In this study, a full apology and acceptance of responsibility were associated with better ratings and greater trust in the physician, but were not associated with decreased propensity to sue. An unexpected finding was that after an adverse event, the patient’s perception of what was said appeared to be more important than what was actually said.
To our knowledge, this is the first study to investigate the importance of how patients interpret the physician’s communication about an adverse event. The video vignette methodology we used allowed us to control what was actually said, observing how participants interpreted this and how both of these factors related to their evaluation of the physician.
Our results support those from earlier studies suggesting that full disclosure of an adverse event leads to greater trust and more positive regard by patients and family members.21,32
This was particularly true when the physician acknowledged responsibility for the adverse event. Interestingly, acceptance of responsibility without an accompanying apology yielded no such benefit and may have even resulted in more negative judgments. This is similar to Schwappach’s finding that equivocal statements acknowledging an error had no effect or even increased the probability of negative ratings.21
Our findings complement those of previous studies in that we obtained a community sample rather than health plan members.21,32
A surprising finding was that the perception
of what is said was more strongly associated with how physicians were perceived and trusted than what was actually said. This finding has face validity, but there have been few studies of how handling of an incident affects patients’ evaluations.21,32
One interpretation is that just because we think we’ve conveyed a message does not mean that it will be heard and understood. In communicating, the sender encodes meaning in his or her words and the receiver decodes the meaning.39
Ambiguous wording from the sender or preoccupation of the receiver increases the chances of translation error. In addition, multiple factors affect how patients evaluate physicians.40
If it is difficult to modify patient perceptions based on language, what can physicians do? One piece of advice is that once you have decided to disclose an error, you should make sure that the patient knows you really mean it. For a discussion that includes explaining, apologizing and accepting responsibility, this may involve repeating the message and aligning other channels of communication (e.g., posture, demeanor) to be congruent with the expression of regret, contrition and empathy. It is also important that physicians ask questions to help ensure the message is getting through. As in aviation, use of a “read back,” where the receiver is required to verbally repeat the sender’s message before taking any action, may be a useful way for physicians to test patient comprehension. There is a need for further research on the disclosure process.
Physicians and risk managers are particularly concerned that disclosure may increase the chances of being sued41
—this is why many physicians never admit their mistakes.42
Studdert has raised a theoretical argument against disclosure43
but empirical evidence on the topic is limited.34,44–46
In our study, full disclosure and acceptance of responsibility were related to only a slight reduction in intention to sue. This may have been influenced by the severity of the outcomes, which are important in determining future actions.10
Mazor found that disclosure had a protective effect of 7.1% against seeking legal advice.32
Schwappach noted that in severe adverse outcomes, an honest, empathic and accountable approach decreased patients’ support for strong physician sanctions by 59%.21
Fisseni found that patients were more likely to stay with general practitioners after serious medical errors if the physician played an active role in discovery and disclosure.33
Our results could suggest that disclosure of an unsuspected error could lead to an increase in the number of lawsuits by making more patients aware they have suffered preventable harm. Given that six out of every seven patients who suffer preventable harm are unaware that it might have been prevented, disclosing the error might actually increase the number of suits being filed. Our finding that disclosure does not appear to increase the proclivity to sue among those who were aware that an error had occurred does not change the absolute risk that any given patient will sue. Regardless, the ethical imperative should compel a full disclosure to patients who suffer preventable harm.
Our study had several limitations. Some are inherent in the use of vignettes in research. Vignettes can be valuable tools for studying peoples’ attitudes, perceptions and beliefs.47–49
It is also known that response biases can be introduced by a subtle difference in how material is framed.50,51
In our study, the scenarios were lifelike, but were compressed in length, possibly making it difficult to appreciate all the information presented. This is a problem that also occurs in real-life patient-doctor discussions. Another limitation is that some viewers may have judged the physicians who did not take responsibility for the adverse events as not having caused them, and rated them highly based on competence rather than honesty. Although this might also occur in reality, it would be unacceptable to recommend that physicians should dodge their responsibility for the incident. Finally, asking participants to rate vignettes is inherently projective. We don’t actually know how the participants in our study would act if they experienced an adverse event.
We may have been underpowered to detect differences, particularly between levels of apology, and to detect differences among the different vignettes. However, the trends observed were consistent with our hypotheses. There was an over-representation of African American and lower educational attainment participants. This group was fairly representative of East Baltimore and many other major metropolitan centers; the results are also consistent with previous results obtained from a primarily Caucasian sample.32
Our results hinted that viewers with more education perceived the physicians more positively. If these subjects were also more sensitive to our designed variations, they might have responded more in the way we hypothesized. In future studies, it would be important to include enough subjects from different demographic groups to test potential associations.
We omitted a possible sixth version of our cases (AoR−). If this affected viewers’evaluations of the vignettes that they did see (for example, by diminishing the contrast between different versions), this could have introduced measurement error. We believe that it is unlikely to have introduced much bias, since version selection was randomized, and viewers gave their evaluations immediately after each video. Finally, due to constraints of time and money, we did not achieve ethnic diversity among the actors in our vignettes. This could have led some of the participants to rate physicians less positively or to identify less strongly with either the doctors or the patients, which could diminish the reliability of their evaluations.
The results of disclosing adverse events to patients and families, including the finding that 'it's not what you say, it's what they hear,' have implications for education and practice. There is broad consensus that physicians and health-care organizations should disclose adverse events to patients and their families. Physicians need support and assistance to accomplish this difficult task successfully. Training is needed to help those in training and practice carry out the difficult task of disclosing adverse events. It will be important to evaluate the effectiveness of that training, including how it is perceived by patients and their families.