When to say “I’m sorry”

It’s been another long day at the office, and it’s about to get longer. As you sit down at your desk after discharging your last patient of the day, you review the diagnostic records produced for 12-year-old Susan. You completed early intervention for her a few years ago to close the diastemata between her maxillary incisors, per her parent’s request, and today’s progress films show over 50% root resorption of the maxillary lateral incisors. Your heart rate accelerates as you fumble through her chart for the original films. The films indicate that the contact between the lateral incisor apices and the crowns of the permanent canines might have contributed to the severe resorption. You reluctantly conclude that it was probably your treatment that led to the root loss.

Your treatment planning conference with the parents, who are prominent physicians, is scheduled in 1 week. Should you inform the family of the potentially iatrogenically-induced findings? If you suspect that the root resorption was caused by your treatment, would you consider apologizing to the family?

Many legal and ethical experts would concur that disclosure—informing the family of an unexpected treatment outcome—is an essential component of the ethical principle of veracity (truth-telling). But an apology is often ill-advised by malpractice insurance carriers. Yet, the issue deserves some attention from an ethical perspective—a perspective that has some strategic benefits.

A number of renowned academicians have perceived great merit in offering an apology when a patient has been harmed by treatment. Dr Lucian L. Leape of Harvard’s Medical School asserted that many lawsuits would involve significantly smaller settlements or might be eliminated altogether if the caregiver offered a sincere apology in cases of unfavorable outcome. He explained that patients expect someone to take responsibility for the occurrence and want to feel that future patients will be spared the same results. According to Dr Leape, an apology heals both parties in several ways, not the least of which are the following:

  • 1.

    It restores a patient’s self-respect by diminishing the humiliation commonly perceived by an injured patient.

  • 2.

    It reaffirms the trust between provider and patient.

  • 3.

    It assures the patient that he or she is not at fault for what happened.

  • 4.

    It provides confirmation for the patient that he or she is safe in the provider’s hands.

Professor Charles Vincent observed that injuries that are a consequence of therapy differ from other injuries. He stated that an injury from treatment is especially traumatic because patients are harmed by those whom they have trusted to help them and often continue to seek care from those same providers. Such factors invoke feelings of “fear, loss of trust, and isolation” in the patient. Vincent cited the consequences to the provider, including a complex sense of embarrassment, ego violation, confidence, and, most importantly, fear of legal retribution. Yet, he values an apology as a viable solution for all involved.

Psychological remuneration for the provider is another product of an apology. Beverly Engel, an author who has studied apologies and their benefits, stated, “While an apology cannot undo harmful past actions, if done sincerely and effectively, it can undo the negative effects of those actions.”

Will an apology increase a provider’s vulnerability in a malpractice suit? Law professors Sciatta and Hodge asserted that “apologies by physicians result in a decrease in the monetary losses that would result from litigating a malpractice claim.” They cited studies from many states in which apologies resulted in more timely settlements and decreased financial remuneration for the injured party. For example, several hospitals in Virginia that have enacted “I’m sorry” policies have seen settlements in medical malpractice cases reduced dramatically. “I’m sorry” policies involve investigation of untoward occurrences, offers of financial retribution, and apologies when appropriate. Thirty-four states and the District of Columbia have legislated apology laws that exclude an apology as admissible evidence during malpractice trials in an effort to encourage physician apologies.

How do you handle your problem of the severe root resorption in young Susan? Disclosure is imperative. Prompt discussion with your malpractice carrier is certainly indicated. From this practitioner’s perspective, an apology and remediation might certainly be viable options when communicating with her parents.

The author is grateful to Dr James T. Rule for his review of this article.

Apr 8, 2017 | Posted by in Orthodontics | Comments Off on When to say “I’m sorry”
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