Case Scenario

As soon as my patient told me she was having heavy, prolonged menstrual periods and fatigue, I realized my mistake. Two months earlier, I had checked her thyroid-stimulating hormone (TSH) level to monitor her response to the treatment of hyperthyroidism. She had been doing well on 0.2 mg of thyroxine a day, but when results of the TSH measurement showed a high level, I intended to adjust her dosage upward. A small dosage increase was all she needed to bring the TSH level into the normal range. Converting milligrams to micrograms in my head, I wrote a prescription for 25 μg of thyroxine in the new regimen. My miscalculation of the conversion factor placed her dosage at a level 10 times lower than I had intended.

Because she did not have adequate thyroid replacement, this young, otherwise healthy patient had suffered from fatigue, thinning hair and heavy bleeding for two months. Her hematocrit level dropped to 30 percent. Embarrassed, I informed her that I had given her too low a dosage of thyroxine. Her symptoms were caused by inadequate thyroid hormone replacement and would resolve after she started receiving a higher dosage of thyroxine.

Although I didn't intend to mislead the patient, I knew that she assumed I had simply underestimated the amount of thyroxine she needed. Wanting to maintain her confidence in me, I did not point out that I had actually made an error in calculating the dosage. Instead, I let her continue to think that I just hadn't given her a high enough dosage. She had no serious or long-term complications, but I wonder if my handling of the situation was entirely ethical or even legally tenable.

Commentary

Despite the frequency of mistakes in medical practice,¹ there is no unequivocal formal guidance on how physicians should deal with medical errors.² It can be a difficult topic to discuss, especially in the current professional and societal climate that expects perfection of physicians.³ For this discussion, it is important to distinguish mistakes from unavoidable risks that may be related to medical treatment or bad outcomes inherent to disease.

In this case, a physician made a mistake that had no long-term consequence but led to two months of symptoms for a patient. The physician gave a partial explanation of the nature of the mistake and corrected it but wondered whether this was the appropriate way to handle the situation. Medical mistakes bring forth ethical, emotional and legal considerations.

In my response to this scenario, I will focus somewhat more on the ethical and emotional implications of medical errors, since a successful malpractice suit for the patient would be unlikely in this case. However, I would point out that fear of malpractice litigation certainly permeates the emotional responses of physicians, as well as ethical debates pertaining to medical mistakes. In a survey⁴ of patients given hypothetical situations of physician mistakes, 98 percent of patients indicated that they would desire some acknowledgment of even minor errors. Patients said that they were more likely to consider litigation if the physician did not disclose the error.

Truth-telling and apologizing to patients has been described as healing for both physician and patient. Truth-telling can free the physician to be human and more open about his or her limitations, thus reducing the pressure of unrealistic self-expectations. Truth-telling helps patients understand what has happened to them and opens the door to appropriate compensation (not necessarily through a lawsuit), if applicable.

In this case, the physician could have told the patient something like: “I'm just realizing now that I gave you a lower dose of your thyroid medication than you even had before. I made a mistake when I calculated the new dose. I think this is why you are having the bleeding and the tiredness. I'm really sorry for the problems this has caused you. Your symptoms should resolve with this higher dose. I'll follow you closely to help you get better as fast as possible. Do you have any questions for me?”

The patient in this case appeared satisfied with the physician's partial explanation of the mistake. Nevertheless, the true degree of the error may become evident to the patient when the corrected prescription is filled or when another physician reviews the chart at a later date. If the patient makes this discovery on her own, she may lose her trust in her physician. On the other hand, if the full mistake had been admitted initially, it is possible that the patient would have become angry and left the physician's practice. However, it is likely that total candor would have strengthened the doctor-patient relationship.

As much as truth-telling is desired by patients, several possible factors that arise in disclosing mistakes can be conflicting for physicians: physicians' personal values, their obligation to prevent a recurrence of the error, the possibility that knowledge of the error will create more suffering for the patient, and the positive or negative effect on the doctor-patient relationship.⁵ Adding to this, risk management and legal counsel may caution a physician against hastily admitting responsibility in an effort to prevent or limit a malpractice lawsuit.

Another important factor is that no accepted (or acceptable) supportive forum exists, either in society or in the medical profession, through which physicians can openly discuss mistakes.² Nevertheless, physicians recognize the importance of acknowledging their mistakes.

In a survey⁵ of physicians given hypothetical situations regarding medical mistakes, 95 percent of respondents stated that they would reveal a relatively minor error and 78 percent stated that they would reveal a major error leading to death. Despite this hypothetical readiness to admit error, some respondents wondered if they would be able to carry through with truth-telling if they were really involved in the situation, despite their wish to tell the truth in principle.

Physicians' emotional reactions to making mistakes also add to the complexity of the situation. Physicians have been reported to experience panic feelings, guilt, embarrassment, humiliation, and feelings of inadequacy and isolation after making a mistake.⁶ In this case presentation, the physician remarks on his or her embarrassment in telling the patient about the dosage error. Such emotional reactions, if ignored, can make it more difficult for physicians to deal effectively with the aftermath of a mistake.

One way for physicians to cope with their emotional reactions after making an error is to discuss such feelings with trusted friends, colleagues or a spouse. Even when a mistake leads to litigation, and lawyers advise not to discuss the case, it is legally acceptable and emotionally beneficial for physicians to discuss their feelings pertaining to the mistake.

It appears that truth-telling is the ultimate goal in the vast majority of cases. However, the current societal and professional climate needs to evolve to a better acceptance of mistakes as an inherent part of medicine, in order to encourage truth-telling. Meanwhile, it is important for physicians who have made a medical error to seek emotional support from colleagues, friends or family to help them deal with their own emotional reaction in order to be more effective in dealing with the mistake. Ultimately, physicians need to consider all relevant ethical and legal factors in a given case and keep patient welfare in mind as they address prevention and disclosures of mistakes, which are inevitable in their careers.