The statutory duty of candour has four components:
- Tell the patient (or where appropriate their representative or family) when something goes wrong that causes, or has the potential to cause, harm or distress;
- Apologise to the patient or their representative;
- Offer an appropriate remedy or support to put matters right, if that’s possible; and
- Explain fully the short-term and long-term effects of what has happened.1
But there is one aspect of the duty where there is still some uncertainty and confusion: the apology.
Outside of the professional relationship we rarely give the social courtesy of an apology a second thought. An accidental stumble into a fellow passenger on the tube will normally elicit an apology from both parties. When comforting a friend who has bad news we will commonly say how sorry we are. We could hardly imagine walking in late to a meeting and not apologising.
So far, so simple. But where an apology is perceived as being difficult to give freely is when the words “fault” or “blame” crop up. On the one hand it can be easy – if I accidentally tread on a stranger’s foot it is plainly my fault and an apology is natural and instinctive. Yet consider the situation where an argument with a friend has ended with much upset because of the depth of feelings on both sides. You may feel you have done nothing wrong, so an apology may seem so much more difficult; the words might stick in one’s craw. But it is still the right thing to do, even if it is not an instinctive reaction, because it is a process of reconciliation.
“An apology is not an expression of liability or an implicit acceptance of fault”
Let’s look at a couple of clinical scenarios to illustrate the tensions sometimes encountered in making an apology.
A broken suture needle
A 40-year old woman attended her GP for excision of a lipoma on her back. The GP, who was skilled and experienced in minor surgery, excised the lipoma without difficulty. The cavity was sufficiently large to require a couple of deep, interrupted sutures to close it. Unfortunately, the curved needle snapped when placing the second suture and took five minutes to locate as it was deeply embedded in the deeper tissues which needed further dissection. The patient was anxious about the additional “digging about” to locate the broken needle.
Whilst an in-patient on a medical ward, a 56-year old man had some blood taken for tests. The phlebotomist put a small adhesive dressing over the puncture wound. The following day the patient had an intense, red, itchy rash where the adhesive dressing had been in contact with the skin. Having reviewed the rash, the patient’s consultant concluded that it was almost certainly an allergic reaction to the dressing adhesive. However, on reviewing the clinical records there was a clear reference to the patient having an allergy to a specific brand of adhesive dressing.
Photo credit: Getty Images
In both scenarios something went wrong, and even though the harm caused was low the professional duty of candour would apply. Telling the patient what went wrong would be straightforward. But what about the apology? In the needle scenario, the doctor may well believe that there was no fault on his part – the technical execution of the surgery was exemplary. So why should he apologise? In the dermatitis scenario the harm, even though it might have been minor, was avoidable. Here the doctor may think that it is not for her to apologise – she did not make a mistake, the phlebotomist did, and in any event the patient should have mentioned an allergy when the dressing was applied, shouldn’t he?
The scenarios are both useful because they demonstrate a fairly typical information asymmetry that can exist in clinical interactions with patients. The patient who suffered a broken needle might have little knowledge of the possibility that a needle could break in the course of minor surgery. The patient with the adhesive dressing allergy might simply have thought that anyone applying a dressing was already aware of his allergy, and was using a type that would not cause a reaction. Addressing this information asymmetry is a great deal of what the professional duty of candour is about.
Regardless of cause, or fault, or blame, it is very likely that the patients in both scenarios would expect and appreciate an apology as well as an explanation. And this is the reason why an apology is so very useful when something goes wrong – it serves as an acknowledgement and demonstrates empathy. Conversely, failure to apologise may come across as aloof or defensive.
How to apologise
What you say when apologising should not be problematic. There is nothing wrong with a simple: “I am very sorry that this has happened”. An apology is not an expression of liability or an implicit acceptance of fault. The following general points may be helpful to bear in mind.
- Speak as you would in a natural conversation – in the first person. “I am very sorry that the needle broke” will sound more sincere and less defensive than “the practice wishes to express regret that the needle broke during surgery”.
- Set the scene. It will often help to explain (as fully as you can, bearing in mind that further investigation may be necessary) what exactly occurred. Once there is context, an apology can naturally flow.
- Think about privacy and body language. A consultant saying the right words, but standing at the end of the bed, towering over the patient with arms folded and surrounded by half-a-dozen colleagues may not seem like an apology at all. Take time – choose a quiet moment to speak to the patient with open body language with perhaps just one other colleague there.
- A meaningful apology is a dialogue. Saying sorry is part of a process, and it is important to ensure that patients or their representatives can ask questions. Sometimes patients would prefer not to hear from the person involved in the incident that went wrong; conversely, some patients may prefer to have the opportunity to meet the staff member. It’s important to be receptive to such wishes and to be prepared to respond to questions.
- Take one step at a time. Some doctors report being concerned that what they say in an apology may be harmful if there is a subsequent complaint or claim. The MDU’s experience is that the opposite tends to be true. The reasons patients make a complaint, or bring a claim, are complex but a culture of openness, with a sincere, timely apology may go some way to preventing them, or lead to an earlier resolution.
Discussions with patients after something has gone wrong can be challenging, but a starting point that understands that an apology will do more good than harm will help develop confidence and maintain the professional relationship. Every set of circumstances will have its own challenges, and if you are ever in doubt about what to say to a patient, or how to say it, speak to the MDU for advice.