Practice Disclosure Cases for Missed Cancer Diagnoses
Two weeks ago we published a column concerning a recent survey that showed that 58 percent to 77 percent of physicians would not fully disclose missed cancer diagnoses to patients/families. See below. Our blog post was widely read, and the survey has been covered extensively by the medical/legal trade media. So, how can staff be trained to handle a potential missed cancer diagnosis? Whether it's a potential miss within a practice or somehow a diagnosis slipped through the cracks of a hospital or other large system?
Answer: Talk about these cases, and practice!
I remember doing a disclosure training seminar for a large northern hospital system a couple years ago, and one of the cases we practiced with their leaders went something like this....a female patient, who had a Pap smear six months prior that raised concerns with her physician, visits the same physician for an unrelated issue, and during the visit the physician asks the following question: "So, did you follow up with the specialist regarding your Pap smear?" The patient, dumbfounded, asks, "What specialist? Why would I need to see a specialist? Was something wrong with the Pap smear?!?"
So, now what do you say?
Some clinicians will want to run out of the room at this point. Others will try to quickly change the subject, or minimize the situation: "Oh, you know, it's nothing important...er...uh....every so often, we encourage our patients to see a specialist as part of a random, double-check process...you know, random double-check?! Well, the fact you didn't go is no big deal...don't worry about it. You know, nothing to worry about at all. Now, let's get back to the reason for your visit today!"
Liar, liar pants on fire!
However, despite the fact it is easy for the physician to assume that his/her office did not inform the patient about the questionable Pap smear, and, oh my God, cancer may have gone unchecked for six months, etc, there is a possibility the office staff did do everything possible to inform the patient and/or the patient simply did not follow through with the specialist appointment. Patients and families make mistakes too!
In the heat of the moment, you don't know...so, what do you do? This is a real struggle for most clinicians and they often run away, lie, or minimize because most have not been trained how to handle such scenarios -- but they desperately need this training!
At Sorry Works! we recommend the following for this type of case:
1) Sit down -- show good body language
2) Say you are sorry for this alarming situation..."I am sorry this is very alarming and upsetting for you." This is empathy, not apology.
3) Show the questionable Pap smear test to the patient, and answer all questions in a truthful fashion, including, "I don't know, but let me find out and get back to you."
4) Tell the patient you are going to move Heaven and Earth to get her seen by the specialist ASAP -- and then do it.
5) Promise the patient you and your office staff will conduct a thorough review to understand what happened, and you will promise to report back at a specific date/time (no less than a week).
6) Meet the immediate emotional needs of the patient -- comfort her, help her make phone calls, make sure she can get home safely, etc.
Make sure the review is conducted in a quick and honest fashion, and report back the findings to the patient, whatever they maybe, including we didn't get the information to you OR we did provide the information and here's the proof we did.
In my travels, there was another case where a cancer diagnosis was delayed for four (4) years with fatal consequences because of a system problem in the hospital. The way the physicians and hospital leadership handled this tragic case was amazing -- click here to read the story and see the video. This is a great case to share with your colleagues.
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originally published November 29 -- Survey Shows Majority of Physicians Would Not Disclose Missed Cancer Diagnoses
A recent published survey of 300+ physicians faced with two hypothetical missed or delayed cancer diagnoses revealed that the majority of primary care physicians would not disclose relevant information to patients/families or apologize. Somewhere between 77 percent to 58 percent of the respondent physicians offered little to no information or apology when faced with the scenarios, according to the study funded by the National Cancer Institute.
Now, if we want to be optimistic, we can rightly say that 10+ years ago the same survey would have probably yielded much drearier results -- I would guess 90 to 95 percent of physicians prior to the disclosure movement would have offered no information or apology. So, some progress has been made, but the authors of the study, led by researchers at Georgia State University and Kaiser Permanente Georgia, indicated they were expecting better numbers.
Here is a link for a news report on the study.
There were many factors and variables reviewed in the study, and the authors conclude by suggesting that risk, claims, and legal professionals need to understand why so many physicians (and other healthcare professionals) are reluctant to disclose information about potential errors with patients and families.
At Sorry Works!, we have a bunch of anecdotal evidence that explains the numbers seen in this study....our information comes from 11+ years of teaching disclosure and apology to clinicians in the field. Here is our take on what is happening:
1) Not enough clinicians were taught disclosure and apology in school. Some universities are adopting disclosure curriculum, but more work needs to be done in this area. Disclosure, apology and the broader issues or communication, customer service, relationships, etc are timeless issues that every student needs to understand before being turned loose in a clinical setting. Moreover, these topics should be part of required coursework...not optional lectures or elective seminars.
2) Not enough CME/CE programs are teaching (or reinforcing) disclosure principles. We have advocated in the past that disclosure/crisis communication principles should be mandated in the continuing medical education requirements for clinicians. Every doc or nurse will encounter multiple adverse events and angry patients/families in their careers, and clinicians need to understand how to handle these situations -- which means training and continual reinforcement.
3) There are not enough formal disclosure and apology programs within hospitals, insurers, and long-term care facilities. Disclosure is a scary topic, and clinicians need support and help...and this means formal programs with workable disclosure policies, the involvement of leadership and staff, and adequate promotion to continually reinforce the disclosure culture.
The bottom line is we have a lot more work to do in the disclosure movement.
A good tool to help clinicians understand how to properly address adverse events is the Little Book of Empathy. Priced from $9.99 to $4 per copy, the Little Book of Empathy is an economical and quick read that helps clinicians understand their role in the disclosure process. Click here to order your copies today.