HEALTH :: JUNE 9, 2004

A novel approach to malpractice: Telling the truth

Last time I wrote about a sad malpractice outcome in Vir-ginia in which physicians were found liable for practicing the type of medicine I consider to be most enlightened. I thought I’d balance the record now by talking about the place I think of as the national model for dealing with malpractice issues and medical mistakes.

The Veteran’s Administration hospital in Lexington, Ky., has been promoting this approach for the past 10 to 12 years. It started when they noticed what many critics of the present system have been noticing: The usual way physicians and staff have been trained to deal with mistakes is to hide them. Above all else, lawyers used to advise: Never say anything directly to the patient and for sure, never apologize – it’s the same as admitting guilt.

The end result? Two big problems. When patients later find out about mistakes, they might sue simply because they are so angry that no one talked to them or apologized. Plus, mistakes get buried and never talked about, so the hospital never finds out ways to make things work better in the future. More lawsuits, more mistakes.

So the hospital staff got together and decided, as the old ads said, “There must be a better way.” Here’s what they came up with.

Suppose I’m a physician or nurse working at the VA there today. I think I made a mistake in caring for a patient. I immediately call a special review committee. I know that if I call this committee and honestly admit what happened, I will not be punished for it in any way. On the other hand, I know the one thing that will bring wrath down upon my head in this hospital is if I made a mistake and don’t report it.

So the committee meets right away and we review what happened. One thing that happens a lot is that it’s decided that I really didn’t make a mistake after all. Something bad happened, but I did not cause it myself. But let’s imagine that we all decide that this truly was a mistake.

The next thing that happens is that a high-level physician, representing the entire VA staff, goes to see the patient. He explains that a mistake was made and what it was. He lists the steps that will be followed carefully now to review the procedures and try to assure that no mistake like this will ever happen again. And he says that if the patient thinks he was damaged by this mistake, he has a right to legal damages and should see a lawyer about this.

The first result of the Lexington VA approach is that malpractice costs have gone down. More people sue because more people know about mistakes. But the hospital does not fight lawsuits when they have admitted error. (On the other hand, if a review shows that no error was made, and a lawsuit is later filed, the VA will fight tooth and nail.) So more suits are settled much earlier. That means far lower legal fees and somewhat lower amounts of damages paid.

The next thing about the experience is the reputation the hospital now has in its local community. Staff at Lexington note that patients who go to a lawyer and want to sue the hospital are asked, “Did the hospital admit they made a mistake?” If the patient says “no,” many lawyers will not even take the suit. They are so impressed with the hospital’s self-policing of its own errors that they figure they’ll lose for sure.

So if you knew then what we know now, you’d figure that the VA went down this road just to save money on malpractice. But the real story, I am convinced, is the VA wanted to correct its mistakes rather than play legalistic games. It was a happy coincidence that later on this also turned out to be smart policy from a financial angle. It’s a nice exception to the adage that no good deed goes unpunished.

Mark Twain said, “Always do right. This will gratify some people and astonish the rest.” The Lexington VA experience has been astonishing quite a number of folks, and one now hears hospital risk managers all over the country talking cautiously about how important it is to apologize to patients when errors are made.

Howard Brody, MD, teaches family practice and medical ethics at Michigan State University. You can reach him at brody@msu.edu.

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