The needles go under the skin, into a layer of fat. Three times per week, for over a decade, Shirley had taken one of the pre-filled syringes from her refrigerator and injected her thighs. Then I met her.
Doctors had given her a diagnosis of multiple sclerosis years earlier. The word crippled her. She’d stopped driving, stopped working, and adjusted to the stigma of having a chronic disease. She didn’t like shots, but “that’s life,” she said. She hadn’t had a flare since her initial diagnosis, and she was grateful for the time she’d enjoyed with grandchildren and great-grandchildren. I talked to her about her symptoms, encouraged her to stop smoking, and ordered more of the medication she’d been taking.
I saw her a second time five months later, after she suffered a rare reaction — anaphylaxis — from the medication I’d renewed. She had been admitted to the hospital, where another doctor had reviewed her history. She’d had an unusually benign course for someone with longstanding disease. The white spots on her brain scan, which we had thought were from multiple sclerosis, were probably from high blood pressure, high cholesterol or diabetes. Shirley might not have had multiple sclerosis at all.
Medical school teaches us to examine, to research, to treat. We don’t learn to err and recover. Nobody stands behind a podium and declares: “Each of you will make mistakes, and some of them will hurt people.” We don’t consider the unavoidable tension between human fallibility and the responsibility to care for people’s lives.
We do talk about errors. Medical departments across the country host “Morbidity and Mortality” conferences, where we scrutinize bad outcomes and “near-misses.” In response, we fix technology. We modify policies to make hospitals human-proof. We don’t talk about the emotional trauma of hurting a patient. Instead, most physicians cope with guilt, self-doubt and fear of litigation in private. After our patients, we become “second victims” of our mistakes.
Earlier this year, my own doctor missed a complication, twice telling me to stay home when I should have been seen.
“I know it wasn’t intentional, but I’m disappointed I wasn’t told to come in,” I said when I saw her.
“I can’t turn back time,” she said.
“I’m not asking you to turn back time,” I said. I recounted the calls I had made to her office and explained what could have been done differently. I described how the error affected me.
“I can’t turn back time,” she repeated.
In her office note, my doctor wrote “she is unhappy with her care.” In response to her mistake, my doctor had removed herself from our doctor-patient relationship.
Apologies are difficult for doctors, not only because we have to cope with hurting someone, but also because we are scared of the legal implications of admitting culpability. Early data suggested that apologizing for mistakes decreases malpractice costs, but recent research has called that into question. Although most states have laws preventing medical apologies from being admitted in court proceedings, statements of fault are still admissible in most places. We can say, “I’m sorry this happened,” but not “I’m sorry I did this to you.”
In countries like Sweden and New Zealand, physicians help patients request compensation after medical harm. The “no-fault” system is based on injury from medical care and not on proof of physician negligence. Cases are adjudicated by people with medical expertise, rather than by jurors. Money goes to patients and not to lawyers. In contrast to what happens in the United States, doctors and patients remain on the same side, and more patients get paid.
Pilot programs in some institutions are teaching medical students to practice apologizing to patients. Participants role-play with patient actors and discuss the nuances of error disclosure. Other training modules are more conservative, advising residents to discuss mistakes with patients, but not to apologize. “An apology is a statement of remorse, regret, and responsibility and essentially proves a case for medical negligence,” authors of one study write.
I saw Shirley again last month. I’d stopped her multiple sclerosis medications a year earlier, and she still had no signs of the disease. “I’m not sure I ever apologized to you,” I said. “I’m sorry.” I said I wished I had reconsidered her multiple sclerosis diagnosis when I first met her.
I spent the rest of the appointment hearing what it was like for Shirley to adjust to the possibility of not having a chronic disease. She talked about how her life had become limited when she believed she was sick. Now she wanted to do things again, but she felt out of practice.
We were back in a therapeutic relationship. She was my patient, and I was her human doctor.
Sara Manning Peskin is a writer and neurology resident at the University of Pennsylvania. She is currently working on a book about molecules that hijack the brain.
