Medical Errors: Is honesty ever optional?

Most doctors say they tell patients about their mistakes. But they also practice "defensive medicine" to protect themselves.

By Berkeley Rice
Senior Editor

Would you inform a patient if you made a mistake that caused an injury or might have an adverse impact on a patient's health? A staggering 94 percent of the physicians who responded to our ethics survey answered a resounding Yes—regardless of their age, gender, specialty, location, or practice size.

That candor is right in line with the AMA's Code of Medical Ethics. "It is a fundamental ethical requirement that a physician should at all times deal honestly and openly with patients," the code states. Even if a patient "suffers significant medical complications that may have resulted from the physician's mistake or judgment, . . . the physician is ethically required to inform the patient of all the facts necessary to ensure understanding of what has occurred. . . . Concern regarding legal liability which might result following truthful disclosure should not affect the physician's honesty with a patient."

While our respondents' hearty endorsement of honesty is admirable, some skeptics maintain that it's easier to brag about virtue on a survey than to actually be forthright with patients—especially in cases involving serious injury. One patient-safety advocate, when informed of our survey results, scoffed: "It flies in the face of what I believe. I doubt that most doctors would really tell."

Be that as it may, many doctors in our survey did confess to errors such as prescribing the wrong medicine or dosage, or giving the wrong immunization. Some admitted to misinterpreting X-ray or lab reports, or missing a lump during a routine breast exam. Others told of accidentally perforating a colon, eardrum, or bladder.

One mistakenly gave a patient a double dose of a narcotic. "We informed him, and observed him for ill effects," says the doctor. "Fortunately, there were none." Roger Willis, a family physician in Texas, recalls a similar error: "I'd given a patient an antibiotic in the ER. It wasn't until I was writing my notes that I saw in her chart that she was allergic to the drug. I informed the family and told them to watch for allergic symptoms."

Several physicians remembered blowing a diagnosis. A pediatrician in Ohio remembers the morning he saw a child with "what I thought was a viral illness. Later that day, her mother took her to the ER with what turned out to be an obstruction. I called the mother in the hospital to tell her she'd done the right thing, and apologized for having missed the diagnosis. She appreciated the call."

A California FP misdiagnosed a patient who came in with severe gastritis and arm pain. "A week later, they discovered that the arm pain was caused by an MI that I'd missed. After bypass surgery, the patient returned, and we discussed my error." An FP in Michigan recalls the worst kind of mistake—one that led indirectly to a child's death. "We informed the parents about the error. Being upfront about it probably avoided a lawsuit."

Based on such experiences, most doctors concluded that honesty is the best policy. "It's better to be upfront about a mistake," says Nancy Cooley, an ob/gyn in Minnesota. "It always comes out eventually, and dishonesty only causes more damage." Another doctor, echoing the same sentiment, adds, "I'd want them to hear it from me first." Says a third: "I may not call it a mistake, but I'll definitely tell the patient." "If the injuries are small and correctable, the patient will be on your side to help correct them," notes a fourth.

Roger Tyson, a family practitioner in Washington state, says, "I create a covenant with my patients: If we're going to do the best we can, we must expect absolute honesty of each other." Another respondent comments, "My patients have always appreciated my honesty, and usually say the mistake was understandable." Finally, as one cardiologist points out, "Honesty decreases the chance of being sued, and besides, it's the right thing to do. In the long run, you can live with yourself."

Some physicians doubt the wisdom of total honesty. "It's probably the right thing to do," writes one internist, "but it's no obligation." Another hedges: "It depends on the circumstances." "Not unless specifically questioned by the patient," writes one GP. An FP agrees with the policy of honesty, but cautions, "I'd be very careful about how I phrase my statements."

Randall Weyrich, a Louisiana plastic surgeon, can testify to the value of that warning. "I told one patient's family about an intraoperative complication that occurred, and what course of action I was taking. Although there was no permanent damage, she still filed a suit."

Several doctors cite the risk of litigation as grounds for caution when discussing medical errors. "I might say that something wrong occurred," says one internist, "but I wouldn't admit I'd made a mistake." Another writes: "No one is perfect. In this litigious climate, the punishment often is more egregious than the error." A cardiologist says he definitely wouldn't tell, explaining, "There are too many lawyers in Florida."

No harm, no foul?

The AMA's code of ethics doesn't clearly distinguish between situations involving real injury to the patient and those that pose no threat. Several physicians did, however. As one puts it, "Yes, I'd tell the patient if the mistake was truly significant, but not if it's trivial." Another writes: "If it caused no harm, I probably wouldn't disclose it, so as not to jeopardize the therapeutic alliance."

To see how many doctors make such distinctions, we also asked, "Would you tell the patient if the mistake didn't cause a serious problem and probably wouldn't be otherwise discovered?" In this less-threatening hypothetical situation, two-thirds of the respondents said they'd tell the patient anyway. As with the first question, the responses varied little by age, gender, location, and size of practice. Among specialties, however, ob/gyns were more likely to confess such minor mistakes, while FPs and GPs were less likely to.

How does the fear of litigation affect the way doctors practice? To find out, we asked: "Do you engage in 'defensive medicine,' such as ordering tests or seeking consultations, to protect yourself legally rather than because you think they'll be clinically useful to the patient?" Two-thirds of our respondents say they engage in such defensive techniques.

The responses varied considerably by specialty, age, size of practice, and geography. Internists, cardiologists, and ob/gyns are apparently more likely to engage in defensive medicine, and pediatricians are notably less likely to. Perhaps because they're less secure or more fearful of being sued, doctors under 45 are more likely to take defensive steps than their older colleagues, who might be more sure of themselves. Soloists, who may be more independent by nature, are less likely to take defensive measures than those in groups of 10 or more. Doctors practicing in the Midwest seem more likely to than those in the Eastern states.

Doctors' tendency to practice defensive medicine certainly isn't new. In a survey we conducted in 1987, for example, 43 per cent of the doctors said they had changed the way they practice in order to reduce the threat of a suit. And in our 1999 malpractice survey, 76 percent of those who responded admitted practicing defensive medicine. (See "Once burned, twice defensive," July 26, 1999.)

But the apparent growth of defensive medicine has caused considerable concern as well as debate. Over the past decade, estimates of the cost of unnecessary tests, medication, and procedures have ranged from $5 billion to more than $25 billion a year. A government report concluded that the subject of defensive medicine was so open to conjecture that it's too difficult to accurately calculate its cost.

Doctors who say they don't engage in defensive medicine insist it's simply not necessary. John Andino, an FP in New York, says, "I always tell the patient up front what I'm doing, or plan to do, and I try to order only tests that are meaningful." And a Pennsylvania cardiologist says: "This defensive strategy is rarely necessary if the physician is knowledgeable."

"I'll certainly cover my tail"

For most doctors, however, defensive medicine seems to have become a routine part of medical practice. It typically means ordering extra lab tests, X-rays, prophylactic antibiotics, CT scans for minor head injuries, and MRIs for back pain.

One doctor orders X-rays of an ankle "that's almost certainly just a sprain." An internist says, "I'll order colonoscopies for minimal GI bleeding to rule out cancer." Another internist admits, "I'll order an MRI for a headache even if there's less than 1 percent chance of a brain tumor." Says an ob/gyn: "I'll always order mammograms for any lumps, and ultrasounds for any pelvic pain." An Illinois GP says, "If a patient wants an unnecessary ECG or X-ray, I'll usually oblige. It keeps good faith."

Katherine Fisher, an Oregon internist, sometimes gets an MRI of the head, back, or knee "when I could probably wait and see if it improves." Debra Burns, a pediatrician in Texas, writes: "I'll occasionally use a screening lab test to prove to the patient that I'm not missing anything." Richard Chiang, a cardiologist in California, says, "I often order a treadmill test for a patient with chest pain, even though the symptoms aren't consistent with angina."

Many doctors report that they often refer patients to specialists as a form of defensive medicine. One routinely orders cardiac consults for anyone with chest pain. Another gets consults for "any patient who's really sick, to spread the burden and the risk." Some doctors are also happy to give a referral just because the patient wants one—and that may be reason enough. A North Carolina pediatrician orders a consult "if the parents are very concerned, and don't seem satisfied with the answers I give them." Roger Willis, a family practitioner in Texas, says, "Sometimes, if a patient feels a certain test is necessary, there may be a good reason for it. I've found several brain tumors that way."

The risk of a malpractice suit is clearly another powerful motivator. Many doctors say they're more likely to order extra tests or consults if the patient is angry, demanding, or possibly litigious. As one FP writes, "In the current environment, what you don't do may come back to haunt you." An internist adds, "Especially in accident cases, where litigation is almost a given, I'll order imaging studies." Thomas Layman, an Iowa cardiologist, says, "If the family seems aggressive or argumentative, I'll certainly cover my tail."

Some doctors who order extra tests and consults see nothing wrong with the practice. "I don't call it 'defensive medicine,' " says a Kansas ob/gyn. "I call it being thorough. And besides, it's what people want." An FP in Oregon insists, "It's just part of good practice: recognizing the possibility that maybe I'm not right." John Corsi, a solo internist in Rhode Island, says, "In this day and age, if you don't do it, you're either stupid or conceited."

Berkeley Rice. Medical Errors: Is honesty ever optional?.

Medical Economics

2002;19:63.