MONTEREY, CALIF. - When things go horribly wrong for patients, physicians must ask themselves some delicate questions in the art of management.
Should I apologize? How do I deal with the patient? Am I legally obligated to tell the patient what I know about what happened? How do I deal with myself?
Dr. Clifford Warren Lober
Medical negligence may be a factor in some cases, but bad results can happen even when there is no breach of duty, Dr. Clifford Warren Lober noted at the American Society for Mohs Surgery meeting. Especially in cosmetic procedures, the problem may be unmet expectations.
The best thing to do is to anticipate the possibility of a bad outcome to be in the best position to deal with it. Be prepared by maintaining appropriate training and experience. Comply with office surgery rules and develop a good rapport with colleagues. Give the patient a realistic description of expected results. Obtain informed consent from patients and dismiss selected patients if necessary to stay out of trouble, he suggested.
Should the physician apologize when there's a bad outcome? "It depends," said Dr. Lober, a dermatologist in Kissimmee, Fla., who is also an attorney.
Make an effort to show concern, compassion, and empathy. Patients are more likely to sue doctors they perceive as callous or unconcerned but "do not readily sue doctors they like," he said. Some states prohibit expressions of regret, sympathy, or benevolence from being entered into evidence, so apologizing won't necessarily help if a subsequent suit goes to trial. Plus, physicians should ask themselves how effective they are at communicating, because some may come across as arrogant instead of sympathetic.
An apology may deflate the patient's anger and make negotiations possible instead of a lawsuit. Patients may expect an apology--many claim they would not have sued if only the doctor had apologized, Dr. Lober said. Apologizing may be the ethically correct thing to do, help put closure on the problem for both patient and physician, and decrease physician feelings of guilt or distance from the patient.
On the other hand, an apology may be misconstrued as legal weakness and encourage a lawsuit. It could be entered into evidence as an admission of guilt in some states, and malpractice insurers may consider it a breach of contract, so physicians should consult their attorney and malpractice insurer before apologizing.
A physician who chooses to apologize should do it soon after the injury and should be the one who apologizes instead of delegating it to a nurse, attorney, or someone else, Dr. Lober stressed. Sincere expressions of sympathy or remorse are okay, but a physician should never admit guilt, he added.
Seven states--California, Florida, Nevada, New Jersey, Oregon, Pennsylvania, and Vermont--require physicians to notify patients of adverse incidents that seriously harm the patient but specify that this cannot be introduced as evidence or construed as an acknowledgment of liability.
When things go horribly wrong for a patient, the physician may experience anger, self-doubt, or depression. Discuss the situation with your attorney, Dr. Lober advised, but be careful about discussing the circumstances with colleagues, a spouse, or others. Consider psychological counseling if the emotional response is strong or persistent, he added.
Dr. Lober stressed that his comments were for educational purposes only, and he advised physicians to seek legal counsel if an adverse situation arose.n
Dr. Lober reported having no pertinent conflicts of interest.