Apology in medical practice: an emerging clinical skill.

THE IDEA THAT PHYSICIANS SHOULD MAKE FULL DISclosure of medical errors to their patients has grown in importance since the late 1980s and early 1990s. This movement gained momentum following the 1999 Institute of Medicine report, To Err Is Human, an indepth study of the extent of medical errors, and the 2001 Safety Standards of the Joint Commission on Accreditation of Healthcare Organizations on disclosure of patient harm. As physicians were encouraged to disclose medical errors, offering an apology would inevitably seem to be the next step. What sense would it make to admit harm without acknowledging responsibility, offering explanations, expressing remorse, and discussing reparations—all parts of an apology? Without such offerings, most patients in response to such disclosures would more likely be offended than soothed. Although the goals of policies regarding disclosure and apology were to enhance patient safety and fulfill an ethical commitment of honesty to patients, an outcome unexpected by many was a reduction in the number and cost of malpractice claims. Such findings have been widely published in newspapers, popular magazines, law journals and nonrefereed medical magazines. A Web site, The Sorry Works! Coalition, which is committed to finding a solution to medical malpractice by “educating and helping all stakeholders understand the value of doctors apologizing for medical errors,” received more than 400 000 hits in its first year, 2005. Some institutions that pioneered disclosure of medical errors, often with accompanying apologies, include the Veterans Administration Medical Center of Lexington, Kentucky, the University of Michigan Health System in Ann Arbor, the Children’s Hospitals and Clinics of Minnesota, The Dana Farber Cancer Institute in Boston, Massachusetts, and Johns Hopkins Hospital in Baltimore, Maryland. Since 2003, 4 states have passed legislation that would make physicians’ apologies, including admissions of fault, inadmissible in malpractice suits, and this inadmissibility law often included other health professionals. Such legislation, it was hoped, would encourage physicians to apologize more freely. Other states, beginning in 1986, passed alternative inadmissibility laws allowing physicians to express benevolent gestures, such as caring, regret, and consolation, but not admitting fault. Taft, an apology advocate, has offered an eloquent moral and psychological critique of the “inadmissibility” laws. Although an apology is a significant part of the dialogue between physician and patient following disclosure of a medical error, there are few, if any, systematic studies or comprehensive discussions of the apology process in medical practice, despite the burgeoning literature on apology in the behavioral sciences. My interest in apologies began in 1993. During the 13 years since then, I have analyzed the apology process by studying more than 2000 nonmedical private and public apologies, mostly from US and other English-language newspapers and famous historical apologies, apologies in novels, and personal stories offered by friends and colleagues. Based on these studies, I have proposed a conceptual framework for analyzing apologies. This commentary presents an overview of this framework in the belief that it is relevant to all apologies, regardless of context, and in the hope of encouraging dialogue between medical risk management experts and behavioral scientists, 2 groups who often approach apologies from different but complementary perspectives.