—Oliver Wendell Holmes, Sr. (1809-1894)

Chester “Trip” Buckenmaier III, MD,
COL (ret.), MC, USA

Despite our best efforts, bad things often happen to good people in medicine. Healthcare professionals are human and prone to error, as much as they would like to deny that hard fact.
The distinction between healthcare providers and other mistake-plagued humans is that provider mistakes that occur in the practice of medicine often result in harm to another human being. The seriousness of this issue is ingrained into every first year medical student when they learn the phrase “primum non nocere, Latin for “first, do no harm.”

Every provider approaches the patient with this fundamental principle of medicine in mind, yet medical interactions with patients all too frequently result in significant, unintended, bodily harm.  Occasionally these injuries are the result of negligence or carelessness on the part of the provider, often described as violations of the “standard of care.” These situations demand disciplinary actions against the provider and compensation for the patient. Of course, there is no shortage of lawyers standing by to adjudicate patient recompense for these instances of malpractice.

More often, though, bad things happen to good patients at the hands of providers with no breach in the standard of care and despite the best efforts and intentions of the providers involved. Unfortunately, when patients do not experience optimal healthcare outcomes when they interact with medical professionals, they often believe medical malfeasance must be a component of their injury and suffering. When physical harm comes to a patient following interaction with the healthcare community, it is perhaps understandable that they desire someone from that community to accept responsibility for the situation.

In my 25-plus years as a physician, I have had my fair share of undesirable outcomes with patients. As far as I know, I have never been named in a lawsuit. I mention this because I admit my perspective and comments on this issue might be significantly different if I had the experience of being sued. It has been my practice with patients under my care who experience a poor outcome to make it a point to speak with them in person and say words to the effect of, “I am sorry this has happened to you, it certainly was not my intention.” Interestingly, in a Medscape Malpractice Report 2017, a survey of over 4,000 physicians who had been sued, more than 80% stated they did not feel saying “I’m sorry” to the patient would have made a difference in the resulting lawsuit.1 This statistic surprised me, as it has certainly not been my experience.

I offer the following short story from my medical past to illustrate how I personally handle this issue and advice I give to residents and colleagues on this difficult topic. Very early in my career as a staff anesthesiologist, I performed a paravertebral block (a nerve block of the spinal nerve roots to provide analgesia to the chest wall) in an elderly lady who had presented for a mastectomy to treat breast cancer. I had specialty training in regional anesthesia and extensive experience with this particular block, which I believed to be in the best interest of this patient. I had counseled both the patient and her son on the technique and the possible complications, to include pneumothorax (lung puncture), associated with the procedure. During the block procedure, which I had thought was rather routine—famous last words— the patient suddenly coughed violently. When I aspirated the needle in her back, I noted air bubbles in the syringe, indicating a possible pneumothorax complication. My day, as they say, had gone from routine to crap.

Since this is not a case report and my space is limited, I will condense this rather long event into a few sentences. I confirmed the suspicion of a pneumothorax with a chest X-ray, but it was deemed small enough to proceed with surgery, if positive pressure ventilation could be avoided. We completed the paravertebral block with fluoroscopic guidance (this is before ultrasound was available) and diagnosed the patient’s scoliosis condition that likely complicated the original block procedure. The mastectomy was completed with no issues, and the patient was pain-free in the recovery room. Unfortunately, her pneumothorax had increased and a chest tube had to be placed as treatment. Fortunately, the paravertebral block was still in place and the chest tube was placed at the bedside without the need of additional anesthesia.

The following day, after the patient had fully recovered from the effects of the sedation, I spoke with her and her son. I explained about the pneumothorax complication and that I accidently had created this condition during the performance of the block procedure. I then stated I was sorry that this complication had occurred. The patient was quiet for a moment, and then said she understood but was not concerned. She already had two drain tubes as part of the mastectomy, the chest tube (which would be removed the following day) was just one more, and she was satisfied with my care and explanation. The son, although far less understanding than his mother, noted he was pleased I had acknowledged the complication and was taking responsibility. This was the last interaction I would have with either of these individuals.

I have tried to approach every patient I have cared for who has experienced an unfortunate outcome with the same honest assessment of what happened, and I make a point to say I am sorry the situation happened to them. In every case, my willingness to acknowledge the patient has experienced an unwanted outcome and that I was involved has been appreciated. Perhaps I have just been lucky and my personal cohort of complication patients has had an unusual aversion to lawsuits. I prefer to believe that my willingness to put my ego aside and admit my fallibility and responsibility for their injury has met some fundamental need in humans for acknowledgement of a perceived wrong.

Notice how I say responsibility not culpability. This is not about assigning blame; rather, it is acknowledging the patient has sustained an unfortunate outcome from a medical course of action which I prescribed. I have personally been on the receiving end of medical malpractice with one of my children, and my wife and I did not receive the respectful acknowledgement of the physician’s failure that I am advocating. The anger from that incident persists in us even today.

It is noble to strive for perfection in our daily practice of medicine; our patients deserve no less. It is the epitome of irrational hubris on the part of any professional to imagine perfection is achievable. Since error is our destiny, as a community we need to get better at communicating this fact to our patients. Our unending effort at flawlessness in the performance of our profession is laudable, but error is our human reality. Suggesting anything else or failing to admit this fact to our patients is just bad medicine.

            1 https://www.medscape.com/slideshow/2017-malpractice-report-6009206#1. Accessed 10 December 2017.