Five steps towards a heartfelt apology – the kind that will begin the healing process with friends, patients, and colleagues alike.
We all make mistakes. No doc in the ED has a golden stethoscope that prevents medical errors (and if anyone is funding a start-up for such a product, please count me in). We, as physicians, don’t walk on water, don’t have the patience of Gandhi or the eloquence of Shakespeare. When all pistons are firing, we are extraordinarily good doctors in spite of our stressful jobs. Shift after shift we multi-task ourselves cross-eyed. On really brutal days, we grow cold with the shadow of decision fatigue. Ultimately, we are all human; fallible, and imperfect. With our patients (or, nowadays, “clients”), coworkers, family, spouses or friends we will, on occasion (drum roll please)…inadvertently say or do something wrong.
There is mounting evidence that sincere apologies decrease the anger of patients and families hurt by medical errors. Decreasing the anger relieves the desire to punish the doctor by proceeding to a lawsuit. Plaintiffs commonly voice that they sued specifically because they felt the doctor didn’t care or learn from their mistake. (If there is increased concern for legal action it is wise to consult your legal department before taking full responsibility for a preventable medical error.)
A minor processing error, omission, or surface mistake will often be forgiven with a simple (and honest), “I’m sorry”. However, a more thoughtful apology is required to move a relationship forward if the mistake you made inflicted physical or emotional pain. It is a humbling experience to truly apologize so the persons in our lives feel our regret and, hopefully, start to forgive. Do the introspection. Search your soul. Does this family member I’m speaking to really feel the weight I carry due to my medical error? Does my child understand I really didn’t mean to crush his joy? Will my wife hear my apology so I can reconnect with her?
These instances could be successfully remedied by following five steps. You want to apologize carefully, thoughtfully and honestly. It is going to be a long conversation. Frankly, it is going to be hard work! Apologize in a private place where you can be present and uninterrupted. It helps if you keep this list. Write these five steps down and practice. Answer these questions for yourself before presenting your thoughts. You may be surprised how difficult it is to articulate what you really want to say, but we are all very good students. With practice, sincere apologies will get easier.
How to Apologize in Five Steps
1. Acknowledge the harm you caused. Quite plainly, own it; all of it. Recognize your fault and verbalize it. There are no caveats or exceptions. Be specific. Address the elephant – there should be no confusion about what the apology is for. Leave out the pronouns and be clear. Saying ‘What I did was wrong’ is not enough. But saying, “’I thought ‘No way are you having a heart attack at age 33 with pain that’s worse with movement. I was so wrong and have delayed treating you correctly for the past two hours’” is on point and meaningful. If you follow step one correctly, you are summarizing the hurt and pain felt by the other person and your delivery cannot get lost in translation. Note to self: Do not apologize yet!
2. Recognize the consequences. List them out loud, in detail to the person you hurt. Make the list complete to the best of your ability. You may have damaged the relationship, inflicted physical pain or maybe you ruined an experience that was supposed to be wonderful. There are a number of topics that are in heavy rotation. To a patient you might say, “Mr. Brooke, I caused you prolonged physical pain by missing your tibia fracture. This will prevent you from working for a long time and you are probably concerned about money. I can only imagine this is emotionally hard and difficult to process.” Mr. Brooke will get the sense that you get the sense of what he’s feeling in the moment. When we are wronged, we want to feel like our physical and emotional pain are understood. You are verbalizing the consequences of your actions, whether it be one or many. Note to self: Do not apologize yet!
3. Ask the other person if they have anything they want to add. Ooooooooh…if this step feels scary, it’s because it is. Once you summarize the consequences, there is always a chance you left out one or more details in your recap. You may think you got the big picture, but asking whether you did will ensure the person knows you did. Maybe they will say, “Nope, you said it all.” More than likely, there will be something missing from your run down and this is their chance to make sure your apology is all encompassing. Also, this is a stop gap for future rehashing when you thought everything was squashed. Asking your wife, “Is there anything else you’d like to add to my understanding?” makes it harder (and less likely) for your wife to say down the road “You apologized for A, B and C, but when it came to D…you never did say anything about D.” Ultimately, if your list isn’t complete, the apology isn’t complete. Sit on your hands and compel yourself to listen without interruption. Note to self: Do not apologize yet!
4. Promise to be dedicated to try and not repeat the mistake. Okay, that felt like a mouthful because it is a truthful promise. Promising to never repeat the same mistake again is not realistic. Trying your best to not repeat the same mistake is truthful. Be specific, but also, be honest. Telling your partner, “From now on I promise to try making decisions as a team” will feel more authentic than “I’ll ask your opinion on every single issue I ever encounter from now on.” Or to a patient, something like “We will work toward overhauling the system so a medication mistake like this does not happen again” will go farther than “I will never do it again.” Also, give the person permission to remind you of your promise if you begin to slip into old behaviors that led to the mistake in the first place. With small reminders, old dogs can learn new tricks. Note to self: Do not apologize yet!
5. Say I’m sorry. Here it is! Step five. Make eye contact, take a deep breath and repeat after me, “I am so sorry, and I hope at some point you’ll be able to forgive me.” Forgiveness is a whole different ballgame with its own set of rules. You said you’re sorry, but saying it with the expectation of immediate forgiveness is not part of the bargain. Maybe you will get it, or maybe the person needs time to process all you have said. Ultimately, giving the apology should be made solely for the other person, to heal the hurt, and not to exonerate ourselves from guilt. For a friend or loved one, a hug is a sincere added gesture.
Following these steps will foster more fulfilling relationships and life experiences. We should not apologize to simply get out of the doghouse. Ultimately, we want to apologize to heal the hurt; hurt bodies, hurt feelings, and hurt emotions. Our interpersonal relationships are what matter most during our short stay here on Earth. That we apologize does matter, but how we apologize truly heals.
These specific steps will go a long way towards helping physicians deal with our intrinsic apologophobia, as well as the fear of transparency and forthcomingness engendered upon us by risk managers.
I do have to add, though, that before apologizing to a patient who has had a potentially compensible event that you MUST consult with your malpractice carrier, risk manager, and or defense attorney. The consequences of apology said wrong in some states can spell the difference between coverage or non coverage, suit or non-suit, or win-or-loss.
I think one point worth mentioning here. We DO NOT directly cause harm. Any honorable, practicing physician that cares for his/her patients, does not directly cause harm. If patients get heart attacks, strokes, cancers, kidney failure, etc, many are direct consequences of their bad health choices in life. However, patients do get complication because of wrong or delayed diagnosis or treatment; and that’s when we can get better.