Errors happen in dentistry and across medicine, with the worst mistakes causing as many as 250,000 fatalities each year. Guidelines to normalize and encourage error disclosure are available to improve patient safety and healthcare outcomes, though they don’t address the psychology that influences how and when practitioners disclose errors and manage their consequences. Researchers now are calling for better education and training focused on these psychological challenges to reduce the number and severity of these errors.
“We must transform the culture of error disclosure in the medical community from one that is often punitive to one that is restorative and supportive,” said Neha Vapiwala, MD, an associate professor of radiation oncology, vice chair of education at the Perelman School of Medicine at the University of Pennsylvania, and co-author of the study. “And to do that, we must tend to the psychological challenges that medical professionals wrestle with when they face the possibility of disclosing an error.”
Initiatives such as the Disclosure, Apology, and Offer model have helped make moderate gains in creating a culture of transparency in health systems, according to the researchers. But these efforts primarily focus on the legal and financial aspects of error closure and do not address other barriers, such as the fear, shame, and guilt that come with error disclosure.
“Arguably, these psychological factors are harder to overcome, especially in this modern age of social media where healthcare providers can be reviewed and scrutinized in very public forums,” said Vapiwala. “There is real concern that any little slipup can live on the Internet for the rest of someone’s career.”
The researchers identified a pair of main cognitive biases that often hinder error disclosure: Fundamental Attribution Error, which is the tendency to overestimate one’s own role in a situation, and Forecasting Error, which is the tendency to overestimate the impact and duration of negative consequences while underestimating the ability to recover from those circumstances.
For example, if an error led to a patient injury, the physician might initially overstate his own role in that error rather than examine any systematic reasons for why that error occurred. The physician may then also overestimate the long-term consequences or recovery time for the patient, leading to feelings of both self-blame and exaggerated doom, both of which damage the physician-patient relationship and may impede a care provider from reporting the error.
“Overcoming these biases is akin to suppressing a reflex. It requires self-awareness, practice, and, most importantly, education and training,” Vapiwala said.
The authors offer several strategies to overcome these patterns, utilizing elements of social psychology to transform the current culture of error disclosure. Recommendations include incorporating standardized patients (SPs), actors who simulate patients not only to “practice” difficult patient encounters but also to help model interactions with family members, peers, and administrators to teach various behavior and coping mechanisms. SPs can effectively mimic the psychological elements of error disclosure, including profound guilt, feelings of ineptitude, and fear of repercussions, the researchers said.
Virtual reality (VR) also can offer an immersive and realistic experience to supplement traditional curricula while providing tremendous scalability at a lower cost than SPs, the researchers said. For example, one recent VR exercise allowed viewers to experience the perspective of a 12-year-old Syrian refugee to incite more compassion and understanding. While similar VR medical content doesn’t currently exist, it is on the horizon for many medical trainees and professions. Still, SP and VR are limited, as users know they are using simulations.
“Standardized patients and other simulated scenarios provide an excellent foundation. But until you are put into a real-world situation and forced to confront your mistake and its potential consequences, you can’t truly understand the psychosocial challenges,” said Jason Han, a fourth-year student at the Perelman School of Medicine and co-author of the study.
Finally, the researchers recommend implementing a professional standard for trainees, including a formal evaluation of the skills needed to disclose and cope with medical errors. This standard would further normalize error disclosure and make it a common practice among physicians and trainees, they said. The researchers conclude that the primary change will need to be cultural, not just among trainees but at every level of medical practice to successfully pivot away from the current stigma related to error disclosure.
“Administrators must make a shift from asking who is at fault to asking why and how did a situation occur, creating a culture that embraces error disclosure and seeks to solve the many systematic factors that led to an error in the first place,” Vapiwala said. “This approach will not only normalize error disclosures but also help us better understand why they happen so we can prevent more of them in the future.”
The study, “Applying Lessons from Social Psychology to Transform the Culture of Error Disclosure,” was published by Medical Education.