At the Sharp End of the System: Disclosure and Apology in Otolaryngology

The illustrative scenarios clarify that there is a big difference between saying something happened and something happened and it was my fault. That difference matters and is a critical factor that is often overlooked, said Dr. Eibling.

Throughout organized medicine regulations requiring disclosure are now being implemented. But disclosure is an institutional responsibility, said Dr. Eibling. It is not the same as apology. Dr. Eibling, who performs all his surgery within the VA, appreciates the policy that the VA published a year ago, which differentiates institutional disclosure (here’s what happened and we are going to do whatever we can do to remedy this for you, including assuming some of the cost of your care) from informal disclosure (disclosure by the provider combined with an apology).21 The difficulty is not in saying something bad happened, said Dr. Eibling, but in saying something bad happened, it’s my fault, and I feel terrible about it.

That wording matters to the patient and the provider.22 Until there has been an apology to and forgiveness from the patient, the patient and family are unlikely to experience closure. And data substantiate that if a patient can reach forgiveness and compassion for the humanity of making an unintended error, he or she is less likely to pursue litigation. In addition, the physician can also find closure.1 Apology is key in moving beyond the error into a continued physician-patient relationship, said Dr. Eibling, because unless the patient and physician both can find closure, the provider may well be a ‘second victim.’23

Dr. Eibling advocates using role play to practice apologizing to patients because the opportunity to disclose and apologize is never one where you plan ahead; it just happens to you, he said, and practicing saying you’re sorry makes it easier when you really need to do it.

For the very reason that the needs for disclosure and apology come up unexpectedly, said Dr. Shah, there are certain imperative aspects of those requisite conversations. Having been able to watch senior physicians disclose problems that have occurred has been a boon to the development of his own techniques and those he now teaches his residents and students. What I notice is that these [conversations] are usually [conducted] immediately after the incident has occurred, he said, and not in the patient’s room but in a separate location that is quiet and private. Other aspects of authentic and respectful apology include sitting down, appearing non-rushed, temporarily ignoring your pager or cell phone if possible, paying attention to body language (avoiding crossed arms or being turned away from the patient; using touch, if appropriate) and letting the patient know that you are there for them at that moment. The senior, classier physicians, he said, whom trainees admire and attempt to emulate don’t look harried or distressed and thus appear to the patient and family as experienced, calm and confident, offering explanations in a very matter-of-fact way.

Systems Are People-Based; People Can Change Them

In his lectures on the subject of medical errors, Dr. Eibling reminds his audiences that the systems in which we work were in fact all designed by people, and since they were built by people, people can change them. Also, he pointed out, it is essential to share creative solutions to systemic problems with colleagues whether by publishing, or in formal or informal discussions. Not only do we have a responsibility to identify and measure problems, if they are measurable, said Dr. Eibling, but we have a responsibility to fix them and then report the fixes so others can benefit.

Putting Advice into Practice

David Eibling, MD, who, in addition to his clinical duties, is the vice chair for education in the department of otolaryngology at the University of Pittsburgh Medical Center, told ENToday about an incident that had occurred only a few days before he was interviewed for this article. He believes it illustrates the need for authenticity in communications and the natural path from disclosure and apology to systems improvement.