Medical Errors and Medical Narcissism
http://www.100md.com
《新英格兰医药杂志》
Why do physicians have such a difficult time talking to their patients about errors made in the course of patient care? This is the main question posed in John Banja's carefully written and useful book. The answer, the author suggests, is primarily "medical narcissism," a muted version of the narcissistic personality that, in many ways, also helps physicians do their difficult work.
Banja suggests that medical narcissists may find the disclosure of an error to be too much of a challenge to their self-image of competence, control, and "treatment-oriented focus." Hence, they have a tendency to rationalize the error as unavoidable, unimportant, or unnecessary to reveal because it will not change the outcome.
Banja argues for a policy of full disclosure to patients as a moral responsibility of the physician and a moral right of the patient. He notes that in 1981, the American Medical Association endorsed the position that errors should be "truthfully and honestly disclosed regardless of their legal consequences." He also suggests that full disclosure can rebuild the shattered doctor–patient relationship after an error has been made and can heal the hurt that both parties feel.
The author touches on the negative role of the tort system and explores the potential effect of tort reform and such alternatives as no-fault insurance and enterprise liability. It is encouraging to see Banja's recognition that current ideas of tort reform reflect the needs of the insurance industry more than they do the needs of either patients or doctors and will do little to promote full disclosure or reduce error. Banja fails to note that any authentic replacement of the tort system has to include rigorous efforts on the part of the medical profession itself to reduce medical errors and improve patient safety. The Swedish no-fault health insurance program rigidly separates compensation for patients from punishment of physicians. Hence, patients are compensated on the basis of degree of harm, not the fault of the doctor.
Because the book focuses on psychological arguments for full disclosure and the medical narcissism that stands in the way, Banja misses another absolutely crucial argument for full disclosure — the need for authentic information about error and patterns of error. The sharing of complete information is the only way that the medical profession can make progress on the reduction of errors. Full disclosure to the patient is a worthy goal, but it must be combined with full disclosure to the institution where the error took place.
One of many ways to improve the dissemination of data is to reshape the dynamics of the morbidity and mortality conference and to make the incident report an acceptable mechanism for physicians. The conference can become not just a mechanism for admitting error but a vehicle for collecting information, and the incident report should be seen as a mechanism for all clinicians, not just for nurses.
It would also improve the understanding of patterns of error (and the language of full disclosure) if physicians would examine more closely what they call "unavoidable," "anticipated," or "known" adverse events. A close examination of empirical studies shows that many such events are more preventable than is commonly perceived.
Full disclosure to patients — and to the health care delivery system — will give the medical profession the tools to maintain the trust that is essential in the doctor–patient relationship and to understand and reduce the patterns of medical error. A combination of these efforts will enhance the ability of physicians to serve their patients according to the standards that both parties ardently seek.
Marilynn M. Rosenthal, Ph.D.
University of Michigan Medical School
Ann Arbor, MI 48104
mmrosent@umich.edu
Banja suggests that medical narcissists may find the disclosure of an error to be too much of a challenge to their self-image of competence, control, and "treatment-oriented focus." Hence, they have a tendency to rationalize the error as unavoidable, unimportant, or unnecessary to reveal because it will not change the outcome.
Banja argues for a policy of full disclosure to patients as a moral responsibility of the physician and a moral right of the patient. He notes that in 1981, the American Medical Association endorsed the position that errors should be "truthfully and honestly disclosed regardless of their legal consequences." He also suggests that full disclosure can rebuild the shattered doctor–patient relationship after an error has been made and can heal the hurt that both parties feel.
The author touches on the negative role of the tort system and explores the potential effect of tort reform and such alternatives as no-fault insurance and enterprise liability. It is encouraging to see Banja's recognition that current ideas of tort reform reflect the needs of the insurance industry more than they do the needs of either patients or doctors and will do little to promote full disclosure or reduce error. Banja fails to note that any authentic replacement of the tort system has to include rigorous efforts on the part of the medical profession itself to reduce medical errors and improve patient safety. The Swedish no-fault health insurance program rigidly separates compensation for patients from punishment of physicians. Hence, patients are compensated on the basis of degree of harm, not the fault of the doctor.
Because the book focuses on psychological arguments for full disclosure and the medical narcissism that stands in the way, Banja misses another absolutely crucial argument for full disclosure — the need for authentic information about error and patterns of error. The sharing of complete information is the only way that the medical profession can make progress on the reduction of errors. Full disclosure to the patient is a worthy goal, but it must be combined with full disclosure to the institution where the error took place.
One of many ways to improve the dissemination of data is to reshape the dynamics of the morbidity and mortality conference and to make the incident report an acceptable mechanism for physicians. The conference can become not just a mechanism for admitting error but a vehicle for collecting information, and the incident report should be seen as a mechanism for all clinicians, not just for nurses.
It would also improve the understanding of patterns of error (and the language of full disclosure) if physicians would examine more closely what they call "unavoidable," "anticipated," or "known" adverse events. A close examination of empirical studies shows that many such events are more preventable than is commonly perceived.
Full disclosure to patients — and to the health care delivery system — will give the medical profession the tools to maintain the trust that is essential in the doctor–patient relationship and to understand and reduce the patterns of medical error. A combination of these efforts will enhance the ability of physicians to serve their patients according to the standards that both parties ardently seek.
Marilynn M. Rosenthal, Ph.D.
University of Michigan Medical School
Ann Arbor, MI 48104
mmrosent@umich.edu