The Art of the Apology

Patient conversations following a life-changing diagnosis or medical error may prove challenging to unprepared radiologists.

As imaging continues to drive clinical diagnosis, it has become a source of medical errors. Most of these errors are attributable to radiologists’ interpretations — through missed, incorrect, or delayed diagnoses.1
 
In a recent interview with the ACR Bulletin, Stephen D. Brown, MD, associate professor of radiology and ethicist at Boston Children’s Hospital/Harvard Medical School, discussed what he sees as a growing need to train radiologists and their teams on how to communicate more confidently and compassionately with patients following an adverse event. Difficult patient conversations often call for disclosure of a mistake and an apology to patients and their families.
 

What type of training could help physicians facilitate patient conversations following a mistake?

You need training targeting high-risk, low-frequency events. Clinicians should practice in a controlled, mentored setting before having to engage in real-time under great stress. We’re all human, and apologies are hard — but they get easier for everyone when you’re prepared to be straightforward. Radiologists can gain much from this kind of training, especially since recognizing the need for compassionate error disclosure is relatively new. The ACGME is now recommending communications skill-building for trainees, particularly around adverse events. The fact is that all of us, even those of us in the field for a long time, can benefit from this training.
 

Why are frank and in-person talks critical in radiology?

Patients may never meet their radiologists, but evolving best practices suggest they should. You never want patients to find out about unfavorable findings or medical mistakes through an online portal. They should find out through direct, open, and honest communication. Furthermore, patients who feel like they have been dealt with openly and honestly may feel more positive about treatment and be less likely to litigate. Poor communication around errors can also generate substantial clinician distress. Conversely, good communication with patients after errors may help physicians heal themselves.
 

How can timely and thoughtful conversations contribute to a better patient experience?

First, patients get the information they need when they need it, so they can make the best and most timely decisions for themselves. If there are financial repercussions for a serious error, they can seek the compensation they need when they need it — not 10 years later. Many patients know that errors occur, and they may access their portals to read their reports. What if they read, for example, that a lesion was present earlier and nothing was done about it or it went undetected? They could lose trust and faith in the entire healthcare process. Open conversations when an error occurs can provide the emotional validation patients need to move forward.
 

How can apology and disclosure training help when treating underserved patient populations?

Certain populations have experienced significant healthcare disparities and may have legitimate historical and cultural distrust of the medical system. To empower them and validate their experience, open and honest communication offers the optimal path. If you hide something and a patient or family finds out later another way, you are likely to undermine their faith in care going forward — and to continue systemic inequities.
 

In radiology, what is the biggest challenge to disclosing errors and initiating an apology?

Although patients hope for and expect disclosure, there’s still a culture in radiology that underappreciates what the purpose is, what the thresholds are, and when disclosure is appropriate. Let’s say someone on your team makes a reasonable interpretation that turns out to be incorrect and leads to a delayed cancer diagnosis. You may encounter considerable debate and conflicting guidance over whether to disclose or discuss it with the family. As a specialty, we need a common framework for understanding what’s appropriate and what to do. There are workshops that provide the when, why, and how for having a conversation.
 

What’s available to radiologists interested in improving their disclosure and apology skills?

I direct my hospital’s Institute for Professionalism and Ethical Practice (IPEP), which works globally, training institutions, teams, and clinicians with a hands-on approach using unscripted simulation situations. For years, we’ve brought in actors trained in improvisation to stretch radiologists’ interpersonal skills. We have a day-long session, run by a variety of faculty members, to help improve the competence, confidence, and comfort of participants.
 
This spring, IPEP is launching a two-hour, online moderated radiology workshop focused on adverse results and error disclosure (learn more at ipepweb.org/workshops). This new course provides CME and is open to individuals and institutions. We hope offerings like this will provide the tools radiologists need to improve the patient experience — before finding themselves in an uncomfortable situation in which everyone in the room is upset.
ENDNOTE
1. Bruno, MH. Understanding and Confronting Our Mistakes: The Epidemiology of Error in Radiology and Strategies for Error Reduction. RadioGraphics. 35(6):1668–1676. Available at bit.ly/Understanding_RadErrors.
 
ACR Legal Disclaimer: Members should consult with a qualified lawyer in their jurisdiction before deciding to apologize or express sympathy to any patient.

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