I apologized as a doctor. This is what happened…
“I’m sorry you feel that way.” He let out this classic non-apology, after I explained why he needed to apologize to me, followed by one of those “I know exactly how you feel because I was in the exact situation as you” impossibilities.
I sighed at the sound of these frequently used sentences that meant to invalidate, and left the conversation at that.
Gosh, I will never non-apologize to someone like that. I vowed to myself.
Little did I know, before long, I had a few opportunities to practice the art of apology myself as a doctor: once to a nurse, and another time to a patient.
Spoiler alert! The world didn’t end in either occasion! But in both cases, I gained precious insight to my own pride and vulnerabilities.
“I’m sorry I raised my voice.”
At some point in nursing school, all nurses must have learned 2 important skills: 1) how to tell the doctors what to do in the form of asking a question nicely (example: “Dr. Zha, I see you are about to put in another dose of Cytotec, but are you worried about tachy-systole?” ); and 2) apologizing to everyone even though they have done nothing wrong (example: [in the middle of the night] “I am sorry to bother you, Dr. Zha, but your patient is complaining of 10/10 crushing chest pain, can you come to evaluate them?”).
But this culture of apology is not reciprocated by the doctors, unfortunately.
As a young attending physician, I am simultaneously acutely aware of my lack of experience/knowledge, and weirdly defensive about it. Frankly, it’s a very exhausting dynamic. And it’s like the itch-scratch cycle of eczema: the more I try to hide my ignorance, the more I get offended by others pointing it out, and the more I try to hide…
“Dr. Zha, would you like to use the Word catheter?” After opening a Bartholin cyst (a blockage of mucus gland near the vagina resulting in a painful, enlarging lump), Alice, the nurse who was helping me, asked.
Word catheter, a balloon catheter that goes into the skin to keep the cyst draining, was an excellent idea! There was just one problem: I’ve never placed one, or even watched anyone place one. I have read about it, but that was it.
I thought about making up some excuse why a Word catheter was not needed just so I could avoid admitting that I didn’t know how to use it. But I fought the urge. I have a lot of imperfections, but I’m no liar, I said to myself.
“Alice, that’s probably a good idea. But I’ve never used it before.” As I let out this admittance, I could feel my face turning red under my mask, afraid of being judged. I pivoted away from her gaze in an effort to end the conversation.
“Well, Dr. Wood usually just puts in it and infuses some saline…” Not taking a hint, Alice continued her suggestion.
Today, when I recall this conversation, I don’t remember hearing any hint of judgement or disappointment in Alice’s tone. But in that situation, at the nursing station with a few others potentially listening in, what Alice said sounded like “Dr. Wood is a better doctor than you. Dr. Wood has learned the basic medical skills but you haven’t. Dr. Wood…”
“Then why don’t you go get Dr. Wood to see this patient?” I snapped, and said loudly.
Immediately after those words left my mouth, I regretted it. Before this, I sounded like a young doctor who was honest about her inexperience. But now, I sounded like someone too proud to learn. And I think we can all agree that the former possesses a much better chance to become a better physician than the latter.
Alice was a little stunned, and muttered “OK” under her breath, and walked away. I went back to my desk, turned the procedure book to the page on Word catheter insertion. Then with my tail between my legs but my pride in my head, I grabbed another nurse to help me put the catheter in. The case went very well and the outcome was excellent. But the incidence ate at me.
I needed to apologize to Alice for yelling.
I rehearsed in my head how I would do it. At some point, “sorry I yelled, it was because I was in a hurry”, or “I didn’t want to bother Dr. Wood that’s why I raised my voice” both sounded pretty good. But…
Gosh, I will never non-apologize to someone like that. Remember that? Ok, fine.
The next morning, I found Alice by herself at the nursing station. I took a deep breath, and said:
“Alice. I am sorry I yelled at you yesterday. It was not OK. And I won’t do it again.”
Alice looked at me, and didn’t say anything at first, as if waiting for me to say more. But there was nothing more to say. So I waited, too.
“Doctora. You are fine! What you did was nothing compared to what I’ve seen. You are a pussy cat compared to some other doctors!” Alice extended a very humorous olive branch at me. It relaxed, yet saddened me. This is the reality nurses live, where doctors are too proud to admit they are assholes, sometimes.
2. “I’m sorry, I was wrong in my diagnosis.”
A mother brought her son in for knee pain after falling onto it during Frisbee practice. Worried about a fracture, I got an X-ray.
I take pride in always looking at my own X-rays, even though I am not a radiologist. I always put my own interpretation in the note, followed by “pending formal read by radiologist”. This time, after reviewing the X-ray, I was convinced that a small piece of bone was chipped off from the lower leg bone, just below the knee joint.
“Unfortunately, you broke your leg here,” I said to the patient and his mother, pointing at the area of “fracture” on the X-ray picture I printed out for them.
“Oh wow!” The mother exclaimed as she took over the paper. “What do we do now?”
I put the patient in a knee brace and send him out on crutches, after putting in an orthopedic surgery referral. There is nothing a teenage boy hates more than hopping around in crutches! And it showed in his face. “But if the radiologist disagrees with my reading, I will call you.” The radiologist wouldn’t disagree with me, it’s an obvious fracture, I thought.
The radiologist disagreed with me. “Normal knee.” Said the report.
What? That has to be a mistake! I immediately called the radiologist, who nicely explained to me that sometimes, in young teenagers, the tibial tuberosity can look a little separated from the rest of the bone, and it’s considered normal. “If you don’t believe me, you can ask the patient to come in and get an Xray of the normal knee, and compare the two.” He said, after realizing that I was not going to be convinced.
So I called the patient’s mother to explain to her about my disagreement with the radiologists’ assessment, and why I thought it was a good idea to get an X-ray of the normal knee to compare. “OK. We will come back in and get the X-ray.”
This X-ray will prove me right.
It didn’t. The normal knee looked exactly the same as the “broken” knee! I was wrong, and the radiologist was right. And it only took the patient’s family the price of a knee brace, crutches, and an additional X-ray to prove me wrong. Although the brace and the crutches were just an innocent mistake which happens every day in medicine, the additional trip and X-ray was just to pay for my own pride.
“Hi, this is Dr. Zha. I am calling you about the X-ray result of your boy.” My voice was somewhat quiet, as I was about to admit my mistake. And I was secretly glad this conversation was happening on the phone.
“Yes?” The mother said, after sensing an awkward pause.
“Well. It’s not a fracture. I was wrong about the diagnosis. And…I…I am sorry about the additional trip and X-ray you had to do.” I braced myself for more questioning, maybe some anger, and was ready to help them dispute any charges of these visits that was caused by my mistake. But perhaps what made this conversation much harder than it needed to be, was my fear that the parent would think of me as someone incompetent. “You don’t know how to read an X-ray?” Or “Dr. So-and-So would have gotten it right the first time" were some imaginary scolding options in my head. “You are not good enough.” Basically.
“Girrrrrrrrrrrl! Don’t worry about it!” The mother, who was about my age, laughed on the phone.
“What?” I had been called a “girl” a few times before by older patients who meant to patronize me. But I sensed no patronizing tone in her voice. On the contrary, it was reassuring.
“Girrrl! I appreciate you double checking! It happens! In fact, we are going to both switch to you as our doctor. ” Once again, I was given an olive branch with a comic relief. And I gladly took it.
These two incidents got me thinking about apologies in medicine. In my life outside of medicine, I don’t hesitate to apologize. “Sorry I interrupted you.” “Sorry my dog jumped on you.” “Sorry I’m late.” “Sorry I didn’t get back to you earlier.” Etcetera, etcetera. But in medicine, it’s as if we all take on a different persona: one that’s hardened, all-knowing, and non-apologetic.
Who infused the idea of perfection in medicine? As if standard of care was just this non-evolving, matter-of-fact thing that was easy to execute? When did the culture of non-apology rise and take over the humanism of medicine? And when will it end?
Traditionally, doctors are advised to not apologize for medical mistakes in fear of malpractice law suits. However, more and more researches are indicating that sincere apologies themselves can mitigate hard feelings from patients and families, resulting in fewer law suits. Additionally, disclosing medical error is a powerful way to improve patient-physician relationship.
Recently, I conducted a poll on Twitter, asking voters if they would sue their doctor if he/she apologizes sincerely. And here is the result:
Out of the 152 people who voted, 82% said they would accept the apology and forgive the doctor. Many commented that it depended on if there was irreversible physical damage done. And only 18% said they would sue/file complaint anyway.
The issue of apologizing and disclosing medical errors remains complicated. In my above cases, obviously, the mistake was not severe, and no permanent damage was done. And this blog post is not meant as a legal advice, of course. In fact, some research data show that the implementation of “apology laws” by state legislation, where the apologetic statements cannot be used against the physician in court, has not actually reduced the rate of malpractice suits.
However, what I could say with certainty is this: apologizing made me more human to both the nurse colleague, and the patient’s family. This was evident by Alice calling me a “pussy cat” (which I had to look up the meaning of afterwards), and the mother’s endearing “girrrrrl” comments. By saying “I am sorry. I was wrong. And I wish to not do it again.” I gave the recipients the permission to see me as an equal, a person whose pride comes secondary to her ethics, and a fellow human they can relate to.
Practicing medicine shouldn’t require us to take on a totally different persona than our true selves. The sooner we come to terms with the complexity of our identity as mere humans, the sooner we can be free from the pretense. And hopefully one day, the persons whom we become in the exam rooms can match the persons who we truly are.
*The story of the above patient and staff were based on a true story, but the details and names were significantly altered to protect confidentiality.*
*This is not legal advice.*
