To Err Is Human, to Apologize Is Hard | Humanities | JAMA | JAMA Network
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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.”

What followed was a long conversation—without an apology.

My 6-year-old son suffered for 5 months before we finally discovered that his agony was caused by a rare type of brain tumor. For all those dark months, the many physicians caring for him missed it completely. He was misdiagnosed at the start, the anchor thrown off our boat, tethering us to a spot off course lost in a sea of uncertainty and misdirection. For 150 nights and 150 days, we squinted through bleary eyes, swollen from tears and sleeplessness, and tried to find a way ashore. Our old lives, ordered and predictable, were shattered and drifting in the current. We paddled frantically not understanding why he wasn’t improving until we finally—ragged and injured—pulled our family onto land by piecing together the data, eventually revealing his actual diagnosis. With truth, came direction.

The vertigo lifted as we started marching steadily, grounded by science, our boy’s future as North. The errors made by physicians during those relentless days adrift cast a shadow of mistrust on our journey. In the immediate wake of his eventual diagnosis, we needed his physicians to take clear and unambiguous responsibility for their role in the painful experience so that we could begin healing and move forward together.

When we tried to open the door for repair with each of the doctors, we were most often met with a dance around an actual apology. They were shocked that “it has gone this way,” as if they were passengers rather than the captain when the boat went off course. They rerouted the conversation to the bright side: “I am so glad you are finally on the right path,” tucking away our pain before we were ready. Or they tried to write themselves out of the story, deflecting blame: “I thought you had said…?” suggesting that we may have distorted the history. These nonapologies left us unmoored as patients, our own stories wrested from us and rewritten to shield the very people entrusted to protect us.

We empathize with our doctors at the same time that we are hurting as patients. We see ourselves in their weary eyes, as the laboratory results and portal messages pile up, pulsing in their consciousness while their children play in the background of a professional tsunami. The pandemic has ravaged what little is left of their boundaries as patients’ needs have skyrocketed while the hours in the day remain fixed. We understand that they too are hampered by the shift from human encounters to a virtual reality where nuances are lost amidst weak signals and poor connections. We understand their—our—jobs are actually impossible, the demands too great. For these indignities of the medical profession, we share their frustration. As physician-patients, we identified with our doctors many times along the way, but when our son slipped through the cracks, we found ourselves across a chasm from the clinicians we had trusted. In the absence of an honest apology, there was no bridge across that divide, and we left these conversations feeling abandoned.

Among the many from whom we needed an apology, only one physician actually used the word “sorry” or “apologize”: the primary care pediatrician who had known our son since his weight was measured in ounces. Our relationship developed its scaffolding through well and sick visits, over many years and developmental milestones. She had been a steady and secure source of reassurance leading to this difficult moment when she looked us directly in the eyes and said clearly and vulnerably, “I am sorry. I failed you.” She had studied his entire medical record, now printed in hard copy in front of her, so she could unravel the whole story for herself, taking note of each time she wished she had steered our journey differently. She brought unfettered humility to that conversation, reckoning with her own shortcomings. Her unguarded and authentic apology offered us renewal in our relationship. Her humanity—the same humanity that made her fallible in our son’s care—is also what ultimately provided us with comfort as wounded patients. As physicians, we saw the rare courage it took for her to walk openly into this anguished moment, exposed to our judgment and allowing in the depths of our pain.

Medical errors leave a wake of trauma. For patients, this can be a mortal blow to their trust in the health care system. For clinicians, paralyzing fears of fraudulence may be validated. In medicine, we seek to combat endemic imposter syndrome by convincing each generation of physicians that they do belong because of their extraordinary skills and accomplishments. This narrative ensnares us in a trap: worthiness in this role is earned only by achievement and perfection. The truth is that our inevitable failures reflect not our fraudulence but our human fallibility. A deep cultural shift is needed in medicine to openly acknowledge and understand that imperfection is part of being human—no one knows everything, makes every diagnosis without delay, answers every patient message, or even delivers an apology just right. It is our humanity that makes us vulnerable to make mistakes and also empowers us to connect and heal.

“Sorry” slips out with ease each time we bump into someone in the grocery store or when we need to squeeze out of a bus. Among strangers when the stakes are low, “sorry” is easy. But in medicine, when apologies imply physicians’ deepest imperfections, the ones that may cause indelible suffering and cost lives, those apologies are hard. For physicians, in spite of focused education and training on apology, these moments can steal our breath and tie our tongues. But for patients like us who have suffered harm, it is in the apology that we know a physician is truly with us as our story unfolds. We have someone who will leave ego aside and guide us to the other side of suffering.

Physicians can be better prepared to own their failures by training them to expect these moments as part of the job. Yes, we must try to prevent errors through careful systems improvement and years of dedicated study and meticulous practices. But mistakes will happen. And when we find ourselves in these terrifying moments, physicians must summon the compassion for ourselves and our patients to apologize honestly and sincerely for the harms caused. Much can be learned from the example of clinical leaders presenting their own morbidity and mortality cases, sharing their errors for colleagues and students to see that mistakes do not need to be shrouded in anonymity. We all falter, but if we are brave enough to admit our humanity, including our flaws, we may become secure enough to preserve trust and provide healing when it matters most.

Section Editor: Preeti Malani, MD, MSJ, Associate Editor.
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Article Information

Corresponding Author: Thalia Margalit Krakower, MD, Department of Medicine, Harvard Medical School, Massachusetts General Hospital, 15 Parkman St, WACC 605 Boston, MA 02114 (thalia.margalit@gmail.com).

Conflict of Interest Disclosures: None reported.

Acknowledgements: I thank my husband and our son’s pediatrician for allowing me to share our family’s story.

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    7 Comments for this article
    EXPAND ALL
    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
    READ MORE
    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
    READ MORE
    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
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