|Year : 2012 | Volume
| Issue : 1 | Page : 38-41
Impact of apology on health care system; communication skills
Department of Pediatrics, College of Medicine and Medical Sciences, Taif University, Taif, Saudi Arabia
|Date of Web Publication||13-Apr-2012|
Associate Professor and Consultant Pediatrician and Neonatologist, College of Medicine and Medical Sciences, Taif University, PO Box 888, Taif
Source of Support: None, Conflict of Interest: None
Medical error and tort reform have increasingly taken center stage in the health care debate in our region and all over the world. Patients, policy makers and health professionals grapple with the striking prevalence and consequences of medical error, which result in patient injury and health care service. Debate ranges from legislating restrictions on cost awards in malpractice trials to ethical and moral imperatives germane to untoward clinical incidents, whether in the hospital or in outpatient settings. Fears of malpractice liability, difficulties in communicating bad news, and confusion about causation and responsibility, have long impeded comprehensive and bold initiatives designed to change the patient, family and clinician experience with medical error. Offering an apology and making full disclosure of harmful medical errors to patients and their families can do much to defuse the hurt and anger that can lead to further emotional and physical trauma.
Keywords: Apology, communication skills, healthcare
|How to cite this article:|
Amin A. Impact of apology on health care system; communication skills. Saudi J Health Sci 2012;1:38-41
| Introduction|| |
The growth in malpractice premiums and claims payments over the Saudi Arabia and worldwide has reflected passively on healthcare provider and health service.
The data of the cases submitted to the Medico-legal committee of the Ministry of Health in Riyadh, Saudi Arabia from various parts of the country for the period 1,420 through to 1,423 H (1999-2003), were increasing dramatically. A total of 2,223 cases had been referred for consideration to the various committees in the Kingdom over the past few years. ,
A recent French study by Ligi and his colleagues,  reviewed iatrogenic events in admitted neonates. A total of 388 neonates were studied during 10,436 patient days. They recorded 267 iatrogenic events in 116 patients. The incidence of iatrogenic events was 25.6 per 1000 patient days. Ninety two (34%) were preventable and 78 (29%) were severe. Two iatrogenic events (1%) were fatal. This kind of medical malpractice raised the importance of medical disclosure of harmful events in the early stages when it happened. A British survey, focusing on disclosure of harmful medical error revealed, 92% of patients believed that, a patient should always be informed if a complication has occurred, and 81% of patients believed that a patient should not only be informed of a complication, but also be given detailed information on possible adverse outcomes. 
In 2001, the Joint Commission on Accreditation of Healthcare Organizations,  now called the Joint Commission, issued the first nationwide disclosure standard in North America. This standard requires that patients be informed about all outcomes of care, including unanticipated outcomes. Furthermore, several states in USA have passed legislation that would make physicians' apologies; including admissions of fault, inadmissible in malpractice suits, and this inadmissibility law often included all other health professionals.  Medical disclosure efforts in the United States took more important steps forward. In March 2006, the full disclosure working group of the Harvard hospitals released a consensus statement emphasizing the importance of disclosing, taking responsibility, apologizing, and discussing the prevention of recurrences. 
The purpose of this article is to focus on enhancing the uniformity and quality of clinician-patient communication, also drawing attention within organizations delivering healthcare, about the increasingly demand of doctors who listen and offer an apology to the patient or his relatives. We like to promote health care providers, to be able to say, "I am sorry for what happened" without fear of the consequences, and to encourage physicians to disclose medical errors on the proper time and location to avoid any negative burden on the health care system.
In the aftermath of an incident, the primary objective of healthcare givers must be to support the patients and maintain the healing relationship. Patients and families are entitled to know the details of incidents and their implications. Communication should be open, timely, and sustained. Health providers must eliminate the adversarial relationship that of a secretive, liability-focused approach to patient communication fosters.  The caregiver's role is to provide comfort and support, and to consider the full breadth of patient's needs. However, not every conversation is necessarily effective, and there are many barriers that may place clear communication at risk. Some of these barriers include:
- The anxiety and intimidation associated with the medical interaction between a highly trained medical professional and an unsophisticated patient.
- Patient stress associated with seeking healthcare services.
- Preconceived patient notions that make them less likely to listen to and understand important healthcare messages from their doctors.
- Cultural and linguistic differences between physicians and patients created by an increasingly diverse patient population.
- Physician time constraints that often result in brief patient interactions and cross-cultural misunderstandings. 
Medical staff is committed to full disclosure of medical error, because it is the right thing to do. The patient and family have the right to know what happened. In addition, honest communication promotes trust between the patient and health provider, so that the primary focus of the clinician-patient relationship remains patient care. Further, open discussion about errors can promote patient's safety by encouraging clinicians to seek systems improvements that minimize the likelihood of recurrence.
Medical faculty programs should stress on teaching and assessing medical communication skills, determining relevant knowledge and attitudes, and later evaluating educational outcome. Recognition of the need for faculty development grows in part from an abundant literature documenting the poor inter-rater reliability of faculty who assess communications. ,,
To achieve uniformity of teaching and assessment in communications, first, there needs be a consensus about what is important. Consensus statements from Toronto and Kalamazoo provide such information.  The Toronto Consensus identified the most important things that could be done now to improve clinical communications. These include physician-patient encounters, in which patients get to identify all of their agenda items and concerns, eliciting patients' perspective on illness and addressing feelings with empathy, information management (including appropriate use of open-ended questions and summaries), and the ability to negotiate to arrive at common ground. Faculty next need to develop the ability to identify when these skills are performed, missing, or poorly performed. The faculty needs to acquire a set of instructional skills that are effective over a wide range of teaching situations, with widely varying communication performances and with learners who perform well and with those who perform poorly, and finally we can reach to a consensus model of what we teach and how we teach it, from medical school to residency, from discipline to discipline, from conceptual model to conceptual model, from all begin to overlap, the field of communication will finally have come of age. The Association of American Medical Colleges recommended the teaching and assessment of communication skills throughout medical schools and residency programs. 
An apology is defined as ''a speech act which is intended to provide support for the hearer who was actually or potentially mal affected by a violation''.  The reactions of patients and their families to incidents are influenced both by the incident itself and the manner in which the incident is handled. Inadequate or insensitive management may cause further emotional trauma, while open acknowledgement of the injury, sensitivity, good communication, and skillful management of corrective actions may reduce emotional trauma. When there has been an error, one of the most powerful things a caregiver can do to heal the patients hurt is to apologize. Apologizing is an essential aspect of taking responsibility for an injury, even if, as is common, several systems failures are responsible for the error rather than one person. Explaining the event, communicating remorse, and making a gesture of reconciliation can do much to defuse the hurt and anger that follows.
Apologies and culture
Speech acts have been found to share certain characteristics in different cultures. However, to say that they share common features does not mean they do not differ in other aspects. 
In cross-cultural comparisons of apology strategies, both similarities and differences are reported throughout the literature. Sugimoto et al. addressed, that Japanese students exhibited more readiness to offer (and receive) apologies than their American counterparts. She further found that the secondary strategies of compensation and promise not to repeat offense were mainly used by the Japanese group, who were also reported to offer elaborate manifestations of the promise not to repeat offense and were more open to requests of forgiveness. American respondents, who did not offer reparation most probably to avoid weakening their position, declaring responsibility, or fulfilling future obligations, were also reported to attribute the offense to forgetfulness or circumstances beyond their control while Japanese respondents, who strived more to save face, stressed the lack of malicious intention yet admitted responsibility for the offense. Saving face is important in apology-warranting situations, which justifies the definition of apology as a politeness strategy that pays attention to the addressee's negative face,  and any utterance which aims at remedying the effect of an offense or face-threatening act and restoring social harmony and equilibrium.  The human tendency to favor in-group over out-group attributions may be why people blame circumstances or another party for any wrongdoing and commend a member of the group for any good deed. 
Apologies in Arabic culture
In Arabic, apologies are defined as the utterances and deeds a person attempts to offer to lift punishment or blame due on him/her for a malicious deed he/she has committed.  This definition may appear too simplistic by Western standards, which may be attributed not only to the fact that the reference is quite old (and probably one of the first on the subject) but also to the emergence of quite elaborate definitions for apology, in recent literature. Using verses from the holy Quran and proverbs to mitigate the victim's anger, was also reported by El-Khalil,  who attributed it to the impact of the Islamic teachings and popular folklore on speech acts. He further reported that most of his respondents used implicit rather than explicit (or traditional) apology strategies, that unlike their female counterparts, Jordanian males preferred explicit apology strategies, and that only a few females promised never to repeat the offense. There are claims that, Arabs are more publicly available to each other and, thus, are less protective of the immunity of their private self, which may explain their keenness to give.
Bataineh et al. investigated the differences in the realization patterns of apology among native speakers of American English and Jordanian Arabic.  Differences in the use of apology strategies were found between the two sample groups, as well as, the male and female respondents of each group. Differences involve using several manifestations of explicit apology among other less explicit apology strategies. The authors further examined the differences between male and female respondents in both groups and found that there were more differences between Jordanian male and female respondents than between American male and female respondents, which may be attributed to the fact that, there is a greater similarity between how boys and girls are raised in the U.S. than between, how they are raised in Jordan.
Another study from Sudan,  outlined the type and extent of use of apology strategies in Sudanese Arabic and on the socio-cultural attitudes and values of Sudanese community. She examined 1,082 responses to a discourse completion test (DCT) that consisted of 10 different social situations of varying severity of offense, strength of social relationship and power between hypothetical speakers and hearers. The informants were 110 college educated adults of Sudan. The survey was written in Sudanese dialect, to elicit responses that approximate verbal apologies that might be given in these situations. However, the selection of apology strategies in this study reinforces the culture-specific aspect of language use, despite the fact that more restricted classification of apology strategies was used as a model for analyzing the data, the results confirm the great significance for understanding differences in language use and successful intercultural communication in Sudanese community.
Resistance to apologize
It is no accident that physicians often resist acknowledging offenses in the medical setting or fail to adequately apologize for them. An obvious and understandable reason for such resistance is the fear of consequences, such as an angry patient, a complaint sent to the court. Initial evidence now suggests that admissions of harm and apologies strengthen, rather than jeopardize relationships and diminish punitive responses. 
Another important explanation for such resistance is the need for physicians to maintain a self-image for themselves and others of being strong, always in charge, unemotional, and a perfectionist. The feared loss of this self-image may lead to unbearable emotion of shame and subsequent feelings of depression. An apology may expose vulnerability, remove emotional armor, and allow emotions to be exposed. Medical professionals and colleagues need to work at tolerating and supporting their own humanity and that of their colleagues. They need to regard apologies as evidence of honesty, generosity, humility, commitment, and courage. ,
The overall responsibility and accountability for an adverse event rests with the hospital. Thus, following a serious event, it is incumbent upon the organization and its leaders to also accept responsibility and communicate that responsibility and remorse to the patient and family. Because every event is unique, organizational leaders and clinicians should coordinate communications with them. On first consideration, it may seem odd that in situations where the physician had nothing to do with an adverse event, she/he should take responsibility for it. In this circumstance, taking responsibility does not mean assuming sole culpability for the adverse event. A host of factors likely contributed to the adverse event, many of them beyond any one person's control. Medical malpractice insurance offers a marginal value of security to healthcare givers and to the organization they belong to. Suitable medical malpractice insurance should be implemented to all medical staff personally or through their hospital leaders.
Explain what will be done to prevent future event
The patient must have confidence that the physician or facility is committed to correcting faulty procedures and avoiding similar offences in the future. Once the hospital investigation is completed and corrective changes are planned, it is important to inform the patient and family of these plans. Injured patients have a strong interest in seeing to it that, what happened to them does not happen to someone else. The patient must have confidence that the physician or facility is committed to correcting faulty procedures and avoiding similar offenses.  Caregivers often underestimate the importance of this aspect of the response to an event. Knowing that changes were made and that some good came of their experience, helps the patient and family cope with their pain or loss. It gives a positive meaning to their experience to know that their suffering is not in vain.
| Conclusion|| |
Effective communication channels and proper way of apology between caregivers and patients or their relatives may restore damaged relationships or even strengthen previous satisfactory relationships. Offering an apology and making disclosure of harmful errors to patients may diminish guilt, shame, and the fear of retaliation and to restore the public's trust in the honesty and integrity of the healthcare system and quality of patients-care.  Medical staff is committed to full disclosure of medical error, because it is the right thing to do. The patient and family have the right to know what happened. By facilitating and encouraging full disclosure, managers help initiate healing process for all involved and can better ensure regulatory compliance.  Medical professionals and faculty staff should emphasize the magnitude of teaching medical student, the value of the standard of communication skills as part of their curriculum in the under graduate programme.
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