The results of this study add to a growing literature about physicians’ attitudes and practices regarding the disclosure of medical errors to patients. Our data contribute new information pertaining to differences between hypothetical attitudes and actual practices, the potential influence of exposure to malpractice litigation on attitudes, differences based on level of training, and a range of relevant attitudes and beliefs. Most notable among our findings is the observation that, although more than 90% of our respondents reported that they would likely disclose a hypothetical error resulting in minor or major harm to a patient, only 41% of faculty and resident physicians had ever disclosed an actual minor error and only 5% had ever disclosed an actual major error. Furthermore, 19% of faculty and resident physicians reported not disclosing an actual minor error and 4% reported not disclosing an actual major error. These results suggest there is a gap between physicians’ hypothetical attitudes and their actual practices regarding disclosure.
One of the possible causes of such a gap is the much-discussed fear of malpractice. Some commentators claim that error disclosure does not increase the risk of litigation16
and can actually decrease liability costs,18,29
and there are survey data suggesting disclosure would not increase the risk of negative consequences for physicians.30,31
However, others question whether routine disclosure of errors will generally result in fewer lawsuits,25,26
and there are survey data to suggest disclosure may increase the risk of a malpractice claim because of the substantial number of persons who believe error-committing physicians should be sued or punished.27,32
In light of such discussions, it is noteworthy that our study found that physicians who had been exposed to malpractice litigation (either as a defendant or a witness) did not appear to be less inclined to disclose errors. Moreover, some of our data suggest the possibility that experience with litigation may have the potential to increase the inclination to disclose errors, paradoxical as that may seem.
We found significant differences based on training level. Physicians with more experience were more willing to disclose hypothetical errors and more likely to believe that disclosure increases patients’ trust, and they were less concerned about possible negative consequences of disclosure and less likely to believe that the decision to disclose depends on the physician’s assessment of whether disclosure will help or harm the patient. This implies that, with experience, physicians become more comfortable with error disclosure. It also suggests that if trainees can observe the practice of error disclosure, the learning environment might accelerate the recognition that errors will accompany even the best clinical efforts and that disclosure of errors is a component of respectful patient care.
Our results support the conclusion that a physician’s willingness to disclose an error to a patient is related to a complex variety of attitudinal variables, both positive and negative. Several attitudes toward disclosure were associated with a greater likelihood of disclosure. These attitudes represent a mixture of personal and professional attitudes that draw attention to factors that facilitate disclosure such as straightforwardness,4
and the need for a patient-centered view of the value of error information rather than a physician-centered view that unilaterally decides when error information will benefit the patient.
Advocates of patient safety have rightly called for the removal of blame and shame from the discussion of medical errors.34,35
Healthcare institutions heeding this call face the challenge of sustaining a rigorous sense of professional accountability without adding blame to the profound emotional burdens already borne by error-involved physicians. In the effort to avoid casting blame, institutions need to recognize that feelings of guilt after an error may be very real for physicians, even in the absence of external criticism. Two thirds of our respondents believed that disclosing a mistake to their patient would help alleviate their feelings of guilt, consistent with the observation by Gallagher et al. that 74% of physicians and surgeons who had ever disclosed a serious error experienced relief after disclosure.36
The origins of guilt feelings after errors are no doubt psychologically complex and may be related to a compulsive mindset among physicians which automatically views bad outcomes as failures.37
Whatever the source of guilt feelings, their possibility emphasizes the need for empathy and reassurance at a time when physicians may be overwhelmed by self-doubt.38
In a similar vein, our results suggest that there may be connections between physicians’ beliefs about forgiveness and their willingness to disclose errors. Respondents who agreed that forgiveness is an important part of their spiritual or religious belief system were more likely to disclose a hypothetical error resulting in minor harm, and these respondents were also less likely to have reported withholding disclosure of an actual error resulting in major harm. Some authors have recommended the pursuit of forgiveness to facilitate constructive approaches to the emotionally burdened aftermath of an error39
and to encourage healing in the patient–physician relationship when apologies are made.21,40–42
Our results encourage consideration of such recommendations, depending on the beliefs, needs, and preferences of the clinicians and patients involved in a given situation.
To our knowledge, only 1 other survey study has queried physicians about their actual experiences with error disclosure or about attitudinal differences toward errors with outcomes of variable severity. Gallagher and colleagues found that 58% of a large sample of physicians and surgeons had ever disclosed a serious error, and when asked about generic categories of errors associated with different degrees of harm, 35% believed errors should be disclosed when there is no harm (“near miss”), 78% when there is minor harm, and 98% when there is serious harm.36
When given a variety of hypothetical vignettes involving a serious error that was followed by full recovery, 94% reported they would definitely or probably disclose the error (although only 42% would use the word “error” in their disclosure).15
These results appear consistent with our data and support the generalizability of our findings.
Our study had limitations. Although the survey was anonymous, social desirability bias may have led some respondents to give answers that were perceived to be more socially acceptable. The study design was cross-sectional, not longitudinal, so training level differences may have been influenced by differences in unmeasured variables between distinct participant populations. Lastly, our faculty and resident physicians were based in teaching hospitals and represented internal medicine, family medicine, and pediatrics, so our results may not be generalizable to physicians in other specialties or in other practice settings.
Ongoing efforts to promote error disclosure to patients by lessening its real and perceived risks are important,25,26,43–45
and our data emphasize that malpractice fears are not the sole source of anxiety when disclosure is contemplated—a point supported by the finding of little difference in attitudes toward disclosure between U.S. and Canadian physicians despite differences in malpractice environments.36
Other concerns – such as negative patient reactions, professional discipline, loss of reputation, and blame from colleagues – remain common and need to be addressed. Healthcare institutions and training programs should take deliberate steps to reduce the professional repercussions that may be associated with disclosure, and risk management approaches to error disclosure should include administrative support for professionals who may feel isolated and vulnerable as they attempt to navigate the psychological demands of the disclosure process and its aftermath. Under the right circumstances, physicians should be able to act with courage and compassion to communicate clearly with patients and families about errors. Creating such circumstances requires concerted efforts to build a culture of learning and healing that supports the physician’s self-identity as a healer, at a time when it may be threatened, and promotes the dignity and wellbeing of the patient after he or she has been harmed.