There are three guarantees in life: death, taxes, and medical errors. Medical errors are ubiquitous and are estimated to lead to 98,000 patient deaths each year. Aside from the potential they carry for significant morbidity and mortality, medical errors – especially in the cases of missed terminal diagnoses – can take away critical time that patients can spend with their loved ones.
Physicians have an imperative to treat the patient holistically, not just to care for their physical ailments. Like a cooling salve of aloe vera applied to a burn, an apology can be an important part of the healing process for patients after a missed diagnosis. Apologies can also be healing for the physicians and help to mend the patient-physician relationship.
But doctors often do not apologize. This comes as no surprise with the ever-present fear that physicians have of being involved in a malpractice suit. While the decision physicians make to avoid apologies is an understandable reaction, it is rooted more in emotions than in reality. Patients are less likely to sue physicians if they apologize and offer an explanation after a medical error. Additionally, many states have apology laws that protect either expressions of regret, error disclosures, or both. Arizona’s apology law epitomizes full protection in that it makes “any statement, affirmation, gesture or conduct expressing apology, responsibility, liability, sympathy, commiseration, condolence, compassion, or a general sense of benevolence” inadmissible in a court case.
Given the protections physicians have, it’s not a question of if physicians should apologize but rather a question of how. All medical schools are required to have ethics curricula in compliance with LCME requirements but this content lacks consistency across all medical schools. Thus, current and future physicians need a standardized mental model to quickly reference for apologies. These “5 A’s of an Appropriate Apology” do just that. It’s important to mention that these are not meant for a “one size fits all” approach but they can instead serve as a guideline or a helpful mnemonic for things to keep in mind.
First, doctors should Apologize with the Active Voice. All effective apologies should use first person language (“I missed a nodule on your last MRI”) rather than the passive voice (“A nodule was missed on your last MRI”) which is used to distance the speaker from the statement.
Second, doctors should Acknowledge the Impact of their actions (or non-actions) on the patients and their families. For example, “I understand that this missed diagnosis has caused you significant emotional pain and distress.”
Third, doctors should Accept Accountability for their part in a medical error without deflecting blame. As an example, the physician could say “I want to take full responsibility for my oversight in your diagnosis. As your doctor, it is my duty to make sure that you receive the most accurate and timely care possible, and in this instance, I fell short of that standard.” An important aspect of accountability is making changes to behaviors to prevent similar occurrences from happening in the future. An apologetic physician could say “This is what I am going to do personally to ensure that this doesn’t happen again and I am committed to learning from this to improve how I diagnose and treat all my patients going forward.”
If appropriate, a doctor can Address their Actions and Intent. This can offer the patient an explanation as to why or how a diagnosis was missed. To do so, a doctor could say “I also want to assure you that missing your diagnosis was not intentional. At the time, I relied on your presenting symptoms and the testing that was available, which unfortunately did not paint the full picture of the condition that we now know you have. I regret not taking further actions to get to a more accurate diagnosis.”
Lastly, physicians should sincerely and respectfully Ask for Forgiveness and Ask if There is Anything Else that they can do for the patient and for their family. This is the simplest of the 5 A’s but it is potentially the most profound in that it draws the patient and their families into the conversation. It also allows them to communicate their hopes and desires.
Apologizing is a difficult, but important step for physicians to take after a medical error. While an apology will not guarantee forgiveness, it will go a long way to promote holistic healing for the patient, for the physician, and for their relationship moving forward.
To recap, these are the 5 A’s of an Appropriate Apology
1. Apologize with Active Voice
2. Acknowledge Impact
3. Accept Accountability
4. Address Actions and Intent (if appropriate)
5. Ask for Forgiveness and if There’s Anything Else
Chikodi Ohaya is a member of The University of Arizona College of Medicine – Phoenix, Class of 2025. She graduated from California Lutheran University with a degree in Biology. She is a first-generation Nigerian immigrant and a former teacher who is proficient in American Sign Language. Chikodi is also passionate about health disparities and photography and enjoys road trips to scenic destinations.