Med-mal suits don't hinder error disclosure, studies find.

Doctors aren't disclosing medical errors as readily as patients would like, but medical malpractice litigation isn't the reason, according to two studies published in the Archives of Internal Medicine--the first to compare U.S. and Canadian doctors.

In Canada, malpractice cases are heard by a judge, not a jury; punitive damages are rare; pain and suffering damages are capped; and the loser pays the winner's legal fees. Yet, Canadian physicians are no more likely than U.S. doctors to disclose a serious error to a patient, the studies found.

"The external malpractice environment doesn't have the impact on doctors' attitudes about disclosure that we thought it did," said Thomas Gallagher, an associate professor at the University of Washington School of Medicine and one of the studies' authors.

One study identified the "culture of medicine" as a major factor in shaping attitudes toward disclosure. "What we mean by that is the way doctors are trained and socialized in the formal curriculum as well as what people call the 'hidden' curriculum," Gallagher said, "Doctors learn, for example, the importance of sharing information, but they also learn that sometimes sharing the whole truth can do more harm than good."

The findings come as no surprise to Jim Perdue Jr., a Houston attorney who handles medical malpractice cases. "Doctors often blame the lawyer and do not examine the conduct," he said. "There's a fundamental culture within the medical profession to avoid acknowledging mistakes, and that's unrelated to malpractice suits."

The study suggested that disclosure may actually reduce the likelihood of malpractice lawsuits and the size of jury awards. Although the literature is not clear on the issue, Gallagher said, anecdotal evidence suggests that disclosure could deter lawsuits because failure to disclose errors reduces patients' trust in physicians. "Many patients sue because they feel the truth was hidden from them," he said.

A second study examined whether practice specialty and the type of error affect physicians' statements about errors. It divided doctors into two groups, medical specialists and surgical specialists, and then gave each group two scenarios, an apparent medical error and a less apparent one. To answer five questions, physicians were asked to choose one of three scripted statements, which measured whether they would give patients full disclosure, partial, or none at all.

Looking at the two groups together, the study found that 56 percent of physicians surveyed chose statements that mentioned the adverse event but not the error, while 42 percent chose explicit statements that an error occurred.

In the apparent-error scenario for medical specialists, a physician's handwritten order for "10 U" of insulin was misinterpreted as "100 U," causing an insulin overdose in the patient that led to severe hypoglycemia. In the less-apparent-error scenario, the patient experienced a dangerously irregular heartbeat due to abnormally elevated levels of potassium in the blood (hyperkalemic dysrhythmia) because the doctor failed to check the patient's potassium level after starting a medicine known to cause hyperkalemia.

In the apparent-error scenario for surgeons, the surgeon inadvertently left a sponge in the patient's abdomen, requiting a second surgery to remove it. In the less-apparent-error scenario, the surgeon incorrectly used a new surgical tool during a laparoscopic cholecystectomy and injured the patient's common bile duct, which required an open procedure to repair.

The researchers concluded that the nature of the error affected disclosure: 51 percent of the physicians who received the more apparent error explicitly mentioned it, compared with 32 percent of those who received the less apparent one.

That study also found that a physician's specialty affected how readily he or she disclosed the error. Although the surgeons indicated that they thought a lawsuit was likely to stem from the error more often than the medical specialists did, they were more likely to report that they would definitely disclose the error. Yet, among those who would inform the patient of the error, surgeons disclosed less information--19 percent would use the word "error," compared with 58 percent of the medical specialists.

Previous studies in several countries suggest that doctors disclose as little as 30 percent of harmful errors to patients. Malpractice suits will continue to be patients' main recourse "as long as the medical profession institutionalizes protecting their own instead of acknowledging medical errors," Perdue said, citing the medical peer review system as an example of a mechanism "designed to create wall of silence around a known error."

The National Quality Forum, which articulates standards for medical practitioners, is expected to adopt a safe-practices doctrine on disclosure soon. Gallagher said he hopes his team's studies will help broaden the medical profession's focus on the problem of errors and encourage development of standards for disclosure. Focusing on malpractice litigation alone "keeps them from thinking creatively about solutions," he said.

The two studies--Choosing Your Words Carefully: How Physicians Would Disclose Harmful Medical Errors to Patients and U.S. and Canadian Physicians' Attitudes and Experiences Regarding Disclosing Errors to Patients--were published in the August 14/28 issue of the Archives of Internal Medicine. They are available online at http://archinte.ama-assn.org/ content/vol166/issue15/index.dtl (subscription required).