Full disclosure of harmful errors to patients, including a statement
of regret, an explanation, acceptance of responsibility and commitment
to prevent recurrences, has been the standard for physicians in the
United States for nearly a decade.
While most primary care physicians would provide some information
about a medical error, only a minority would fully disclose important
information about potentially harmful medical errors to patients, suggests a new
‘Majority of primary care physicians would not fully disclose a harmful medical error, providing only a limited or no apology, limited or no explanation and limited or no information about the cause.’
Most of the nearly 300 primary care physicians would provide only
partial disclosure of a medical error for two hypothetical cases
involving cancer diagnoses they were asked to evaluate. Most would offer
only a limited or no apology, limited or no explanation and limited or
no information about the cause. The researchers report disclosure by
physicians in this study falls short of patient expectations and
national guidelines. The findings are published in the journal BMJ Quality and Safety
The purpose of this study was to examine the extent to which primary
care physicians' perceptions of event-level, physician-level and
organization-level factors influence their intent to disclose a medical
error in challenging situations. The strongest predictors of disclosure
were perceived personal responsibility, perceived seriousness of the
event and perceived value of patient-centered communication.
"The intent to disclose was not as frequent as we thought it might
be," said Dr. Douglas Roblin, professor in the Division of Health
Management and Policy in the School of Public Health at Georgia State
University and researcher at the Center for Clinical and Outcomes
Research at Kaiser Permanente Georgia. "The two vignettes gave pretty
consistent findings. The majority would not fully disclose, and we were
hoping for full disclosure because that is the ethical expectation."
Researchers said there is
evidence that effective disclosure often doesn't occur. An absent or
poor response by clinicians can make a bad situation much worse, while
full disclosure could lessen the negative impact. Understanding the
factors affecting providers' tendency to disclose is important to
developing effective interventions to improve physician-patient
Participants in this study were primary care physicians from three
integrated healthcare delivery systems in Washington, Massachusetts and
Georgia, which were part of the HMO Cancer Research Network's Cancer
Communication Research Center. A total of 333 primary care physicians
out of 630 responded to the survey.
The majority of respondents (71%) had been in practice for
more than 10 years, over half (55.6%) indicated they often
questioned whether the demand of their practice was worth the toll and
over a third (36.7%) often thought about leaving practice.
In the vignettes, physicians were asked to evaluate two difficult,
but realistic, hypothetical cases:
1) a delayed diagnosis of breast
2) a care coordination breakdown that caused a delayed
response to patient symptoms. Both cases involved oncology diagnoses and
multiple physicians sharing responsibility for the error.
Each vignette was followed by four questions asking what the
physician would be likely to say with respect to an apology, an
explanation, information about the cause of the event and plans for
preventing recurrences. Physicians could choose from non-disclosure,
partial disclosure and full disclosure responses.
Participants also assessed event-level, physician-level and
organization-level factors for each vignette. Event-level factors
include personal responsibility for the event, beliefs about the
seriousness of the event and predictions as to whether the patient would
file a lawsuit as a result of the event. Physician-level factors
include the value placed on patient-centered communication,
self-efficacy with respect to communication and feelings about practice.
Organization-level factors include perceived support for communication
and time constraints.
The study found the majority of respondents would not fully disclose
a harmful medical error in either vignette situation, providing only a
limited or no apology, limited or no explanation and limited or no
information about the cause. When asked what they would tell the patient
about the cause of the error, 77% of physicians for the case
involving delayed diagnosis of cancer and 58 percent of physicians for
the case involving a care coordination breakdown would offer either no
information or make vague references to miscommunications. In both
cases, more than half would not volunteer an apology or would offer only
a vague expression of regret.
Physicians would be more forthcoming in the care coordination
breakdown compared to the delayed cancer diagnosis, but most would
provide only partial disclosure after either of the events.
The researchers conclude that in order to make meaningful progress
toward improving disclosure, physicians, risk managers, organizational
leaders, professional organizations and accreditation bodies need to
understand the factors that influence disclosure. This insight, which
could be achieved by using vignette-based surveys, is necessary to
update institutional policies and provider training.