The encounter between patient and doctor is often characterised by lack of time, and the art of communication can be complex. Sometimes things go wrong.
The Medical Ethics Council regularly receives complaints from patients that have had an unsatisfactory encounter with a doctor. Often this is related to a feeling of not having been treated with respect, either because the doctor has not taken enough time to listen or because he/she was perceived as being insensitive or arrogant. Complaints of this nature are dealt with in accordance with Chapter 1: General provisions section 2 of the Code of Ethics for Doctors, which states the following about the encounter between patient and doctor: ‘Patients must be treated with care and respect’ (1).
The Medical Ethics Council does not carry out investigations. Complaints are elucidated by means of contradiction, i.e. by each of the parties in the case presenting their version of events. If only the patient and the doctor were present during the consultation in question, they will usually have different views about what happened and how things were said; they will remember the situation differently. There will be allegations and counter allegations, and the Council may be unable to reach a decision on whether a breach of the Code of Ethics has taken place or not. Nevertheless, in many cases it is clear that there has been a breakdown in communication between doctor and patient. It is also evident that the entire procedure can boil down to a single small but crucial word: ‘Sorry’.
The word ‘Sorry’ can have a magical impact when said by the right person at the right time (2). Not only is the word important to the person to whom it is said, but also to the person who says it. Saying sorry means admitting fault and taking responsibility for an incident or situation. In addition, an apology will legitimise and demonstrate respect for the feelings of the offended party. The experience will give the person apologising greater insight and self-knowledge. Saying sorry eases the burden of a bad conscience, it clears the air and allows both parties to put the incident behind them and move on.
The Council’s experience from previous cases shows that, conversely, the absence of an apology can have adverse effects. At worst it is detrimental to the doctor-patient relationship and the patient’s trust in the health service going forward. The same applies to silence and evasion.
If an apology is to have the desired effect, however, it must be made unconditionally. The person saying sorry must mean it. Unfortunately, the Council for Medical Ethics has seen a number of examples of the opposite: non-apologies made by unrepentant doctors. Such apologies, where the doctor clearly does not take responsibility for the occurrence of an unfortunate incident or conversation, can sometimes make matters worse. The conflict escalates, hurt feelings deepen and the whole thing ends up in a complaint to a higher level, for example the chief county medical officer.
If an apology is to have any value for the patient, the doctor must treat the patient’s hurt feelings seriously, not ridicule them. The following is an anonymised example. An elderly man made a complaint about a general practice specialist because of unacceptable behaviour during a consultation. The background was that the patient had been waiting for a long time because the doctor had been held up. When the patient came in, he felt that the doctor was stressed and had little interest in what he had to say. The patient said to the doctor that he had been waiting for a long time whereupon the doctor replied abruptly and told him to get to the point instead of complaining about how long he had had to wait. The rest of the consultation was unpleasant for the patient, and he returned home without having been able to say what was on his mind, namely that his brother had recently been diagnosed with cancer and that he was afraid that he might also be stricken by the same disease.
It is easy to see this case from the viewpoint of both parties. The patient is frustrated by the long wait and feels that the doctor is uninterested. As if that were not enough, he is reprimanded by the doctor for commenting on the delay. The doctor for his/her part has had a busy day and is attempting to ensure that the waiting time does not increase further for other patients so tries to speed up the consultation and explodes when the patient uses valuable consultation time to complain about the delay. All in all, it is easy to understand that there was a breakdown in communication in this encounter between patient and doctor.
That brings us to the patient’s complaint. The doctor states in reply to the complaint, ‘I’m sorry if the patient thought I was arrogant’. Here is the seed for new rounds of contradiction between doctor and patient. The doctor’s use of the word ‘if’ functions as a major reservation. It appears as if the doctor really believes there is nothing to apologise for. If you are going to apologise for something, you must do so unreservedly, otherwise it is not an apology. The doctor must make a choice. If the doctor thinks the whole thing is a storm in a teacup or that the patient him/herself is to blame for the breakdown in communication, it is more honest to refrain from apologising. On the other hand, if the doctor feels responsible for having set the tone of the consultation or acknowledges that he/she was short-tempered that day and in fact replied abruptly or arrogantly, which is both human and understandable, and decides to apologise, the apology should be made for example by saying, ‘I apologise for being so abrupt with you during the consultation’. This then shows that he/she has reflected on the incident and reached the conclusion that it is the doctor and not the patient who bears greatest responsibility for the communication in a consultation. The doctor takes responsibility and apologises in a proper manner. In the example given above, he/she might just as well have said, ‘I didn’t do anything wrong, but if you absolutely must have an apology I can give you one, but I don’t mean it.’
When doctors make mistakes
There are many more serious examples of inadequate apologies: cases where mistakes made by the health services have led to injury or death without the doctors responsible and other health personnel apologising. Such incidents make a strong impression and create distance between patients and their families on the one hand and health personnel on the other.
People are not stupid. They understand that doctors are people, that to err is human, and that doctors and other health personnel sometimes make mistakes, also mistakes with a fatal outcome. And most next of kin can accept a lot. However, non-disclosure, secrecy and poor excuses are difficult to accept and can make loss and the grieving process even harder.
Why is it so difficult to apologise? Partly because it is not normally one doctor or one nurse who alone bears responsibility for a serious incident such as an unexpected death. Who was actually at fault when the routines failed? Who should really say ‘Sorry’ – the senior consultant, the hospital director or the doctor on duty when the incident in question took place? Another reason why apologies are difficult to make is that we are trained not to make mistakes. We have too little training in taking the blame. Put simply, we lack a culture for saying to a colleague who has made a serious mistake, ‘It could just as well have been me. I hope this doesn’t mean that you are considering giving up your job as a doctor. Making mistakes is unfortunately part of the job, even though we do everything we can to avoid it’.
Sometimes patients die unexpectedly without it being anyone’s fault, without any errors having been made, for example because the patient had a paradoxical reaction to a medication, medical procedure or operation. It may be difficult for the next of kin to understand and accept this. In such cases, the general public’s expectations of medicine in general may play a role. We should preferably be able to cure the patient regardless. In such cases it is not an apology that is needed but empathy. The doctor must set aside time, sit down with the next of kin and give a detailed and lucid explanation of what happened and why. It is then easier for the next of kin to move on.
Openness and clarity are prerequisites for good communication. So obvious, and so important.