis, then the truth of course must be told. But what if not? What if the patient tells the physician to keep all medical-related news to his chart and to keep the patient in the dark? This is the patient's right to want this (and I do not think this request is a very rare one) and thus the truth must be witheld.

 

I just don't think that when it comes to telling the truth, it is always 'yes, immediately and in every situation.' Ultimately your job as a physician is to support your patient and to provide him with the best care possible, and this imo involves knowing when to tactfully withold the truth.

[terryann]

Agree, if someone does not want to know, they have that right if they are of sound mind. Assume you would have to have previously discussed DNR with them, beforehand.

[Jochi1543]

aKDGH, I disagree with you, as does the lawyer/doctor team who gave us 10 lectures on the legal aspects of patient care. The example you gave is a perfect example of a paternalistic attitude (don't worry the silly patient with unnecessary details), which is something they are trying hard to erase in medicine.

[Renin]

aKDGH, I disagree with you, as does the lawyer/doctor team who gave us 10 lectures on the legal aspects of patient care. The example you gave is a perfect example of a paternalistic attitude (don't worry the silly patient with unnecessary details), which is something they are trying hard to erase in medicine.

 

You went to those? You're a better person than me

[aKGDH]

I am fully aware of what it means to have a paternalistic attitude in medicine. Not telling a patient unnecessary details is NOT paternalistic, provided the details are truly unnecessary. Like I said, the example I provided with the physician leaving something in the patient was taken straight out of Doing Right, which was an actual case where the physician had left something in the patient and did not tell her citing 'causing the patient unnecessary and excessive worry' as the reason. The judge ruled in his favour. However, I admit that this example may not be the best. So here's another one:

 

In cases dealing with patients with serious illnesses, like terminal cancer, often times a patient just wishes to be left in ignorance, so that they may hope for a miracle. Disclosing the truth of their prognosis in this case is not warranted, and the prognosis may indeed be considered an 'unnecessary detail.' Would this be paternalistic? No, because the physician is acting in accordance with the patient's wishes and for the betterment of the patient.

[MSc-microbiology]

The problem in the surgical example is that YOU are deciding that the information is "unnecessary" instead of the patient. YOU are making a decision that the patient should be making themselves. That IS paternalistic.

 

When you disclose the information, they might very well say something like "oh, you left something in... well as long as it won't kill me thats ok" or "what the hell kind of doctor are you, I'm going to pursue this". Ultimately this is the patient's decision to make.

[aKGDH]

I admit that the example, as I have said, is not the best one to use. But I still do not believe that telling the truth is always the right thing to do.

[Jochi1543]

You went to those? You're a better person than me

 

I played Settlers when it got really bad, but I did attend every single one. Hopefully I can save several million in lawsuits through osmosis.

[rmorelan]

hmmm, just skimming doing right here and I am having trouble finding that section aKGDH is referring to. Actually it seems to say the opposite most of the time except in very exceptional cases - can you help me out by giving a vague page number to the area you are referring to?

[Byrne]

I think if I were ever to get a medical ethical type scenario that I was unsure of (or maybe even sure of, for that matter), I would probably respond by first pointing out what the ethical dilemma is, admit that I am not entirely sure what the "right" course of action would be (after all, I have not been trained in medical ethics) and that I would consult a colleague or a medical legal expert at the hospital.

 

However, in the case of when you screw up, I think the best course of action would always be to consult a colleague or medical legal expert -- isn't the latter there, in part, to assist physicians who will inevitably screw up at some point during their careers?

[aKGDH]

@Alastriss: I am not taking Doing Right as law, but I do take the book more seriously than other students' opinions. The book is a far better authority and while I keep an open mind reading it, I do not feel that this instance requires me to disagree with the author. It seems that everyone agrees with Jochi's very simple mantra of 'always tell the truth.' I feel that it is too simple to make such a statement and if I were asked this at an interview I would most definitely not make that blanket statement, as I can think of several situations that do not call for truthtelling.

 

1) A physician leaves an object in a patient and the object is known to be harmless. In most cases, it is probably wise to make the patient aware of the situation, but if the patient were emotionally unstable and telling this news to the patient caused him to commit suicide, as the physician you would take full responsibility for making a poor decision. So in this case, do not tell the truth.

 

2) A capable patient has made it clear that he does not wish to be told the entire truth because he prefers to live in some ignorance. Ignoring this wish and telling the patient everything about his medical situation is also exhibiting poor decision-making by telling the truth when it is not warranted.

 

3) A patient with Alzheimer's refuses to take this medication. He throws his pills in your face everytime you give them to him. You can physically force-feed your patient (the 'truth'), or you can mash them up and discretely sprinkle them in his daily dessert (the 'lie') and have a discussion with his family about your new 'strategy.' Would truthtelling be the best choice in this case?

 

 

Unless my points are appropriately refuted, I will stick by what I think. I understand that I am new in jumping into premed101 discussions, but this does not make me discountable and bambie-eyed with all my opinions stemming solely from a book.

 

@rmorelean: Page 75, middle section.

 

 

Edit: However, I do believe that truthtelling is very important and should be exercised in most cases. I am simply pointing out that truthtelling is not always a question of 'yes' or 'no,' and that is the beauty of ethics.

[aKGDH]

There are very few instances where you should hide the truth. This isn't a simple mantra, it's what we were told to do in medical school. When the MD/JD prof and the lawyer that handles medical cases tells you to tell the truth, you listen.

Well, by definition, if it's something you're taught in medical school and a doctor tells you to do it and you do it, then it is simple and it is a mantra. Although I agree to telling the truth most of the time, I would not claim to always tell the truth if asked this question in an interview, as it is NOT a black and white issue.

 

Doing right sometimes forgets a key dimension: the law. Don't forget that your medical license can be on the line and sometimes that makes the decisions a lot easier (just don't break the law) albeit hard to digest.

Yes I realize the law is intimately associated with medicine. But you did not answer the points that I raised. In all cases, if you had told the truth, you would be legally responsible.

 

Number 3) is just flat out unprofessional. If the patient is fully aware of his decision and has a comprehension of it, they can refuse treatment. That is their right.

No, you missed the point of my example. The patient has Alzheimer's, meaning he may be considered to be an incapable patient. The role of a physician is to do what he can to encourage patient autonomy (which the patient lacks if he is mentally unstable) and if this involves telling the nurse to surreptitiously give an uncooperative patient his meds, then so be it. Of course, it is necessary to explain this action and obtain consent from his family as well. But in this instance, the truth does not work when the patient is obviously not capable of understanding it.

[intouch]

aKDGH...

 

I think some of what you are missing is the distinction between practical outcomes, and the moral obligations we have to one another as human beings.

 

Simply because "no harm will come" doesn't mean anyone has the right to do anything they want in secret. Sure, there may be no practical consequences of a medical mistake, but I, and I am sure many people on this forum, believe that as physicians, we have more that a nuts-and-bolts obligation to our patients.

 

Honesty, respect, morality, and trust are not virtues that I base on the consequences of my actions, but are rather deeply seated in who I am as a person, and the feelings I have about others and how they should be treated.

 

As a bad example, you are taking care of your neighbour's bird while he is out of town. You are feeding it, and the bird escapes, flying out the door that you left open, never to be seen again. Your carelessness cost the neighbour his pet. When the neighbour returns, you have already obtained a gift certificate at the local pet shop for a new one... so you have minimized the practical consequences of the incident.... now, do you tell the owner that you came over one day and the bird was just dead, and you had to dispose of it? Or do you take responsibility for your actions. Either way, your neighbour will be upset, perhaps even more upset in the latter case. But I believe you owe him your honesty and respect as a person.

 

Do you see the difference?

[Jochi1543]

 

No, you missed the point of my example. The patient has Alzheimer's, meaning he may be considered to be an incapable patient. The role of a physician is to do what he can to encourage patient autonomy (which the patient lacks if he is mentally unstable) and if this involves telling the nurse to surreptitiously give an uncooperative patient his meds, then so be it. Of course, it is necessary to explain this action and obtain consent from his family as well. But in this instance, the truth does not work when the patient is obviously not capable of understanding it.

 

If the patient is incapable, he will have a substitute decision maker (whether family or someone appointed by court). You would therefore discuss your strategy, whatever it may be, with their decision maker. You would NOT simply implement it because your patient cannot make a decision on his own.

[aKGDH]

aKDGH...

 

I think some of what you are missing is the distinction between practical outcomes, and the moral obligations we have to one another as human beings.

 

Simply because "no harm will come" doesn't mean anyone has the right to do anything they want in secret. Sure, there may be no practical consequences of a medical mistake, but I, and I am sure many people on this forum, believe that as physicians, we have more that a nuts-and-bolts obligation to our patients.

Never did I say that was what physicians had the right to do. I am merely pointing out situations where truthtelling is not the best option.

 

Honesty, respect, morality, and trust are not virtues that I base on the consequences of my actions, but are rather deeply seated in who I am as a person, and the feelings I have about others and how they should be treated.

 

As a bad example, you are taking care of your neighbour's bird while he is out of town. You are feeding it, and the bird escapes, flying out the door that you left open, never to be seen again. Your carelessness cost the neighbour his pet. When the neighbour returns, you have already obtained a gift certificate at the local pet shop for a new one... so you have minimized the practical consequences of the incident.... now, do you tell the owner that you came over one day and the bird was just dead, and you had to dispose of it? Or do you take responsibility for your actions. Either way, your neighbour will be upset, perhaps even more upset in the latter case. But I believe you owe him your honesty and respect as a person.

 

Do you see the difference?

Your example has nothing to do with the examples that I gave. In the examples that I gave, the physician does his best to ensure that the patient gets honesty and respect, and if this involves withholding some or all of the truth FOR THE BETTERMENT OF THE PATIENT, then that's what should be done. Should you tell the truth to an emotionally unstable patient whom you believe may commit suicide or go on a killing spree should they learn the truth? Should you tell the truth to a patient who has previously expressed not wanting to know the entire truth?

 

Not telling the truth DOES NOT equate disrespecting a patient. Rather, it's thinking outside the box and understanding that "always tell the truth" is not just some rule to blindly follow.

[aKGDH]

There is nothing to refute. The law isn't up for debate. If you leave something inside a patient there are a million things that can happen. What if there are complications with the object you left that you don't forsee, what if they need another surgery and another doctor sees that object you left inside?

It isn't black and white but the law makes it so.

Not according to the case that I presented. The physician who left something inside the patient did not tell the patient citing 'excessive worry' as the reason and in court, he was found innocent. So? Is the law black and white? Or is there something you're missing?

 

If the patient's proxy states that their wish would have been to not take the medication then you don't give it to them whether it will help them or not.

Please continue to miss my point. The patient was admitted for Alzheimer's and has tantrums regarding taking his medication. Given that his family has sent him here, they wish for him to be treated and thus have given you their consent. As I have previously already stated, you must consult the family on your new medication-giving strategy, but must be prepared ultimately to find a way to 'deceive' the patient and have him take his medication anyway. Why do this? Because your duty as a physician is to promote and respect patient autonomy, which the patient cannot have if he is mentally unstable.

[aKGDH]

If the patient is incapable, he will have a substitute decision maker (whether family or someone appointed by court). You would therefore discuss your strategy, whatever it may be, with their decision maker. You would NOT simply implement it because your patient cannot make a decision on his own.

 

Originally Posted by aKGDH

 

No, you missed the point of my example. The patient has Alzheimer's, meaning he may be considered to be an incapable patient. The role of a physician is to do what he can to encourage patient autonomy (which the patient lacks if he is mentally unstable) and if this involves telling the nurse to surreptitiously give an uncooperative patient his meds, then so be it. Of course, it is necessary to explain this action and obtain consent from his family as well. But in this instance, the truth does not work when the patient is obviously not capable of understanding it.

[rmorelan]

@rmorelean: Page 75, middle section.

 

Edit: However, I do believe that truthtelling is very important and should be exercised in most cases. I am simply pointing out that truthtelling is not always a question of 'yes' or 'no,' and that is the beauty of ethics.

 

That is the author's preamble I think about what we used to do (citing a case from the 1950s). Hebert goes on to describe the reasons where you could reasonably lie (as generally accepted by the medical field I suppose):

 

patient's waver (doesn't apply)

incapacity (doesn't apply)

medical emergency (doesn't apply)

therapeutic privilege (could actually apply here )

 

The privilege can only be used when telling the truth would be expected to cause significant physical and/or mental harm to the patient, and the courts support this use. Is this the tenant that you are supporting your case with?

[aKGDH]

yes rmorelean. I was referring mostly to those points that the author brought up, which I believe are reasonable situations where telling the truth is not warranted. Everyone seems to think that it's always best to tell the truth and I simply do not think so.

[intouch]

aKDGH

 

If you think everyone here thinks the only thing to be done is to tell the truth, absolutely and always, you are either not reading their posts, or being intentionally thick.

 

Therapeutic privilege is paternalistic, full stop. Therefore it is only warranted in extreme or extenuating circumstances, which would occur extremely rarely. Otherwise, you owe the patient the information about their body and medical situation... both as a doctor, and as an honest, compassionate, and empathetic person. I think that is the feeling that has been pretty well laid out by many posters.