Medical errors are a leading cause of death in the United States, with some research suggesting that errors can cause as many 250,000 fatalities each year. The medical community has made strides to normalize and encourage error disclosure for physicians and medical trainees in order to improve patient safety and health care outcomes, but these guidelines fall short when it comes to addressing the social psychology that influences how and when physicians and medical trainees disclose errors and how they manage the consequences of those errors.
In a paper published this month in Medical Education authors Neha Vapiwala, MD, an associate professor of Radiation Oncology and vice chair of Education in the Perelman School of Medicine at the University of Pennsylvania and Jason Han, a fourth-year student in the Perelman School of Medicine, call for better education and training focused on the psychological challenges that coincide with errors and error disclosure in order to improve outcomes and reduce the number and severity of medical errors.
"We must transform the culture of error disclosure in the medical community from one that is often punitive to one that is restorative and supportive," Vapiwala said. "And to do that, we must tend to the psychological challenges that medical professionals wrestle with when they face the possibility of disclosing an error."
Initiatives such as the Disclosure, Apology, and Offer model have helped make moderate gains in creating a culture of transparency in health systems, but these efforts primarily focus on the legal and financial aspects of error disclosure and do not address other barriers, such as the fear, shame, and guilt that come with error disclosure.
"Arguably, these psychological factors are harder to overcome, especially in this modern age of social media where health care providers can be reviewed and scrutinized in very public forums," Vapiwala said. "There is real concern that any little slip-up can live on the internet for the rest of someone's career."
The authors identified two main cognitive biases that often hinder error disclosure: Fundamental Attribution Error (FAE), which is the tendency overestimate one's own role in a situation, and Forecasting Error (FE), the tendency to overestimate impact and duration of negative consequences while underestimating the ability to recover from those circumstances.
For example, if an error led to a patient injury, the physician might initially overstate his own role in that error rather than examine any systematic reasons for why that error occurred. Secondly, he may then also overestimate the long-term consequences or recovery time for that patient, leading to feelings of both self-blame and exaggerated doom, both of which damage the physician-patient relationship and may impede a care provider from reporting the error.
"Overcoming these biases is akin to suppressing a reflex. It requires self-awareness, practice, and most importantly, education and training," Vapiwala said.
Looking at other fields that have high-stake consequences when an error occurs, such as the airline industry, the authors offer several strategies to overcome these patterns of thought, utilizing elements of social psychology to transform the current culture of error disclosure. Recommendations include incorporating standardized patients (SPs), actors who simulate patients, not only to "practice" difficult patient encounters, but also to help model interactions with family members, peers, and administrators in order to teach various behavior and coping mechanisms. SPs have been proven to effectively mimic the psychosocial elements of error disclosure, including profound guilt, feelings of ineptitude, and fear of repercussions.
Virtual reality (VR) is another tool that can offer immersive and realistic technology to supplement traditional curricula, while also offering tremendous scalability at a lower cost than SPs. The authors cite an example of a recent VR exercise which allowed viewers to experience the perspective of a 12-year Syrian refugee to incite more compassion and understanding. While VR medical content doesn't currently exist, it is on the horizon for many medical trainees and professions.
However, both SP and VR do have limitations, as the users ultimately know that the scenario is simulated. "Standardized patients and other simulated scenarios provide an excellent foundation, but until you are put into a real-world situation and forced to confront your mistake and its potential consequences, you can't truly understand the psychosocial challenges," Han said.
Finally, the authors recommend implementing a professional standard for trainees, including a formal evaluation of the skills needed to disclose and cope with medical errors. This standard would further normalize error disclosure and make it a common practice among physicians and trainees.
The authors conclude that the primary change will need to be cultural, not just among trainees, but at every level of medical practice, in order to successfully pivot away from the current stigma related to error disclosure.
"Administrators must make a shift from asking 'who is at fault' to asking 'why' and 'how' did a situation occur, creating a culture that embraces error disclosure and seeks to solve the many systematic factors that lead to an error in the first place. This approach will not only normalize error disclosures but also help us better understand why they happen so we can prevent more of them in the future," Vapiwala said.
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