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Medico-legal - Knowing when to say sorry

Saying sorry is not always easy. MPS adviser Dr Janet Page explores when and how it is appropriate to do so.

The doctor-patient relationship is based on trust and requires honesty and integrity (Photograph: SPL)
The doctor-patient relationship is based on trust and requires honesty and integrity (Photograph: SPL)

Patients who sue their doctors are not only motivated by a wish to seek financial redress for their injuries.

Insensitive handling and poor communication following the injury, together with the need for an explanation and acknowledgment of accountability are also drivers for litigation.1

A survey of Medical Protection Society (MPS) members in 2008 showed that even though 90 per cent of respondents agreed that patients are less likely to sue or complain if they received an explanation or apology, only two-thirds believed GPs are willing to be open with patients when things go wrong.

Professional obligations and legal position
In accordance with GMC guidance, doctors have a professional obligation to be open and honest with their patients when things go wrong, to offer an apology and a full explanation of what has happened, and wherever possible take all necessary steps to put the matter right.

Many doctors are wary of saying sorry as there is a common misconception that apologising is an admission of liability. This is not the case in UK law.

Saying sorry
Saying sorry is not always easy and patients and doctors may respond to an adverse event in a number of ways. After a serious incident, emotions may be running high and patients and their relatives may react with anger, disbelief, fear, anxiety, frustration and confrontation.

The doctor may also be anxious or have feelings of guilt about what has happened and have to deal with these at the same time as managing the patient's reactions, which may include a personal attack on the doctor's integrity or professionalism.

On the other hand, if the matter is handled sensitively and professionally, patients will often respond with acceptance, understanding and even gratitude.

An apology should comprise firstly of an acknowledgment of the patient's feelings and regret that things have not turned out as the patient would have wished. When there has been an error, the doctor should explain to the patient that the error will be investigated and all necessary steps taken to reduce the risk of a similar incident occurring in the future.

Even in cases where the cause of the event is disputed and the doctor disagrees with the patient's account of events, it is still appropriate to acknowledge the patient's feelings.

The 'AcTION' plan is one way to help prompt you through the steps of saying sorry:

  • Acknowledge the patient's feelings.
  • Treat the consequences of the error.
  • Investigate the cause of the error.
  • Operate change.
  • Notify the patient of the outcome.

There are some things, however, that should not be said or done. You should not:

  • Act defensively.
  • Launch a counter-attack.
  • Focus on your own feelings.
  • Say: 'It is all my fault.'

GPs are particularly well-placed when it comes to communicating with patients about adverse events, as they often have a long-standing and established relationship with the patient based on mutual trust and respect. This can give them a significant advantage over situations where the relationship with the patient has been more short-term.

Case study
A patient complains to the practice that her GP was rude and dismissive of her concerns. The GP's recollection of events is different, but instead of a bald denial which might aggravate the situation he responds by saying: 'I was very surprised and concerned to learn of your unhappiness at our recent consultation. I am sorry if you felt I was abrupt and dismissive of your concerns as this was certainly not my intention.'

When explaining about an adverse event to a patient, try not to be defensive and avoid laying blame at the patient's feet, even if this may be justified. It is not advisable to articulate your own feelings of hurt, anger or frustration at a patient's behaviour.

As a professional you are expected to deal with criticism in a dispassionate and objective manner, regardless of the impact on you personally.

Generally, it is advisable to focus on expressions of sympathy and empathy rather than responsibility. Of course, there may be occasions where a glaring error has occurred, in which case a refusal to acknowledge obvious fault may aggravate the situation.

Your defence organisation should be able to advise you if you are unsure how to respond in any given situation.

In conclusion
The doctor-patient relationship is based on trust and this requires honesty and integrity on the part of the doctor when things go wrong. Saying sorry is not always easy.

However, generally speaking, a genuine apology accompanied by a full explanation and an action plan for resolving the problem is often well received, and may prevent the matter from escalating into a formal complaint, claim or disciplinary matter.

While there is a general consensus that openness in the NHS should be encouraged, the current debate is about how this can be achieved - either by mandating openness through legislation, or by developing a stronger culture of openness. MPS believes a shift in culture, underpinned by training, mentorship and leading by example is the way forward.

  • Dr Page is a medico-legal adviser for the Medical Protection Society.

References
1. Vincent C, Young M, Phillips A. Why do people sue doctors? A study of patients and relatives taking legal action. Lancet 1994; 343: 1609-13.

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