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Contributors: The original idea for the study arose jointly in a meeting of the three authors. GV and MH designed and piloted the questionnaire, and all three authors collected data and jointly wrote the paper. MH performed the statistical analysis. MH acts as the guarantor of the paper.
Unintended injuries (adverse events) caused during treatment are much more common than previously believed.1 Recent legal and disciplinary cases have shown that, although patients are increasingly dissatisfied with a perceived lack of openness in the medical profession, doctors are not legally obliged to provide an explanation after an adverse event.2 Because of this, the General Medical Council has revised its guidance on good medical practice, stating that after an adverse event a full and honest explanation and an apology should be provided routinely.3 We surveyed patients’ and doctors’ attitudes to the provision of information to patients after a hypothetical adverse event in cataract surgery.
A specifically designed questionnaire (box) was used to survey all patients attending a consultant ophthalmologist’s clinic during five weeks in 1998; 246 of 302 (81%) patients agreed to participate. All 48 ophthalmologists attending a regional meeting also participated. The questionnaire asked about the postoperative information that should be given routinely in a hypothetical situation in which a common intraoperative complication (posterior capsular rupture) occurred in cataract surgery, with an estimated 10% risk of an adverse effect on vision.
The attitudes of the patients differed substantially from those of the ophthalmologists: 226 (92%) patients, compared with only 29 (60%) ophthalmologists, believed that a patient should always be told if a complication has occurred (χ2=34.5, 1 df, P<0.001; odds ratio 7.4 (95% confidence interval 3.7 to 14.3)). The ophthalmologists who did not believe that patients should always be told replied that either the patient should never be told or that it depended on the circumstances. Two hundred (81%) patients, but only 16 (33%) ophthalmologists, believed that a patient should not only be informed of a complication but also be given detailed information on possible adverse outcomes (χ2=47.1, 1 df, P<0.001; 8.7 (4.7 to 15.9)).
Please read the following story (which is typical but fictional):
Mrs Brown has an operation for cataract. During surgery, there is a complication. The lens capsule breaks and the surgeon has to make a bigger cut than planned, use stitches and put in a different style of lens implant. There is approximately a 1 in 10 chance of her vision being affected by these changes.
The next day, she sees well and is pleased.
Should Mrs Brown be told about the surgical problem? Yes / No
If yes, do we discuss the possible consequences? Yes / Only if she asks / No
Please comment on your decision overleaf.
What is your age? 25 and under / 26-60 years / over 60 years
Our survey shows that after an adverse event patients expect more detailed information than doctors believe should be given. Doctors’ reluctance to provide detailed information to patients after adverse events is often an attempt to protect the patient from potentially detrimental anxiety. However, doctors may also avoid telling patients because it is a time consuming, difficult, and unpleasant task and because they fear losing a patient’s trust, being blamed, and perhaps sued. In addition, it has been suggested that the current medical culture, in which error is often automatically equated with professional incompetence or inadequacy, makes admission to either patients or colleagues difficult.4 Many studies show, however, that failure to provide information, an explanation, and an apology increases the risk of litigation and erodes the patient-doctor relationship.5 After an adverse event, patients want disclosure of the event, admission of responsibility, an explanation, an apology, and prevention of future similar errors; in some cases, they also want the offender to be punished and to obtain financial compensation.5
The practice of medicine can never be free of errors,4 and changes are required in the attitudes of both patients and the medical profession, with realistic expectations of the limitations of doctors and medicine and greater, blame free openness. In the light of the new regulations from the General Medical Council, failure to acknowledge an adverse event arising during treatment may now have serious professional consequences for a practitioner.
We thank Mr Jeremy Joseph for his advice.
Competing interests: None declared.