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In a recent lecture to the European endoscopy community in Berlin, I described how the obligation to discharge the duty of candour was something we need to prepare young doctors for. I thought this was uncontroversial. The UK is unique in that the requirement to apologise after patients come to harm during medical care is not only a professional obligation, it is also a legal one. This means that if a patient is significantly harmed, either physically or mentally, and it later comes to light that there is no record of verbal and written apology, the hospital can be taken to court. This has already happened.
For the individual, that duty is another source of stress to deal with when they are reeling from the impact of having harmed a patient. In all of these discussions, it is necessary to remember that caring for the patient comes first, but the point of my talk was that if we do not prepare medical staff, they may come away damaged, despondent or disillusioned. This will help nobody.
In the question & answer session, somebody stood up and said there was no need for doctors to apologise. She explained that we are all doing our best, that accidents happen, that complications occur. So what is there to apologise about?
These are thoughts that I have had before, and this is an argument I have had to work through with colleagues. 10 years after candour became law, it is worth working through it again here. What is an apology for? Why bother?
We apologise when we have done something wrong. When we have said something hurtful, made a decision that has negative consequences for another, or involved somebody in an accident. When we make an apology, we put ourselves, morally speaking, below the person we are apologising to; metaphorically, we kneel and ask for forgiveness. An apology may be deep and prolonged, or it may be brief and cursory. The latter will be received as such, and may, if significant hurt was done, be judged as insincere. As described in a Harvard Business Review article The Elements of a Good Company Apology, ‘Too often, these statements come across as empty rhetoric — saying what’s expected without really meaning it, making excuses, or blaming others for what went wrong.’ In that case, the apology can do more harm than good, and will help neither the harmed individual, the organisation or the person delivering the message.
Apologies are founded on an acceptance, by the ‘perpetrator’, that they have done something wrong. It is here that the problem arises in healthcare. If you come to work with the best intentions, bringing your A-game, and with a degree of expertise that is commensurate with many years of training, and someone is hurt… did you do something wrong?
The answer is usually no. Bad things happen. So who owns the harm? If someone has been hurt, someone must be responsible. The most visible candidate is the surgeon, the endoscopist, the doctor who prescribed the wrong drug or failed to make the diagnosis. But if we are going to insulate them from blame, based on their good track record and the fact that they brought no malice into the hospital, we have to look elsewhere.
At this stage we begin to look to the department, the organisation, the system, the NHS as a whole. Most safety incidents are attributable to systemic failures, in the end. This is certainly the conclusion of many investigations. It is generally accepted that finding a single healthcare worker to take responsibility, to carry the blame, is not constructive, and will not actually lead to improvement. Scapegoating is out, system-wide learning is in.
If this is the case, then those who apologise to patients are doing it as representatives of the ‘system’. To me, this feels unsatisfactory, and may lead to a kind of remote, cold apology – rather like the ‘company apology’ referenced earlier. The alternative, that the doctor ‘owns’ the harm, may lead to a more heartfelt apology, but this comes with a risk – emotional exhaustion. As humans, apologies costs something. We need to prepare ourselves, consider the words we will use, anticipate the reaction and how to deal with it. These are skills that do not come naturally to all – after all, some people apologise more readily than others in everyday life. We have to take into account the spectrum or personalities when discussing this.
Hospitals count how many apologies they make, there are targets to meet, and the CQC looks for evidence that we are meeting those targets. Apology has become a performance metric. Yet, we have not achieved consistency. A recent study of medical students and their preparedness for candour, concluded that there was ‘a dire need for more frequent experiential training in the disclosure of medical errors’. Around half of 4th and 5th year students said that senior doctors ‘senior doctors seldom or never modelled patient-centred care in the clinical training setting’. Descriptive, real-world accounts from clinicians and patients/families are emerging, such as this one from a paediatric haemato-oncology unit in Scotland where preventable harm occurred from a waterborne infection.
Other studies show how varied are the thresholds for candour among clinicians and surgeons, such as this one from a neurosurgical unit. It found that individual surgeons were swayed by how common or rare complications were, with those occurring say 10% or more of the time, not requiring an apology even if harm resulted in long term disability or death. This demonstrates the principle voiced by my audience member – if things are occasionally ‘unavoidable’ (and a 10% risk of disability after certain brain surgeries would fall into this category), why are we bending over backwards to say sorry? Whatever the rights and the wrongs, we are not all doing the same; in medicine, variability is usually unwelcome.
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Based on personal experience, I believe the duty of candour succeeds in bringing doctors and patients into proximity after harm has occurred. It ensures clear and transparent explanations, and the ‘paperwork’ that follows go some way to assuring families that the incident is being taken seriously rather than being swiftly forgotten. Nevertheless, ten years after it became law, we are still trying to work out how to do it consistently and how to do it well. That’s how hard it is.
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