Mitchell Goldstein, MD, MBA, CML, Mita Shah, MD, Munaf Kadri, MD, T. Allen Merritt, MD, MHA, Elba Fayard, MD

The title of this piece makes it sound too much like a legal ques- tion that involves patient care, but in this case, it is not. Instead, this situation can arise when a physician is accused of something, be it an action, inaction, failure, or mistake that subsequently turns out to be misstated or flat-out wrong (1). These instances are in- creasingly common even as we work to figure out ways to cast aside individualized blame and work towards systems improve- ment.

A medical director or division chair is typically involved in the “initial” encounter. In many situations, the “investigation” has concluded, and the accused is guilty until proven innocent. This supervisor may be incredulous that the accused has no recollection or a different recollection of the incident. The issue is often so compelling that the accused faces punishment or some action of compunction designed to remediate the deficiency. The wrong- fully accused’s hurt and perceived loss of face is almost too much to bear.

In many cases, there is a loss of trust, compassion, and a feeling of exile from the team dynamic. Indeed, the initial punitive response may involve separation from the institution or relegating the individual to a less prestigious position. If not, this individual is at high risk of leaving that institution in search of another position where they feel they can be treated fairly.

If there is a recognition by the leadership team of its error before this individual has left the institution or been relegated to a position from which they cannot recover (e.g., transferred or referred to another department or division), how does reconciliation take place? Indeed, the first step is an apology, but is this enough? A simple apology is never enough; it is merely a first step. Often, there has been such a significant trajectory change experienced by the accused that subsequent opportunities are kept from them based on a misunderstanding of the facts. Let us look at an example.

Suppose a programming or configuration error in the electronic health record was to prevent other physicians from seeing notes authored by a physician (2). In that case, it may be “reasonably” concluded that the physician in question is not preparing patient notes or making only minimal changes to the notes authored on a day-by-day basis. This information is passed on to nursing, the other physicians in the group, the practice’s medical director, and finally to the accused individual. The physician in question, the accused, is identified as a problem and is then “finally” made aware of the deficiency – days to months after the process has begun. What happens when it is determined that the notes were completed and updated but not visible to the accuser? The accuser indicates to the accused that the notes have been found but does not necessarily apologize. There is vindication, but the damage is done. Aside from the initial accuser, everyone believes the accused still has a problem with note writing. It may show up in evaluations, perceptions of this individual as a less than-careful physician, loss of leadership opportunities, and predilections to additional accusations in the future. When another issue occurs in the unit, the accused’s name will always rise to the top of the usual suspects.

Why is it that the apology cannot undo the accusation? It is because the apology was incomplete. No one knows that it occurred. Where accusations have a broad base and involve many individuals so that a pattern can be “identified,” apologies are generally very private affairs that involve a single accuser and the accused. The accuser may use particular language to avoid indemnifying their apology, such as, “This time you were not to blame,” “We will watch to make sure this issue does not occur again,” or “You should feel relieved that we have resolved this issue.” The accused still feels on edge, barely legitimized, but no one else knows that the issue has been resolved in favor of the accused. Everyone else involved in the initial accusation is still of the impression that the accused is guilty. Indeed, they may be of the impression that the accused “got off easy,” “was given another chance,” or “used influence” to avoid having to answer the initial concern. An apology is just the start of the process.

The team philosophy in QA/QI process improvement needs to find its position in the apology to the team member wrongly singled out for correction (3). As we should avoid blaming the individual in the first place and look for systemic problems that contribute to errors or omissions, we should look for team and system modalities of recognizing and alleviating the harm done to the individual. Everyone aware of the accusation must be made aware of the apology. Those who were complicit or complacent in the process must also apologize. There must be no equivocation or attempt to save face. The accusers were wrong. Further, depending on how the accusers handled the issue, they may be subject to discipline instead and, at the very least, required to read a manuscript like this one so that they understand the consequences of their actions (4).

References:

1. Wojcieszak D. Review of disclosure and apology literature: Gaps and needs. J Healthc Risk Manag. 2020 Jul;40(1):8- 16. doi: 10.1002/jhrm.21396. Epub 2020 Jan 7. PMID: 31909542.
2. Zhang EJ, Tan H, Sanford JA, Michelson JD, Waldschmidt BM, Tsai MH. Rebooting the Electronic Health Record. J Med Syst. 2022 Jun 7;46(7):48. doi: 10.1007/s10916-022-01834-y. PMID: 35670870.
3. Tigard DW. Taking the blame: appropriate responses to medical error. J Med Ethics. 2019 Feb;45(2):101-105. doi: 10.1136/medethics-2017-104687. Epub 2018 Nov 9. PMID: 30413557.
4. Roberts G. When punishment pays. PLoS One. 2013;8(3):e57378. doi: 10.1371/journal.pone.0057378. Epub 2013 Mar 6. PMID: 23483907; PMCID: PMC3590188.

Disclosure: The authors have no disclosures.