Study finds gap between practice, attitudes toward medical errors

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"Our goal was to learn more about clinicians' attitudes but also what they actually have, and have not, done," said the study's lead author Lauris Kaldjian, M.D., Ph.D., associate professor of internal medicine in the UI Roy J. and Lucille A. Carver College of Medicine and director of the college's Program in Biomedical Ethics and Medical Humanities. "We were interested in what factors or beliefs might be motivating physicians who are more likely to disclose errors to their patients."

Kaldjian and his colleagues received survey responses from 538 faculty physicians, resident physicians and medical students from academic medical centers in the Midwest, Mid-Atlantic and Northeast regions of the United States. Survey questions focused on respondents' attitudes toward disclosing medical errors; whether they would disclose an error from a hypothetical medical situation; and whether they had ever disclosed a real-life medical error.

Ninety-seven percent of the faculty and resident physicians indicated that they would disclose the hypothetical medical error that resulted in minor medical harm (resulting in prolonged treatment or discomfort) to a patient, and 93 percent responded that they would disclose the error if it caused major harm (disability or death) to a patient.

However, only 41 percent of faculty and resident physicians reported actually having disclosed a minor medical error, and only 5 percent responded as having disclosed a major error. Moreover, 19 percent acknowledged having made a minor medical error and not disclosing it; 4 percent indicated having made and not disclosing a major error.

Taken at face value, the responses would imply that more than half of the physicians surveyed have never made a medical error in their careers. This is striking, Kaldjian noted.

"It seems fair to assume that all of us have made at least a minor error, if not a major error, sometime in our careers," he said.

Kaldjian acknowledges biases that can influence survey data like this - for example, a respondent's reluctance to reveal information that may be embarrassing or unflattering. The point remains, however, that there appears to be a discrepancy between how physicians and trainees believe they would act when faced with a medical error situation and how they have acted when in these situations, he said.

"Most doctors recognize that they're fallible, but they still strive for perfection and, for the most part, hold each other accountable to a high standard of practice that approximates perfection," Kaldjian noted. "The idea persists that the physician rides into the clinic on the white horse. To come in as the healer and then realize that you have harmed is a difficult thing to accept, let alone admit."

Fear of malpractice has been cited as a reason why doctors do not disclose medical errors, but the study authors report that their survey found that physicians who had been exposed to malpractice litigation were not less inclined to disclose errors. The researchers also found differences among the survey respondents based on training level. Physicians with more experience were more willing to disclose medical errors, suggesting that with increased clinical competence and confidence, doctors become more comfortable with error disclosure, according to the study.

Kaldjian also noted preliminary survey data showing that physicians who indicated that forgiveness is an important part of their spiritual and religious belief systems were more likely to disclose medical errors to their patients.

"This is not to say that forgiveness should be a course in medical school," Kaldjian said," but it does suggest that medical schools should consider ways to encourage trainees to draw upon the deeper personal beliefs they bring to the practice of medicine that may be relevant to the challenges of disclosing medical errors."

University of Iowa