Naveed Saleh, MD, MS | January 10, 2022
Every healthcare provider strives to help patients by the most compassionate and effective means possible. However, mistakes are inevitable. Distressing outcomes can occur for patients, and errors can lead to legal problems.
Even when coming clean and making restitution, however, one consequence is usually guilt. Unfortunately, coping with guilt is challenging for many providers, with no easy answers, but a few available options can help.
The guilt that physicians feel when making mistakes may be rooted in the culture of medical practice, said June Tangney, PhD, professor of psychology at George Mason University, in an interview with MDLinx.
“Physicians are in a real bind compared with other professions,” said Tangney. “They are trained to be experts and present themselves as having the answer. They are forced into a certain lack of humility. Being wrong [in medicine] has very different implications than it does in science research.”
She continued, “There’s a more general sense in our society that somehow medical personnel shouldn’t make mistakes like the rest of humanity, and somebody has to be blamed.”
Tangney compared mistakes made in the medical field with pilot or airplane error in the case of a plane crash. With plane crashes, every shred of evidence is brought to the table as efficiently as possible to obviate any future disasters. Something similar should be done in the medical field. If a mistake is made, transparency is widely regarded as the best strategy.
Tangey recommends the Michigan Model, which is also promoted by the AMA.
The Michigan Model entails four steps. First, report early and assess adverse events. Second, explain everything in full to patients and family members. Third, provide emotional support to healthcare professionals involved. Fourth, apologize and compensate when the hospital is culpable.
“Let’s try to call them when we see them,” Tangney said. “We need to figure out exactly what happened so the mistakes don’t happen again.”
Nevertheless, Tangney realizes that outside pressures, including those of litigation, can make it difficult to freely admit blame, which is an unfortunate consequence of an imperfect legal system.
In a system that can make it difficult to outright admit responsibility, providers must often come to terms with their own role in terrible outcomes. Therapy can help.
Before becoming the Vice Dean for Faculty and Administrative Affairs at the Penn State College of Medicine, Daniel Shapiro, PhD, authored a book titled Delivering Doctor Amelia (Penguin Random House), which describes the experiences he had while counseling a skilled obstetrician who made a life-altering medical mistake.
Shapiro also provided robust psychotherapy to physicians who were named in malpractice litigation on behalf of the defense counsel. Because it is usually safest to require defendant physicians to avoid discussing their cases after being named in a suit, many of these physicians were barred from seeking advice from colleagues and family. Consequently, counseling sessions were the only safe place to discuss guilt.
“Physicians have a wide range of responses to complicated and difficult outcomes related to their work, and their own roles in bad outcomes,” he said in an interview with MDLinx. “One-third were deeply devastated, one-third were largely unaffected, and one-third were somewhere in between.”
He noted that reactions can be dynamic and change over time. “Some of these cases can drag on for years. Even a person who is calm now can have a variety of other responses to the same set of facts years later. You put it in context: Everyone makes mistakes. But, downstream, people can feel worse after having to revisit the same tragedies over time.”
“Unfortunately,” he said, “sometimes it’s the people who are most sensitive—the people we want to be our physicians and who care a lot and are deeply invested in their patients—who are the most vulnerable to feeling devastated and leaving medicine.”
Shapiro said the mainstay of grief counseling is usually cognitive behavioral therapy (CBT). This approach focuses on “thinking patterns related to their experiences.”
Although psychologists usually provide psychotherapy, some psychiatrists also play an active role in counseling. When medications are required, they are usually low-risk antidepressants that are prescribed by a primary care physician or psychiatrist.
According to Shapiro, outcomes are variable. “I think we were incredibly successful with a lot of physicians and nurses. There were some we couldn’t reach. They were devastated and felt completely responsible.”
Even with success stories, from which physicians can grow and learn from their mistakes, the experience never truly leaves some doctors.
“I don’t think the guilt is permanently gone,” opined Shapiro. “You realize that this is part of the human experience for those trying to heal others.”
One special case involves older physicians, such as surgeons, who have lost the skills necessary to perform their jobs. These skills include manual dexterity or eyesight. For these physicians, personal consequences can be tragic.
“It’s a minority, but some doctors leave medicine,” Shapiro said. “They do something that they’ve done literally for decades—they are experts at it—and then they are simply less capable of doing even simple versions of the case. It’s a different guilt, but it’s brutal. Facing your mortality, aging, and loss of identity. Most go through it quietly and privately and don’t talk about it much.“
1. The Michigan Model. University of Michigan.