Case Scenario

A patient was recently diagnosed with tuberculosis, and her physician sent her to a public health clinic for treatment. She came to my office for a second opinion after a family member, who is a nurse, told her that the diagnosis did not make sense. A work-up in my office revealed that she had lung cancer.

The patient told her first physician of my diagnosis. His response was, “I never told you it was tuberculosis, you must have misunderstood me.” At our next appointment, the patient told me about the physician’s response and that she was sure she had not misunderstood his original diagnosis. She had believed it and was ready to start tuberculosis treatment. I was embarrassed because I know the physician personally and occasionally see him at the hospital where we both have privileges.

How should I handle this situation? The patient did not specifically ask me what she should do about the initial physician’s attempted cover-up and did not mention taking legal action against him. In this case, the misdiagnosis was quickly corrected, but what if it had caused a delay in proper treatment? Should I confront my colleague about this? If I say nothing to him, how can I face him at our next meeting?

Commentary

In the past, physicians had no formal medical ethics training and learned that the best way to deal with medical errors and possible malpractice lawsuits was to say as little as possible, deny everything, and never to apologize or acknowledge error. Today, physicians receive very different ethical and legal advice.

Specific to this scenario, the current physician only has the patient’s version of what happened. Physicians should give their colleagues the benefit of the doubt and not assume anything until they have clear, unambiguous evidence. If in fact the original physician had treated the patient as described, the first question is what might have motivated him to attempt to cover up the error? Is the physician purposely being malicious, or is he just ashamed or afraid of legal action?

It is generally agreed that patients have a right to know the truth about their conditions, including if their physician made errors during evaluation or treatment.^1–3 Open disclosure of errors can produce valuable outcomes (e.g., patients receive the information needed to make decisions, physicians often can clear their consciences, future errors can be reduced).

An American Medical Association (AMA) report⁴ on medical ethics addresses the physician’s responsibility to disclose errors, express concern for the patient, and ensure ongoing care. The AMA suggests giving a general explanation regarding the nature of the error as well as the measures that the physician or office is taking to prevent it from occuring again.⁴ The report does not distinguish between errors made by physicians themselves and those made by colleagues. However, the literature on disclosure of errors committed by others is lacking compared with the burgeoning literature on disclosing one’s own errors.

A textbook on medical ethics⁵ briefly reviews four possible approaches to medical errors: (1) say nothing unless the patient explicitly asks for an opinion; (2) confront the other physician and ask him or her to disclose the error; (3) arrange a joint conference with the patient and the other physician; or (4) tell the patient directly, without involving the other physician, about the error. The author of the textbook does not offer explicit advice and acknowledges that each approach has significant disadvantages.⁵

In this scenario, the patient knows that she was misdiagnosed and that the original physician attempted to cover up his mistake. Therefore, the current physician does not face the difficult decision of whether or not to disclose these facts. However, the issue of how to approach the colleague still remains. The possibility that the patient misunderstood the original physician or misrepresented the situation should be considered. I suggest approaching the colleague and gently bringing up the situation in a nonjudgmental way. This may be the first opportunity for him to discuss the error in a supportive setting. This could lead to considerable relief and comfort and provide an 4HE opportunity for him to open up and to learn how to better handle similar incidents in the future. If the colleague reacts angrily and rejects the inquiry, the physician may have to distance himself from the colleague in the future.