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September 05, 2001

Medical Mistakes and Disclosure: The Role of the Medical Student

JAMA. 2001;286(9):1080-1081. doi:

"To Err Is Human," declares the title of the recent, well-publicized report by the Institute of Medicine.1 According to this study, errors cause between 44 000 and 98 000 deaths annually in hospitals in the United States. While these figures have gained much attention, this is not the first examination by the medical community of its mistakes. Since 1990, several studies have also scrutinized medical error. These publications mark a break from the traditional secrecy surrounding mistakes by physicians.24 A new approach in medicine encourages physicians to acknowledge mistakes, both to themselves and to others.

Physician error commonly affects patients, physicians, and other health care providers. A 1998 study of registered nurses, for example, showed 33% were aware of at least 1 incident of patient harm caused by physician error in the previous month.5 Those surveyed reported a troubling dilemma in deciding when to report other health care providers' mistakes. Similarly, some medical students will witness physicians' medical mistakes. The student must then reconcile conflicting desires to ensure patient welfare through truth-telling with those to protect and remain loyal to the teaching physician. Facing this dilemma, the medical student will find many reasons to facilitate disclosure of the error.

A physician has a multifold ethical duty to admit mistakes to the patient. As the American Medical Association Principles of Medical Ethics states, "A physician shall . . . be honest in all professional interactions."6 Moreover, in cases in which "a patient suffers significant medical complications that may have resulted from the physician's mistake . . . the physician is ethically required to inform the patient of the facts necessary to ensure understanding of what has occurred."7 This ethical requirement to inform the patient of the mistake can be concluded from both deontological and consequentialist perspectives, that is, both by considering the ethical value of the action alone and by considering the possible consequences of the action.8

The patient-physician relationship is fiduciary in nature; as such, it relies on principles of autonomy, beneficence, nonmaleficence, justice, and fidelity in all actions. The physician must act in the patient's best interest at all times. Most often, disclosure of mistakes would benefit patients. For instance, to gain patient cooperation, it is often necessary to explain exactly how a condition arose. In some cases, knowledge of a mistake could affect the patient's current and future decisions regarding care. Thus, to maintain autonomy and to give true informed consent, the patient must know of relevant errors.9 Also, understanding that a mistake occurred may relieve patients' anxieties about slow recovery or complications. Even knowledge of an iatrogenic cause could allay fears that a worse problem exists. Providing such relief is an important example of beneficence. To knowingly allow continued anxiety would constitute maleficence, as the physician would consciously impair the patient's well-being. Furthermore, if the physician's error resulted in increased costs to the patient, justice would dictate disclosure to ensure patient compensation. Indeed, some cases may require monetary reimbursement to the injured patient.8 Finally, fidelity demands truth-telling at all times. A recent survey of patients found that 98% desired acknowledgment of even minor mistakes.10 This refutes the assertion that nondisclosure "protects" patients by maintaining an image of physician infallibility; patients want physicians to disclose their errors. For all these reasons, and because a physician must always act in accordance with the principles of the patient-physician relationship, disclosure is clearly the ethical action after a medical mistake.

In addition to reasons arising from these principles, consideration of future consequences also compels the physician to disclose errors. Accurate information could improve the patient's subsequent treatment. Other caregivers can then work with better facts, while the cooperation of the informed patient greatly facilitates recovery. Additionally, disclosure could aid in relief of the physician's own emotional stress while fostering a stronger patient-physician bond.8 These practical results alone suggest disclosure is the best course of action.

While it is relatively clear that a physician has the ethical obligation to admit medical errors, what should the medical student do when the physician refuses to disclose a mistake? In determining a course of action, the medical student must consider duties to the patient, physician, and him- or herself. It is inappropriate for the student to unilaterally disclose the error, yet the student must not allow the patient to be deceived.

Although the student's responsibility to the patient does require acting to facilitate disclosure, the same responsibility precludes responding to patient queries by accusing the physician of error. In clinical situations, the medical student has a unique relationship with the patient. The student often accepts the description "student doctor" and thus is obligated to maintain ethical conduct appropriate for a physician. As such, all of the reasons for physician disclosure considered above also apply to the medical student. However, there are also reasons a medical student should not independently tell a patient of a physician's mistake. The student's limited medical knowledge may make it difficult to explain the nature of the error adequately. Also, a small number of patients specify before treatment that they do not wish to know if anything goes wrong. Moreover, the attending physician may see reason to wait before disclosing his or her error.8 For example, it might be prudent to wait until the patient has achieved a certain degree of recovery before mistakes by the physician are discussed. In any of these cases, for the medical student to preempt the physician would do a gross disservice to the patient by undermining the relationship and trust between the patient and attending physician. Instead, the student could tell the patient that he or she would like to invite the physician to help explain the circumstances. The student must ensure that disclosure of the physician's error does occur, but only after discussing the situation with the attending physician.

Not only do duties to the patient necessitate disclosure, but the student can help the physician avoid negative consequences by doing so. Telling the physician the patient would like a clear explanation of the current circumstances gives the physician an opportunity to discuss the mistake with the patient. It alerts the physician that the patient is concerned about the cause of the complications. Communicating this concern may allow the physician to resolve anxiety before hostility develops. This can save the physician from future emotional strain and legal repercussions. Indeed, there is some indication patients may be less likely to pursue litigation if the physician promptly admits a medical mistake. Risk management organizations note patients often file lawsuits out of anger at not having been told the truth about their conditions.11 Likewise, surveyed patients responded they would be significantly less likely to file a lawsuit if the attending physician informed them of a mistake than if they found out by some other means.10 Attempting to conceal a mistake could extend legal repercussions: many states hold the statute of limitations in abeyance when a physician has concealed negligence, and a physician caught concealing error is more likely to be perceived negatively by a jury if a lawsuit does proceed to court.11 However, in cases where a mistake is admitted, reimbursement for subsequent treatment is rarely paid by the physician personally.

In reality, physicians may use fears of litigation primarily as conscious or subconscious pretexts to avoid the unpleasantness of admitting mistakes12 or even acknowledging an error. These admissions can be very difficult and painful. Yet when the physician takes responsibility for the mistake, both physician and patient benefit. Admittedly, this reasoning may provide little comfort to the student when facing the attending physician. Nonetheless, the student can minimize awkwardness by discussing the matter with the physician appropriately. The student may privately approach the physician and nonconfrontationally state that the patient has asked about the situation, and the student would appreciate the physician's help in informing the patient of the mistake. While approaching the physician may remain difficult, it remains the duty of the student to both the patient and the attending physician to encourage disclosure.

Unfortunately, an attending physician may not be eager to admit a mistake. In such a case, the student has an additional responsibility to him or herself and fellow students to pursue disclosure. A second opinion regarding the incident should be sought, preferably through an official, impartial group, such as the hospital's ethics board.8 The student should notify the attending physician of such intentions and contact the board personally. This will ensure that the proper steps are taken to promote the patient's best interests, which remains the student's primary duty. By pursuing the matter through official channels, the student takes the best means possible to guard against any negative repercussions from the attending physician.

Ethical actions are often unpleasant and difficult to perform. Yet in doing so, the student develops professionally in reaffirming personal ethical standards and learning firsthand how to manage conflicting priorities. To ignore the opportunity would be to abandon a chance to learn how to handle medical errors, an ability that will most likely be needed in the future. By pursuing disclosure, the student further ensures that peers will not be required to maintain silence when other medical mistakes occur; the act serves to defy the stigma of admitting a mistake. Beyond duties to the patient and physician, the student has a responsibility to him or herself to practice responsible medicine. This responsibility begins as a student; there is no easier way to learn to be an ethical physician than to engage in ethical practice from the start.

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