When Doctors Apologize to Their Patients: The Role of Language Access, Cultural Awareness, and Implicit Bias

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Mistakes happen. That is an axiom of life in general. But in health care, admitting medical mistakes can seem to be counter intuitive, leaving health care providers open to court decisions that they have admitted liability for negligence, malpractice, or deviations from the accepted standard of medical care.

However, there is considerable opinion within health care that genuine admissions of error can be part of the healing process when families are faced with the life-changing consequences of medical error.

According to a recent article by Dr. Diane Solomon in Medpage Today:

“Medical “wisdom” covertly, or overtly, says apologizing to a patient (or colleague, for that matter) — any admission of wrongdoing — leaves one open to a lawsuit. Beyond that, it admits imperfection, something we are not allowed or supposed to be in healthcare. Period.

Wrong. Wrong, wrong, wrong, wrong, wrong.

There is incredible power in apologizing. Counter-intuitively, apologizing holds more power than defensiveness. We open and offer our true selves. It takes strength to let our humanity meet another’s in an admission of error. If you don’t believe me, see how anxious you feel the first time you try it (it gets easier over time)…

Becoming a healthcare provider indoctrinated me further into defending myself. I have never been sued, but I’ve made plenty of mistakes. I started in obstetrics. One patient lost 21-week-old twins due to “cervical insufficiency” that I might have diagnosed if I’d not been in a rush in clinic. It still would have likely been too late to prevent a bad outcome, and she went on to deliver a term baby in a subsequent pregnancy, but that still stings. In psychiatry, I’ve snapped at patients in less-than-my-best moments, or felt I let them down for not anticipating incipient depression or hypo/mania. I’ve wondered what I could have done better when they ended up in a higher level of care, or in the ED.

In “healthcare school,” no one explicitly barks at us, “Never apologize!” But we see colleagues and mentors covering for their mistakes, or for those of other colleagues.

“Yes, we definitely did the best we could with what we knew at the time. Knowing what we know now is hindsight, and probably wouldn’t have made any difference for your…”

Dr. Solomon runs a private psychiatry practice in Portland, Oregon, and is assistant professor at the Oregon Health & Sciences University School of Nursing

While there is a strong argument in favor of the potential psychic, healing, and emotional benefits of a true medical apology for malpractice or medical negligence, the medical apology must not be regarded as a one size fits all answer.

There is a significant power dynamic in the health care relationship between doctor and patient. Many people are reluctant to question medical decisions and to second-guess their doctors who are often respected members of the local community. Add to these factors myriad issues of gender, race, and cultural mores and one can readily see how a medical apology is more complicated than just the act of contrition.

Examining how a medical apology must be culturally appropriate for specific patients and families for the apology to have its desired beneficial effect is necessary before beginning the process. In addition, understanding how implicit biases influence medical decision-making is similarly important before facing a family that has suffered a loss because of medical error.

“Unconscious or implicit bias refers to attitudes or stereotypes about certain groups (eg, women, racial minorities, LGBTQþ people) that affect understanding, actions, and decisions unconsciously…

Sex and racial biases, in particular unconscious ones, often         manifest in the form of microaggressions. Microaggressions were originally described n the context of theories of race and racism, as “subtle, stunning, often automatic, and non-verbal exchanges which are ‘put downs’ of blacks” and other minorities. “Micro” refers not to insignificance of these exchanges, but rather to their being “commonplace, daily exchanges.” Although the term “aggression” may seem harsh, it is important to understand its application within the context of intent and influence. Although a comment may not be intended to offend or cause harm, this does not change its effect on the receiving party.

The importance of taking responsibility for the result of a statement, even when the intent is positive, is effectively illustrated through the lens of medical error… Although the physician’s intent was to help the patient, harm resulted nonetheless, and the physician should understand his or her role in preventing future recurrences.”

Addressing the Elephant in the Room: Microaggressions in Medicine

Melanie F. Molina, MD; Adaira I. Landry, MD, MEd; Anita N. Chary, MD, PhD; Sherri-Ann M. Burnett-Bowie, MD, MPH: American College of Emergency Physicians, 2020

In addition, what if the patient and/or family members are limited English proficient or deaf? How do the medical providers account for English language proficiency? Have they arranged for fully competent, bilingual, and legally compliant language access BEFORE beginning the medical error apology process?

If such arrangements are not fully in place, the physicians’ apology will literally fall on deaf ears and worsen an already fraught, painful, and possibly tragic situation.

To achieve the goals of a genuine medical apology, language access, communication, and cultural factors must be fully accounted for before the type of apology described below by Dr. Solomon can actually occur. Otherwise, an already bad situation will inexorably become much worse and indescribably more painful.

As Dr. Solomon writes:

“But a true apology? An admission of responsibility, acknowledgment of how we hurt another, and a concrete pledge to repair? Ah, there is a gift. An unexpected and disarming gift to both giver and receiver. In this age of burnout, true professional connection with patients creates gratification and meaning in healthcare. Rather than being an open door to a lawsuit, you’ll find it defuses anger and recrimination. Because it’s deeply felt by both humans.

When I have apologized — to a child, a friend, a patient — the room goes still. The other person pauses. If we are in conflict, everything suddenly softens around the edges. It’s rare and lovely. The other person seems almost stunned, but then grateful. We are two humans, one admitting we make mistakes, the other knowing they do too.

What a relief to admit: even healthcare providers are not immune, not perfect. After an apology, the room seems to sigh, the apology receiver often saying little. Only an honest, calmer, grateful, “Thank you.”


© Bruce L. Adelson 2022. All Rights Reserved The material herein is educational and informational only.  No legal advice is intended or conveyed.

Bruce L. Adelson, Esq., is nationally recognized for his compliance expertise.  Mr. Adelson is a former U.S Department of Justice Civil Rights Division Senior Trial Attorney.  Mr. Adelson is a faculty member at the Georgetown University School of Medicine and University of Pittsburgh School of Law where he teaches organizational culture, implicit bias, cultural and civil rights awareness.

Mr. Adelson’s blogs are a Bromberg exclusive.

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