Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Tuesday, May 27, 2008

Owning Up

The comment thread in a previous post of mine has been hijacked by a discussion about lying; doctors and pharmacists and patients all castigating each other over lying about whether or not med refills had been called in, left on voicemail, faxed over; whatever. Aside from the fact that this is a non-issue in my office, as we always do our best to respond promptly to all such requests, the discussion got me thinking.

We're not talking about big lies here; just little, face-saving ones, like when you forget to call in the script but tell the patient you did -- and then hang up and call it in right then. Or telling a patient that you tried to call them back and couldn't get through when in fact you just forgot. Or telling a patient that the nurse forgot to draw the blood when you only decided to do a test after the patient had left. Or that the file room lost the results when you just never got around to calling the patient back with them promptly.

Why do people do this? If they think they're doing it to avoid looking bad to their patients, then all I can say is that they are dead wrong!

Not only is lying wrong -- little ones as much as big ones -- but it makes you look like a jerk, completely defeating the purpose of saving face. Frankly, I'm shocked at how often I hear these kinds of transparent little lies from doctors (and their staffs, though as far as I'm concerned, it's the same thing) and I disapprove. Heartily.

And I never do it. I just don't. I don't mean that my staffers and I never make mistakes, but that we don't lie about it when we do. We own up to it; we apologize.

An apology has three parts:
  1. Acknowledgment that one has made a mistake,
  2. Expression of regret that the mistake was made, and
  3. Correcting the mistake as quickly as possible.
All three part are necessary. Here's why:

This is an "apology" without the acknowledgment:
I don't know what I did wrong, but whatever it is, I'm sorry.
What the hell does that mean?

Here's what it looks like without the regret:
Yeah, I know I forgot your birthday. I'll pick up a card on the way home.
That's not going to cut it.

Then there's this:
We forgot to call back with your results. Sorry about that.
So tell me about the freaking results already!

Offering a sincere apology, complete with all three parts, may seem complicated and time consuming, but it's not:

Patient: You never called in my refill.

You're right, we didn't. [acknowledgment]
I'm so sorry about the oversight. [regret]
We'll call it in right now. (Then do it!) [correction]
The first thing, of course, is to see that mistakes don't happen very often. If they do then you have far more of a problem on your hands than can be solved by mastering the form of the apology. There are other kinds of situations, though, for example when you research a patient's condition and change your mind about what you want to do (order a different test; prescribe a different med, etc.) that I see many physicians treating like "mistakes;" at least in terms of telling those little face-saving lies.

Once more, I claim that any approach that includes lying will backfire.

I once heard a doctor try to convince a patient that they had discussed performing an MRI during an office visit, when in fact the doctor had decided it wasn't necessary at the time, but had later changed his mind. I found myself squirming, listening to him try to get the patient to believe she was mistaken about what had transpired during the visit. Although he probably thought he was saving face by making the patient think he couldn't possibly have made a mistake, I know if I were that patient I would have hung up the phone and said, "What an asshole."

Here's what I do when this happens to me: I call the patient and I say, "I looked this up," or "I called another doctor about your case and he suggested I do something different," or "I thought about it some more," or even "I changed my mind," and then explain what I want to do differently from what we'd discussed in the office. Guess what: no one has ever thought less of me as a result of receiving that call. Here's why: admitting when you're wrong (or when you change your mind) enhances your credibility for when you're right; hopefully the vast majority of the rest of the time.

There's a lot to be said for owning up.


At Tue May 27, 07:35:00 AM, Blogger MedStudentGod (MSG) said...

Sound advice. Most patients already believe that docs are lying to them. Owning up to making mistakes rather than trying to cover them up would disarm many.

At Tue May 27, 10:01:00 AM, Blogger Cindy said...

Because I read your blog almost every day I could not resist tagging you with meme. Cheers, Cindy

At Tue May 27, 10:37:00 AM, Blogger Radioactive Tori said...

This also applies to husbands who try to apologize for things by simply saying "I'm sorry" in an annoyed tone. Not that I have any experience with that.

This was a great post. I guess I lucked out because my doctors rarely make mistakes, but when they do, they fix it and apologize right away.

At Tue May 27, 12:46:00 PM, Blogger Christopher Boondoc said...

Good article. I try to always give patients enough refills to make it to their next visit. If they have run out, they are probably overdue. It's probably best not to get into the habit of always calling in refills because either the doctor or the patient have not handled this responsibly. This also leads to confusion.

At Tue May 27, 02:43:00 PM, Blogger Doc said...

Wow. New here, so just catching up. That was some rant, and commentary. This post is slightly more genteel.

Your method of owning up also reduces the likelihood of being sued.

I do love the refill requests I get from one of my local pharmacies that are always sent on the "second request" paperwork, regardless of first, second, or tenth request.

At Tue May 27, 05:44:00 PM, Anonymous Anonymous said...

As a new GP, I often dither about tests. I discuss with others. I change my mind. Once I decide for good, I call the patient and put in the paperwork.

They seem to like it, they know I've thought things out.

At Tue May 27, 06:03:00 PM, Anonymous Anonymous said...

Wow, I'm glad I didn't bother to keep reading the discussion on the other post. What a waste of time.


Telling these little white lies to save face almost always ends up biting you in the ass later on. It's better to be uncomfortable for ~5 seconds when you apologize for something boneheaded than to tell a little white lie to save face, because sooner or later you are going to be called out in a big way, and end up looking (and feeling) like a complete douchebag -- and rightfully so. And this karma has a way rearing its head at the worst possible time: in front of a bunch of people, in front of your boss, in front of a group of patients, or all of the above.

I am fortunate to work with people who think and act as I do, and I don't know if I could work in a different kind of environment. Today, as a matter of fact, I chastised an intern who told me he was going to tell one of those little white lies to a patient when they came in to cover a relatively insignificant error he had made. (He had misplaced an Rx, and couldn't find it after looking everywhere.) That's the kind of behavior that should be stomped out early in training, if for no other reason than it's counterproductive in every conceivable way. (Building and maintaining trust, wasting time later on, ill feelings engendered, etc.) It amounted to procrastination at its very worst.

We called the office and had a duplicate faxed over 2 minutes later. Much easier than continuing to look and then lying to patient when the search proved fruitless. He still has a long way to go, but there's a lot of promise if we can file these idiotic rough edges off.

At Tue May 27, 06:48:00 PM, Blogger jmb said...

You are so right about this, Dino and it is something I have practised all my life but you have articulated so well.

Will Dino's three rules of apologizing be joining the three rules of blogging in the sidebar?

At Tue May 27, 07:12:00 PM, Blogger #1 Dinosaur said...

jmb: Thanks for the kind words. They're not my rules, though; I learned them in synagogue one Yom Kippur many years ago. I think Dr. Phil probably espouses them as well.

At Tue May 27, 08:26:00 PM, Anonymous Anonymous said...

Bravo! Great post! After 13 years in the non profit industry, I am starting a job as an office coordinator for a doctor. One of my biggest frustrations regarding the interaction between the patient and the staff is the lack of integrity. I have found that people appreciate the truth - and are often more understanding when we admit our own shortcomings!

At Wed May 28, 07:06:00 PM, Blogger Ian Furst said...

great advice. I like to think i do it all the time and am sure that I don't. Now ask me how often I get shit on by referring practitiones for telling the truth. Ms. X has surgery then develops some minor complication/problem. Gee Ms. X, sorry about you're luck to be honest that's not very common but I'll help you get through it. Not really an apology but an acknowledgment of the problem and solution. Only to get a call telling me I shouldn't be so "open" with the patients. "Act like it's a normal & everyday thing", blah, blah. If I wouldn't want to hear the BS from someone caring for me why would i tell it to one of my patients?

At Wed May 28, 09:32:00 PM, Blogger Dr Mike said...

Excellent post. And I really can't add anything. Except that Ian Furst points out an interesting counterpoint/difficulty when you are a part of a team of providers (post cardiac surgery perhaps) who have varyiung ideas about how honest to be both to the patient and in the chart/record. Can be hard to say who has or hasn't had a perioperative MI, but even harder to admit you didn't remember to call in 100% of the prescriptions they needed to go home on.

Honesty is truly the best policy, even if it means eating a little crow along the way. Can definitely prevent a law suit or two as far as I'm concerned.

At Thu May 29, 01:11:00 AM, Anonymous Anonymous said...

You forgot the most often used non-apology, "I'm sorry you feel that way". That has to be my least favorite line in the world.

In a medical setting that might be appropriate, as in "I'm sorry you're feeling ill. Let's try to figure out what's going on". But usually (not referring to medical contexts like the one above), it's used to say, "You're upset and I'm not going to admit that I did something to make you upset. Instead I'll give you a condescending line that expresses no regret at all".

At Thu May 29, 12:04:00 PM, Anonymous Anonymous said...

Many Thanks for your post. As a nursing student, I have seen doctors make errors in communication to a patient. Rather than owning the mistake this doctor in particular tried to convince the patient that he had said something different and thus, the patient became exceptionally dissatisfied with her care and became extremely needy to the nursing staff. OH HURRAY! That is not to say that nurses and pharmacists don’t make mistakes in communication as well, we do. What I have learned so far in the hospital about mistakes is, if a mistake is not personally accounted for by the person who has made the error, we all have to quell the storm of negativity that is to come. YEAH!

All I really want to say is this: The last time I checked innate and humoral immunity does not protect us from error. We all make mistakes and a zero-sum approach to those mistakes only promotes negativity and distrust in the patients. Be accountable for your actions. Your character is priceless and it seems silly to sell it for a white lie or a little mistake.

- Ginger

At Sat May 31, 03:53:00 AM, Blogger Steve_Roberts said...

It's not just in medicine, but in life, lies create and sustain evil, and evil needs lies to survive. In a way the little lies are worse than the big ones, because they show that some people are prepared to sacrifice their integrity for next to nothing.

At Thu Jun 05, 09:13:00 PM, Blogger webhill said...

Dino, that is such an awesome post. I have to say, you are really lucky to have such a fabulous patient population that you are able to be so open with them and you don't get harassed in return. Because seriously, while I too strive never to NEED to make such a call in the first place, of course I do occasionally err, or change my mind - and more often than not, the client is a jerk about it. I'll say "Hi Mrs. Jones, listen, I am really sorry but although I said originally I didn't want to do any bloodwork, I was so worried about Fluffy that I went ahead and contacted Dr. Big Important Expert, and he sent me some newly obtained and as-yet-unpublished information, and I've decided Fluffy might have Yada Yada syndrome, which is diagnosed by serological assay. I need to get some blood from Fluffy to confirm the diagnosis and then we can start treatment, which I'm happy to say should cure her." Then I get in return "What do you mean I need to bring Fluffy in for a blood draw? I was just there. I don't have time for this. Are you going to pay my salary for the extra half-day off?" It is enough to make me crazy.


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