SORRY might seem to be the hardest word but for doctors it shouldn’t be. The Scottish Public Services Ombudsman (SPSO), the Parliamentary and Health Service Ombudsman, the NHS Litigation Authority and the General Medical Council all advise on when and how doctors should apologise. The language they use is unsurprisingly formal. I wonder, though, how much resonance their advice has with doctors on the frontline in the UK today. For me the questions surrounding the importance of sometimes saying sorry are simple: what sort of doctors do we want to be and how do we want our patients to perceive us?
What complainants want
When something goes wrong or patients think something has gone wrong they want to know that their doctor still cares and understands their concerns. They want honesty and responsibility. They want to know someone is prepared to vindicate their understanding of the error and ensure the same thing will not happen again. That is not to say that we should accept blame when the error is not ours but, even in a no-fault situation, patients still expect their doctor to empathise. My hope is that doctors in the UK care about their patients (especially when things go wrong), always act with integrity and have the professionalism to shoulder blame when it is theirs to take.
It would be naive to think this is always the case. Indeed some evidence suggests that doctors avoid apologising up to 75 per cent of the time. Mindful of scandals like Mid Staffordshire, I find it worrying that as a profession we keep these barriers up. Doctors have traditionally been the most trusted individuals in their communities. The approach to mistakes – and acknowledging those mistakes with an apology – by some of our profession runs the risk of ruining this.
Former SPSO Professor Alice Brown has said: “Particularly in the health service, there is a resistance to saying sorry when things have gone wrong. That is a great barrier.”
There are many reasons for this resistance. An overriding concern is that by apologising you may be admitting liability. Section 2 of the Compensation Act 2006 (an act of the UK Parliament) says: “an apology, an offer of treatment or other redress, shall not of itself amount to an admission of negligence or breach of statutory duty”.
This particular section only applies in England and Wales. My understanding is that the law on this point is likely to be regarded similarly in Scotland. The proposed Apologies (Scotland) Bill – now under consideration by the Scottish Parliament – covers similar territory and includes protection against admissions of liability.
No such thing as perfect
There are, of course, cultural barriers to making an apology, particularly in the medical world. The elitist and macho culture that is at times present in our hospitals and surgeries has always puzzled me. If the reason for being a doctor is to help people (as we all said when trying to get into medical school), why do we maintain the culture of always having to be right? Why do we find it so difficult admitting mistakes?
Psychiatrist Aaron Lazare, author of the book On Apology, wrote: “We tend to view apologies as a sign of a weak character. But in fact they require great strength.
“Despite its importance apologising is antithetical to the ever-persuasive values of winning, success and perfection. The successful apology requires empathy and the security and strength to admit fault, failure and weakness. But we are so busy winning that we can’t concede our own mistakes.”
No doubt this will resonate with many medical professionals. So can we learn to be more rational about acknowledging mistakes?
When it looks like things have gone wrong, correctly interpreting what has happened is important for both sides. Complainants are often unable to differentiate between poor service and negligence, and doctors often don’t distinguish between making a mistake and being negligent. We all make mistakes. They are an inevitable part of being human, especially when practising a high-risk profession like medicine.
Doctors do not get sued (successfully) for making mistakes – they get sued for being negligent. So if you have made a mistake, own up. Be honest and say sorry. It won’t do any harm and it may do a lot of good (apart from being the right thing to do). Doctors do sometimes get sued for practising below an acceptable standard of care – if that substandard care results in harm to a patient for whom we have a duty of care. Remember that if you have been negligent, evidence has shown that a heartfelt apology can reduce the likelihood of legal action – but some form of intervention may be inevitable no matter what you do. To my mind that is fair enough.
Apology – a reasonable response
While many doctors have good communication skills and make appropriate apologies, I think there needs to be a cultural change within the UK medical fraternity for apologies to be more widely accepted. One change that may help is teaching our undergraduates the importance of being able to recognise their mistakes and say sorry for them.
As well as working as a GP, I am a medical adviser to the SPSO. The vast majority of complaints that are escalated to the SPSO, having failed to be resolved at a local level, would in my opinion never come to us if the doctors involved had sat back and tried to see things from the complainant’s point of view. If we could allow our defences to drop and consider our patient’s position I am convinced the number of complaints being referred to the SPSO would reduce.
We understand that having a complaint sent to the ombudsman is stressful for doctors. The ombudsman uses the standard of reasonableness – what would we have expected a reasonable doctor to do? The ombudsman’s medical advisers all work in the NHS and have good insight into the different perceptions doctors and patients have. If an adviser finds that a doctor has acted reasonably they will tell the complaints reviewer this, and often the complaint will not be upheld.
A genuine apology when a mistake has happened is usually thought to be part of acting reasonably. To have not apologised properly will, at times, weigh the case against the doctor. Making a proper apology is a frequent recommendation from the ombudsman. If this has already been done then the ombudsman may feel there is nothing to be achieved by investigating the complaint further.
In my opinion, until we change the perception of apology from an admission of failure that may ruin our reputation to a sign of professional and emotional strength, we will still see patients pursuing complaints and legal actions that would never have happened had the doctor just said sorry and meant it. When a complaint comes in or a mistake is noticed, I would urge my colleagues to act with integrity and professionalism.
Take a deep breath and try to see both sides of the issue. If the patient has been upset or harmed, acknowledge this and let them know how genuinely sorry you are that they have suffered. If you can see that your actions have contributed to a mistake, acknowledge this and let the patient know you are genuinely sorry. Explain what happened and how you plan to ensure it does not happen again. I am convinced that this empathic and professional approach will be more likely to result in the hurt and anger around a complaint dissipating without further action being taken.
NHS Education for Scotland and the SPSO have developed an online module about apology. I recommend taking the 20 minutes required to work through it. It will leave you well informed about how to make an apology that your patient will appreciate.
Dr John Dudgeon is a GP and medical adviser with the Scottish Public Services Ombudsman