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A Piece of My Mind
July 20, 2021

To Err Is Human, to Apologize Is Hard

Author Affiliations
  • 1Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston
JAMA. 2021;326(3):223-224. doi:10.1001/jama.2021.10840

"We don't blame you or anyone,” my husband said over Zoom to our son’s doctor.

We waited expectantly, as the stammering and uncomfortable shifting revealed a new side of this physician, someone we knew as a brilliant, thoughtful, and compassionate clinician, never lost between words.

“We do need all our son’s doctors to look his suffering in the eye and acknowledge the role you played. To repair, we need everyone to apologize and learn from this horrible experience.”

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    8 Comments for this article
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    Owing an Apology
    Mayank Mishra, MD | All India Institute of Medical Sciences, Rishikesh, India
    This is such a powerful write-up! An eye-opener to the entire physician-community.
    CONFLICT OF INTEREST: None Reported
    Honesty Can Be Comforting
    Elyse Rogers, R.N., B.S., M.A. | Medical writer/columnist
    Most people (even hurting parents) appreciate and value an honest apology. And when we as health professionals show we are grieving too, it unites and comforts us all.
    CONFLICT OF INTEREST: None Reported
    Empathy Can Be Taught
    Joseph Sherman, MD | Physician Coach, Clinical Assoc. Prof. University of Washington
    What a powerful and courageous article! Thank you for pointing out how our medical culture glorifies imperfection, self-sacrifice, and emotional distancing instead of our common humanity. The need for senior physician leaders to unlearn these false beliefs and replace them with empathy, humility, and honesty is imperative. Then, they can role-model a new way of being a physician which facilitates growth of empathy in medical training instead of squelching it.
    CONFLICT OF INTEREST: None Reported
    Litigation and Apologies
    Eugene Breen, MBBChBAO, MRCPI, MRCPsych | Adult Psychiatry Mater Misericordiae University Hospital Dublin Ireland
    My sincerest sympathies to Dr Krakower and her husband on the terrible ordeal they went through. As an explanation for the non-apologies of her physicians could I suggest the following: a real issue at the heart of many such outcomes is genuine paralysing fear of litigation on the part of the treating physician. I have recently seen a harrowing case of possible medical neglect and a patient's description of the shutters coming down and no cooperation and little communication except through legal channels. We are urged by medical defense organisations, risk managers (one such already this morning in my inbox), and insurers and medical regulators to be super-cautious and not to admit liability or error. They advise judicious choice of words and availing of legal advice. The experience of colleagues dragged through medical regulatory hearings over months or years is chastening and frightening - especially when the complaints are vexatious and unfounded. Such a backdrop to medical practice causes good humane doctors to freeze at the sound of error or misdiagnosis and to run for cover. Unfortunately humanity is sacrificed in the process, both their own and that of their patients. So, Dr Krakower, the physicians who didn't apologise maybe felt they couldn't, not because of hurt professional pride or ego, but because of fear of litigation. The bottom line is we all should apologise and empathise with suffering patients for what happens - which is not the same as accepting liability. Legalism has frozen the humanity in many doctor-patient relationships.
    CONFLICT OF INTEREST: None Reported
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    Saying Sorry
    William Sellers, FRCA | Retired Anaesthetist

    I do hope your son is well.

    Your powerful writing will persuade more: ´I am so sorry for my error(s)’; an approach I have relayed to all my trainees during non-error-free years of practice.

    CONFLICT OF INTEREST: None Reported
    We Need to Be Healers And Not Just Doctors
    Kwabena Adubofour, MD, FACP | Internal Medicine Residency Program, Dignity Health Saint Joseph's Medical Center, Stockton, California
    Dr. Krakower, what really distressed me the most were the following words.
    "What followed was a long conversation - without an apology".
    Here you were a mother and a professional colleague and yet the involved clinicians could not look at you, could not look at your husband, and utter the most compassionate, caring, dignified, and forgiving words under such circumstances - "I am truly sorry this happened to your son".
    There, unfortunately, lies the difference between being just a doctor and being a healer.
    Healers believe in the common humanity that enshrouds all of us.
    Healers are present and in
    attendance during every conversation and are quick to tell you when they do not have all the answers.
    Healers, especially healers when they make a mistake, are the first to acknowledge such and the first to offer support and explanation.
    Healers have a mindset that relegates thoughts of litigation and malpractice to the background.
    A quick note here - the evidence is out: Healers are the least likely to be involved in malpractice litigation and just recognizing that an error has occurred and having not the courage but the compassion to say sorry goes a long way to prevent entry into a courtroom.
    Your sons' pediatrician acted as a healer. We need more healers. Our responsibility as faculty in GME programs is to help produce more healers and not just doctors. We need to ensure that no other mother has to put pen to paper and write as painful a piece as this. My apologies Dr. Krakower.
    CONFLICT OF INTEREST: None Reported
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    Fear of Litigation
    Pandiyan Natarajan, MBBS, DGO, MD, M.N.A.M.S. | Professor & Head of the Department of Andrology and Reproductive Medicine, Chettinad Super Specialty Hospital, Chennai, Tamil Nadu, India- 603103
    Medical mistakes are commonplace. All of us have made mistakes in our practice of medicine. I have admitted to my and my colleagues' mistakes and apologized to the patients in the past.

    However, days are changing. In an era rife with litigious practice of medicine, most physicians are worried about the consequence of an apology.

    No-fault compensation may be the way forward to bring back humanity to the practice of medicine.
    CONFLICT OF INTEREST: None Reported
    One of the Most Powerful Pieces Ever Written on This Subject
    Louise Andrew, MD JD | MDMentor.com
    This poignant history from a physician mother regarding the care of her child with a devastating delayed diagnosis is a superb piece that not only details several insincere apologies but, perhaps most importantly, an exemplary, unguarded and heartfelt apology from her pediatrician.

    As a lawyer myself, I understand why risk managers and hospitals advise physicians not to apologize. In most US states doing so can still be used against you as an "admission against interest" (though MA is a state whose Medical Society champions a strong Disclosure, Apology and Offer program). And yet, as Krakower explains,
    apology is probably the ingredient that is most essential to beginning the healing of a family that has been harmed by medical error. Beginning the group healing process with accurate acknowledgement of errors along the way and explanation as to how they could happen and might be prevented in future is actually a remarkably strong deterrent to litigation.

    I believe it is even more difficult to apologize to physician patients than to non-physicians, because our colleagues will see and know our sometimes ignorance, and recognize our occasionally shoddy care. Fellow physicians know and share our frustration at a system that often is inept; and yet, they still may feel unable to admit their own contribution to the ineptitude.

    As a physician who has suffered delayed diagnosis, unexpected surgical mishap, and permanent damage at the hands of other physicians, I can confidently say that the ones I would never sue are the ones who were honest with me and who admitted their errors and who put caring for me as a human being and patient above fear for their own legal safety. Those who avoided me, or gave false excuses instead of sincere accountings are the ones I might have sued, if I had needed financial support as a result of a medical injury.

    Upon further reflection, I believe that any system or policy that limits or prevents our natural inclination to apologize when we know or believe we have contributed to the injury of a fellow human being is probably a significant source of moral injury to physicians. Causing harm to another, even when your intent was the exact opposite, is an event that cries out for apology. A thwarted need to apologize and atone creates a moral dissonance that is demoralizing at best, and devastating at worst.
    CONFLICT OF INTEREST: None Reported
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