The above scenario is presented to serve as an illustration. At one time or another, most practicing physicians have experienced unexpected complications or poor clinical results.
Although this untoward outcome may not technically be considered an error, the surgeon who performed the procedure may feel as if he or she did something to cause this problem. The doctor may repeatedly review the surgery in his or her mind and attempt to identify what may have gone wrong and how he or she may have been responsible for what the patient now has to endure. In some corner of his or her consciousness, the surgeon is likely to feel some guilt for the patient's fate and some measure of inadequacy in his or her performance.
Furthermore, the patient and the family are likely to view the untoward outcome as a medical error. Regardless of how well patients are informed preoperatively about possible complications, they and their families often have unrealistic expectations of a perfect fix for their problem. When something does not turn out well, people are often quick to think in terms of someone to blame—someone who wronged the unfortunate victim.
The example scenario raises the general question of how a surgeon should respond to an error, or even to an untoward outcome that may be perceived as an error. Human nature is likely to trigger two reactions. In envisioning the sadness, anger, and recriminations of the patient and family, the doctor would likely want to eschew any encounter. This reaction would lead to the doctor avoiding the patient and family. Likewise, the natural response to an anticipated hostile attack is to take protective measures, which would lead the doctor to assume a defensive or even combative posture. Both of these instinctual reactions, avoiding contact with the patient and developing a defensive posture, are counterproductive and unprofessional. Avoidance will only send the message that something shameful is being hidden, and defensive aggression will suggest that culpable behavior has made the surgeon vulnerable and in need of a defense.
Considering an appropriate response from the safe distance of a hypothetical case of an untoward outcome allows us to think through the scenario and develop more appropriate and useful strategies. Beginning with the ethical core of medical practice, a doctor's focus should always be directed at working toward the patient's good. To help the patient, the doctor will have to use empathic imagination to more fully envision the condition and needs of that patient. Appreciating that the discovery of the new disability has made the patient feel a true sadness and loss can give the physician clear goals for future interactions.
Individuals who experience sadness and loss need to be consoled. They also need help in learning to accept and adjust to the situation. These insights should direct the physician to spend time with the patient and share in the patient's sadness. The doctor's presence and compassion can be a meaningful benefit under these circumstances. Similarly, an explanation of the physical cause of the problem, a clear and honest prognosis, and an offer of any potentially beneficial interventions, such as physical therapy or bracing, would help the patient to appreciate the context of the condition and assist him or her in coming to grips with what lies ahead.
It is important to discuss with the patient and family the specifics of the complication, the reasons why the complication may have occurred, and the proposed treatment. Depending on the patient's response, the possibility of a second opinion may be worth considering. The treating physician must remain involved in the patient's care and convey to the patient the sense that he or she is responding to the patient's complication. The patient must never feel as if all is lost and the physician is giving up on him or her.
It is also useful to understand the psychological forces in play with regard to the anticipated anger of the patient and family. They will be sad, irate, and fearful. Family members may feel a sense of guilt at not having done more to protect their loved one from harm, even if there was nothing that they could have done. Consequently, they will want to do whatever they can to make things right, even though there may be nothing that they can do. In response, the physician can allow the patient and family to express their anger. The physician can also offer them an explanation as to the likely cause, treatment, and prognosis. The evidence clearly suggests that failure to establish a reasonable rapport with patients as well as family members by meeting their emotional needs during a time of crisis and apprehension leads to sentiments of resentment and an impulse to lash out1.
Likely to compound the situation are concerns about malpractice issues and potential litigation. Again, the tendency may be for the physician to avoid any encounter with the patient and family, especially if they are angry or hostile. However, it is important to remember that their hostility is likely arising from a sense of fear of the unknown, anger over the loss of function or the poor cosmetic appearance of the affected limb, and a desire to fix blame somewhere. The physician can be a source of comfort and knowledge as well as a source of advice on coping with the untoward outcome. It is also useful to note that patients who feel their doctor's empathy and note the doctor's responsiveness are likely to appreciate the doctor's caring attention. Patients who sue their doctors are most typically the ones who are angry with their doctor's lack of attention or callous response.
A survey of suing patients and the physicians who were sued found that the two groups differed substantially in their perceptions of the doctor-patient relationship. The physicians were often unaware that their patient's emotional needs had not been met. In addition, the study demonstrated that patients who experienced undesirable outcomes sought expressions of sympathy and compassion from their treating physicians2. Vincent et al. reported that 85% of the surveyed litigant patients believed that they had been given explanations by their physicians that were either inadequate or untrue or that served only the physician's interest. Some indicated that they had received no explanation at all3. Poor physician communication skills are more likely than any other single factor, including actual bad medical practice, to precipitate a lawsuit1. Sadly, if litigation is initiated, the physician's malpractice carrier will likely insist on cessation of all contact with the patient and family.
In summary, an appropriate strategy for responding to errors, or even poor clinical outcomes that may appear to be errors, amounts to being with the patient, expressing regrets at the outcome, demonstrating compassion, and offering to be there to try to help the patient achieve the best possible outcome under the circumstances. Visiting often and repeating the message is in order. Despite hostility during the initial encounters, with time, the patient and family are likely to calm down and come to appreciate the physician's concern and attention when those sentiments are sincerely expressed.