The study intended to analyze physician's post medical error disclosure process. This is a qualitative understanding research with ten Brazilian physicians from a private hospital. Participants were interviewed following a semi-structured script. From the data obtained in this research, results indicated that the surgical specialties or those in related fields had a higher error incidence. Classical medical training further reinforces a specific behavior by physicians that makes it difficult to acknowledge a mistake in their practice. Overall, disclosure was well received by physicians, and they realized the possibility of rethinking their actions and evaluating their behavior as one of the benefits of the process. Nevertheless, they suggested that disclosure should also focus on the mental health of the professionals involved. The social barriers of the country, which favor an error-free culture and make it more difficult for professionals to make mistakes could be rethought by using disclosure as a tool to improve the physician-patient relationship. Emotional support to physicians is necessary, as it helps giving better advise to medical professionals to resume their practice without anxiety and fears. Therefore, we expect disclosure to serve as a strategy for countries to invest in improving patient quality and safety, and to advance the practice of medicine.
Medical error, Disclosure, Emotional support
Medical error causes diverse consequences for physicians, patients and family members, and one of the alternatives to address this situation is the process of disclosure. It is a tool that has been adopted by several countries, such as the United States, Canada and the United Kingdom, with good results that favor patient quality and safety and reduces occurrences and new medical errors [1,2].
It can be conceptualized as a practice established in health spaces that allows institutions and health professionals to openly inform the patient whenever a poor outcome or unexpected outcome occurs during treatment [1,3,4].
This process has been gaining greater publicity because of its dissemination in the health spaces in America. The practice of disclosure is endorsed by major health regulatory bodies and the medical professionals of the country. Many US hospitals and universities have developed training programs and improvements in patient quality and safety that resulted in great benefits, such as reducing the number of errors and the suffering of professionals in their relationships with patients [1,3,4].
Because of these variables, we believe this tool can help other countries implement a type of service based on the benefits that the American community has obtained in order to improve the quality and safety of patients worldwide. And Brazil should be no different. In Brazil, the practice of disclosure is still incipient. However, there is already a movement that implemented this process in a private hospital in Brazil. This study evaluates this service as a tool to improve health and minimize cases of health errors in this institution. The scope of the study was to analyze physician's post medical error disclosure process and investigate how the physicians involved in the disclosure process assess this resource.
Qualitative study involving ten Brazilian physicians who experienced health errors in their professional practice. All the participants are physicians working at a private hospital in the State of São Paulo/Brazil, which has more than 6,000 physicians in its clinical staff. This hospital is a general teaching hospital with 600 beds.
All participants were involved in disclosure between 2015 and 2017, and they are all duly registered as physicians with the council that regulates the profession in Brazil. The study did not include professionals who never experienced health errors in their careers, or had a disclosure prior to 2015 because it would be too long ago, or professionals who did experience errors, but had not gone through disclosure at the hospital. These physicians were recruited by the hospital from the errors records. However, the refusal rate was very large, which made it difficult for a large number of participants. When the medical error happens the hospital performs disclosure in order to openly communicate information with the patient and family member. These errors are those that cause harm to the patient's health, from malpractice or professional negligence.
The physicians are between 36 and 61-years-old. All physicians were male. The average years of experience since graduation is 21.2 years, and the average weekly workload is 53 hours (Table 1).
Table 1: Study population. View Table 1
Research was carried out between August 2016 and September 2018. Interviews with semi-structured questionnaire were conducted. The questions addressed issues such as health errors, difficulties in admitting the error, evaluation of the disclosure, and differences of the medical professional with errors and without disclosure.
Meetings were recorded, allowing the total recording of the report. The transcription, analysis and interpretation of the interviews were supported on assumptions and concepts from phenomenology in a qualitative research with a comprehensive approach. The research is approved by the Ethics Committee in Research with Human Beings in Brazil, and follows all the ethical and normative requirements.
From the results obtained, the analysis was made according to the phenomenological assumption in a qualitative research: It intended to find out what meaning and sense is given by physicians to the daily experiences in the process of disclosure. The attempt to reach an universal explanation was abandoned in order to stick to the concrete experience that physicians were faced with. The material was read on many occasions, during which written comments were made and significant sections were identified. Based on the analysis, a descriptive text was drafted, producing a dialog between the core themes identified and the references adopted by this study .
Table 1 briefly summarizes the types of errors that medical professionals have experienced, and the disclosures made from these errors. We are taking these as the central point for debate in this study.
It is important to highlight that all errors are related to the surgery environment and specialties related to surgery and their specific variations. Not all of them resulted in the death of the patient, as in the cases of P6, P7 and P9. In the other cases, the death of the patient was not expected at that time in the patient's life, proving that an complications arising from medical errors can be fatal and they need to be studied.
According to the participants, there is a variety of reasons for medical professionals to avoid admitting an error, some of which are linked to intra-personal and personality aspects such as lack of modesty and arrogance. Medical training itself in Brazil carries the view that the physician knows the whole truth, and this comes accompanied by the socially instituted belief that making mistakes is not possible, which creates a fear of being prosecuted or punished [6,7].
I think that admitting one was wrong is related to the individual's perception of their lack of knowledge. I think the more people admit the little they know; the easier they'll have a chance to truly understand they were wrong. People need to acknowledge their limitations, and this is how they will understand they were wrong and apologize (P8).
The lines above provide a closer analysis of a discourse that privileges the patient and the ethical and human way medical professionals act. To have the clarity that Medicine is always evolving and that knowledge must always be updated.
As a consequence of these actions, we can count on the fact that professionals know they can act in peace in the future, knowing that they have acknowledged their mistake and apologized. Of course, we must remember that in some cases they can also be prosecuted by Justice and with this, which involves legal and economic reparations. P10 believes that psychological support during the period the physician reports to the patient can be of great value.
There was a patient referred from another State who had a complication from a procedure performed in the ICU. And eventually, the patient's leg was amputated. This was unrelated to the patient's abdominal condition. It was a straightforward situation, the family was unhappy and they were explained the seriousness of the case.
My approach was as transparent as possible. I wouldn't use the words "medical error"; I would say fatality. My disclosure was only asked to explain everything, and it was the perception of the difficulty of the procedure that resulted in the complication. I did everything according to the protocols stipulated (P7).
Two things are clear in this speech. In addition to the difficulty admitting the error, there is a technical approach distanced from the error itself. Physicians seem to sublimate personal/affective issues to the detriment of what protocol requires as the most important thing.
In general, the process was well assessed by physicians. They realized that the benefits bring improvements for the professionals themselves, for the institutions and for the patients. Many of them highlight the opportunity to learn from that situation.
Another good thing is that you get out of your comfort zone. You go through an event and, the next few times, months and years you will double check if things are correct. You will always refer to this event to give you more security. This event certainly made me more cautious and worried. I'm not saying that going through such a thing was good, but I've been keeping alert ever since (P2).
Regarding the points for improvement, we emphasize that the way in which the disclosure process is based in this institution is somewhat questionable, since it seems that different cases had different structural procedures.
The institution often gets carried away by personal issues and its own benefits instead of properly conducting disclosure because, according to P1, the physician who caused the error was never heard and was not even called to provide any clarification on the case, which left the team deeply affected. P3 reports that many decisions about the case were not passed on to the disclosure team, and that much of the information was given to the media when the hospital disclosed information about that specific case. P5 asked about the same thing, based on a lack of feedback on the process.
I think communication was the biggest issue. We only had a few meetings with the hospital management. We were not informed of a series of decisions the management had made regarding the family, for example, media disclosure and exposure. We knew it was the worst-case scenario. And I'm in the hospital and they don't tell me anything? (P3).
Another thing pointed out by medical professionals is the anxiety generated during the process, and how physicians are bothered by it, which interferes and disrupts work productivity. Some physicians even reported being followed and intimidated by relatives of their patients, which inhibits professionals outside their workplace.
P2 talks about the novelty in Brazil regarding the disclosure process in this hospital and being able to be part of this team. However, he acknowledges that there is a lack of attention to the mental health of physicians.
In general, going through disclosure allows physicians to rethink how they act, and to see in which situations they need to act differently. Disclosure provides understanding for the professional and an opening of the case to the patient. Physicians who only experience the process of error through court trial become more limited because their actions are interpreted by other people and professionals from other areas, often in distorted ways.
The worst situation is when the professional has no evaluation or judgment model, allowing physicians to act freely, without worrying about how they treat their patients.
That is terrible. Because they will miss all chances for improvement. Professionals may even get used to making mistakes and make that something normal, depending on the hospital. They will get used to the mistake and think it is trivial. Without taking other people's lives into consideration (P6).
Initially, something that draws attention is the fact that all cases are related to medical specialties in connection with surgery. The surgical environment is extremely complex and full of standards to be followed. Therefore, exposure to risks is also greater. A physician that makes mistakes due to lack of organization or non-compliance will have problems. Surgeons or those working with them are professionals who develop their technical skills during their residency, but their development of communication and interpersonal relationship skills during residency leaves a lot to be desired [8,9].
Discussing and developing communication skills and patient relationships should be mandatory courses in medical residencies around the world. In Brazil, the technical aspect prevails during medical training. In the United States, training institutions care about guaranteeing good physician-patient relationships and professional ethics. Disclosure training is often developed in American medical residency programs, where physicians do role play with a fictitious patient to develop the non-technical skills of the medical knowledge [8,10,11].
It is clear that questions related to affective and cognitive aspects or the way physicians learn from an error situation are distanced from the narratives they express. This reflects perhaps a difficulty for Brazilian physicians to get involved in the process of the error, and to eliminate anything that could get to them, emotionally speaking. A Brazilian study on victims of medical errors showed that most physicians did not own their mistakes and that, in addition to feeling disrespected and without rights, these victims demanded the acknowledgment of the situation by the physician involved. The financial reward was not greater than the request to acknowledge the error [12,13].
Another situation worth analyzing is how the technical aspect seems to be sublimating the human aspect. Protocols and checklists are becoming the key to the lack of a process involving medical professionals. Is the technical aspect the great escape from being humanly involved in cases of medical errors for Brazilian physicians? It seems to be easier to use the justification of technical failure, and medical training itself has been covering this lack of involvement that seems to bring some security to the professionals . It is putting the blame on the technical aspect to cover for a lack of human involvement. But what about the ethical issues and existences placed next to the technical aspect? Again, training leaves a lot to be desired in this sense. Brazilian authors claim that achieving technical excellence accounts for almost 75% of the contents of medical schools, and it is clear that ethical and human discussions are negatively affected [14,15]. We need to think of balancing strategies for technical and affective issues during training so that medical interlocutors are not totally isolated from the medical error situation and are able to be humanly involved in situations involving technical errors.
Physicians not being able to acknowledge their mistakes reflects Brazilian culture. This is a country where mistakes are considered weaknesses and acknowledging them makes a professional be considered as technically incompetent because he made a mistake. In a Boston/US hospital, the management was able to change the hospital culture of physicians by implementing the disclosure service. Professionals realized that making mistakes was not condemnatory, but a possibility to review processes and adjust small details that may lead to errors. This was not an easy task because physicians initially resisted support or counseling .
We believe that disclosure can be they way to overcome this cultural barrier, because if physicians can rethink their mistakes, they can have a reflexive attitude towards the patient and recognize fragilities. To that end, disclosure objectives should be clear and well-defined so that a new culture is established, as it happened at the Brigham and Women's Hospital with the creation of a peer support program that provides guidance to eliminate the prejudice, criticism and mistrust associated with medical error .
The disclosure is standardized, but it must always be adapted to the nature of the event, the context and the patient. These are difficult and challenging conversations that require appropriate preparation. This disclosure talk is supported by the ethical analysis of professional standards and is characterized by being a central component of high quality health care. This disclosure conversation is supported by an ethical analysis of American professional standards and is a central component of high-quality health care. In addition, there is a growing body of evidence showing that disclosure offers substantial benefits to both patients and physicians, such as improving patient safety and reducing frequency, cost, and suffering associated with medical errors, attenuating the physician's anguish resulting from broken relationships with patients and facilitating peer support, decreasing patient's frustration and anger due to lack of information and perception of lack of empathy from their caregivers [1,4,18].
It is essential to ensure that disclosure does not become a tool to avoid legal proceedings, because in this way the original purpose of disclosure is lost and it becomes a financial tool for institutions. It is not only an apology, but an analysis technique to better manage health care.
The hospital of this study failed to address the demands of physician's anxiety during the process. There was no follow-up on the emotional and psychological issues of these professionals. Often, mistakes or errors are understood by professionals as a career failure and that they need help, but they often would rather not share, out of fear of not meeting the expectations of perfection. Physicians are in charge of the care of their patients, often doing things impulsively to try and save someone and do everything for the other, even to their own detriment, and when they find themselves in a situation of failure, they get defensive and in denial, and therefore they have a hard time admitting an error or asking for help thinking they are actually protecting themselves. Thus, psychological help is necessary and important [19,20].
Becoming a physicians means doubting yourself and then trusting yourself, believing in what you have learned, and continuing to discover new lessons, not worrying about moving forward, reaffirming yourself professionally and personally, without losing the focus that tomorrow will be better than today.
The study has limitations because this is the only hospital working with disclosure in the region, and it was not possible to extend the scope of the study and compare it with other health institutions within a same culture. The cases were provided by the institution itself, and the rate of physician's refusal to participate in the research was extremely high, which shows a need to better structure the disclosure process with emotional support for physicians, and not only technical and legal support. All participants were male and it is a gender bias and including female participants is important to extend the scope as well.
We believe that even though the disclosure process does not have clear goals and needs adjustments, it is innovative and it is being employed in the institution we studied. This is a breakthrough for the general community in the country.
We expect new health institutions and training schools will be able to develop the practice of disclosure and that this becomes customary, as it can improve medical practices in the country and train a more humanized professional focused on the quality of the patient care, always paying attention to the emotional aspects of the physicians involved in error situations. Therefore, it is recommended that new studies assess the implementation and development of new disclosure programs worldwide.
Grants 2015/09289-9 and 2016/23681-1, Sao Paulo Research Foundation (FAPESP).