A guest post by Zackary Berger, MD

SorryWatchers must know by now the right way to apologize. I wish I could say the same about my colleagues, members of the medical profession. In their defense, though, and in my own, let me talk about what goes into the making of a health care mistake, why it might be hard to apologize, and how we (whether we’re doctors, nurses or patients) can make things better.

1. There are lots of decisions being made all the time. Most of them aren’t explictly labeled “decisions,” and often — because the people making them aren’t conscious of the decision-making they are doing — they aren’t based on the best available evidence.

2. Even when the doctor or nurse is explicitly making a health care decision,  it’s very likely that no one is asking you, the patient, what you think.

Both these things make mistakes more likely to happen. If you are doing things just because you’ve always done them — whether you’re the doctor, pharmacist, nurse, or receptionist — you’re more likely to get into the habit of action by rote rather than by thought, and you’re more likely to stumble on the way. For example, if I, the doctor, routinely decide to give people medication for mildly high blood pressure, even though there’s no strong evidence that these medicines help people who are otherwise healthy, I could cause real harm through these medicines. You might be elderly, get dizzy from hydrochlorothiazide and slip in the bathroom; you might get leg swelling from your amlodipine.

I’ve made mistakes like this, out of simple thoughtlessness, more than once. Ms. Harrington (not her real name), who had had a heart attack and a stroke in the late 1990s, came to me several months ago with terrible migraines. We successfully treated them with medications; I was sure she was not having a second major stroke because she had had a normal brain scan earlier this year.

But I got a rude shock in my inbox  just as I started writing up this post. To my surprise and guilt, I found out that Ms. Harrington was discharged yesterday from the hospital: she had come to the ER with two days of nausea and was diagnosed with a mild stroke. I never heard about this and she didn’t call me. What did I do wrong? I followed the treat-migraine script, lulled into a false sense of security by her recently normal scan, although I should have been more mindful, always keeping an open mind to the worst possible scenarios. I don’t know if her migraines were the harbinger of another mild stroke — in fact, they could have been unrelated — but it was a mistake not to consider the possibility. I wasn’t clear enough in my mind about the possible dangerous alternatives.

Even if the doctor is making a good decision, it might still be quite possible for mistakes to happen if you, the patient, aren’t included. First, if you’re not involved, or just not paying attention, it’s more likely for errors to slip by. You are the only person advocating only for you and no one else.

Second, without asking the patient what they think, the doctor will probably fail to take into account the person’s unique characteristics which might make the difference between an effective, well tolerated treatment…and the opposite. If you know you have low blood sugar, you don’t want to take a medicine that makes it even lower. If your throat closed up with a particular kind of antibiotic, you might want to avoid that in the hospital.

Then it happens: a doctor makes a mistake. Occasionally, though, that mistake is not really the fault of the individual doctor. Like the time I didn’t even know that Mr. Zhang had been admitted to the hospital (that would be the hospital I work at — it’s not like they don’t know where I am). His medications were changed around without anyone checking with me, and he came out completely confused with terrible blood pressure and low sugar and I couldn’t figure out why, to his family’s consternation. Oh, but I did get a fax two weeks after he was discharged. Hearing about it via fax was the crowning indignity; we must be the only profession that still uses them.

How does a doctor apologize for mistakes that are really to be laid at the feet of the entire health care system (“system defects” is the current term of art in patient safety)? Sure, there are errors that doctors make as individuals. And they should be apologized for in the ways you’ve read in this space: Be specific. Do not evade. Say what you did. Don’t obfuscate.

But what about the last step in this list: Avoiding such errors in the future? How is the mistake-making MD supposed to make things better? Part of it is the doctor’s responsibility, clearly: they need to step up their personal practice. Whatever they did should be a lesson to them. Maybe they need to consider a particular diagnosis earlier than they have been, or be more careful with a particular class of medications. Maybe their workflow, or information handoffs, need to be improved in their clinic or hospital. I should have widened my mental landscape for Ms. Harrington, and been more on top of Mr. Zhang’s whereabouts since his last visit.

It’s all very well for us, as patients, to tell doctors: Be smarter! Work harder! Screw up less! But patients need to step up too. We can no longer be passive so-called “consumers” of health care advice. It is up to us to build lasting, productive, and communicative relationships with health care providers. We need to be able to say that we have helped root out error from our health care system in our role as unique self-advocates. Then we can partner with doctors of the right kind. And the error-prone doctors, the ones who don’t listen? We can be sorry we listened to them.

And sometimes we patients have to apologize too. Just like people in general, patients can be obnoxious, manipulative and boundary-transgressing. It goes without saying that such behavior is well within the realm of necessary apologies. I think, though, that if we (as patients) shirk our necessary responsibilities to the health care partnership, we might need to say sorry as well.

I can’t help but mention one of my patients. The details are fictionalized but the story is true-to-life. Mr. G. is a 75 year old man with a passel of medical misfortunes that he manages to tolerate with good humor: bad diabetes, heart attacks, strokes, lupus. Sometimes, unfortunately, I suspect that his good humor is cover for a reluctance to discuss unpleasant realities. And so it was when he came to me last week, with abdominal pain that had lasted for a couple of weeks. Eventually, I ended up sending him to the hospital out of worry that he just wasn’t eating and drinking enough. And there, completely randomly, we found through a lab test that he had had a heart attack, which had affected the flow of blood to his abdomen. Hence the pain. “Oh,” he said to me, “I’ve been having some tightness here” — he pointed to his chest —  “over the past couple of weeks. I didn’t think it was a big deal. I didn’t want to make everybody worry.”

“Worrying is my job!” I told him. Doctors are supposed to listen to your complaints, worries, kvetches, aches and pains. Hiding symptoms does no one any good. I’m not going to ask Mr. G to apologize, but the next time we go over a list of possible symptoms, I’ll remind him to be open and forthright. And I won’t hold back about reminding him what happened last time. Failing to reveal needed information or open up about our behavior out of a misplaced sense of delicacy helps no one. Sitting back and refusing to take part in the relationship, because you see the doctor as “the boss” — that won’t fly anymore. Not this late on the healthcare clock. When such unthinking passivity leads to error, it can be the patient’s fault as much as the doctors.

In our current health care system, there’s plenty to be sorry for. Doctors and patients can do so in the right way, recognizing our individual flaws and systematic defects, and get back to the partnership that makes long-term health possible in the context of a supportive relationship.

Zackary Berger, MD, PhD, is a primary care doctor and communication researcher at Johns Hopkins School of Medicine. His book Talking To Your Doctor is new and useful. You should buy it. And check out his website, chock-full of information and excerpts!