Authors: Robert Troug, David Browning, Judith Johnston, Thomas Gallagher
This book addresses the often overlooked subject of communication between physicians and patients following adverse events. It set out ‘… to explore the critical yet exceptionally difficult conversations that follow adverse events and errors…’ (page xiv). The authors explored the sentiments underpinning these discussions, sentiments that are ‘…more about feelings than words, more about heart than methods…’ (page ix). They stressed that ‘…how something is said can have as much impact as precisely what is said’ (page xv). They approached the subject from the perspectives of patients and their families, as well as of the affected physicians and institutions.
The authors set out what they consider to be good communication practice after harm. They built on Lucian Leape‘s foreword which listed the essential principles of disclosure which are honesty, transparency, and apology (page viii). The book explored the practical steps of disclosure using 34 guidelines which cover issues such as timelines of communication, emotional support, and the need for follow-up (page 74). They reviewed what disclosures should contain, where and when they should take place, and who should be involved (pages 75- 91). They also offer invaluable tips, such as the advice to ‘…resist the pressure to come up with premature explanations…’ (page 88).
The book makes several recommendations to health institutions to improve and support their disclosure process. An important example is the introduction of disclosure coaches. These are people who are trained in disclosure communication, and who provide ‘just-in-time‘ guidance immediately after adverse events. They facilitate collaborative conversations (pages 69-71), and are guided by five core relational values: transparency, respect, accountability, continuity, and kindness (TRACK, page 66). Another important recommendation for institutions developing disclosure strategies is to use the 4-A framework; this consists of promoting awareness, creating accountability, developing disclosure ability, and turning ability into action.
The book also addresses the barriers to disclosure which are ‘…deeply rooted in the human psyche…’ (page 121). These include the fear of litigation, the hierarchical nature of medicine, the ‘fantasy of perfection‘, and ‘medical narcissism‘ (pages 41-44). These obstacles explain why clinicians often do not disclose errors to patients and their families, and this practice results in a disclosure gap. This situation is further compounded by patients ‘who may be too intimidated or unsophisticated to ask the right questions’ (page 6). The authors however say these factors do not lessen the ethical and judicial responsibility of physicians to disclose harm. They reassure that a well-managed disclosure process minimises the emotional impact of harm on patients and their families, and sustains the patient-doctor relationship (page 32).
The book covers several other topics such as apology laws and their impact on malpractice suits. It discusses the concept of the second victim in relation to the emotional impact of harm on physicians (pages 43). The authors highlight the inadequate training physicians receive in disclosure communication. They also cautioned against some patient safety practices such as the zero adverse events policy which may hinder, rather than enhance, disclosure (page 30)
This relatively small and handy book exhaustively addresses a subject that hasn’t received the attention it deserves. It offers very practical guidance to encourage and support a very difficult process for both patients and their care givers. The authors addressed the broad spectrum of disclosure, highlighting the necessary steps of the process. They proffer excellent recommendations although some, for example disclosure coaches, may be difficult to implement.
Patient harm is ever present in health care, and the aftermath affects patients and physicians alike. The book complements similar texts on the subject such as After Harm and The Patients’ Guide to Preventing Medical Error. The authors have provided a practical approach to a delicate subject, and I highly recommend the book.
- Publisher, place and year: The Johns Hopkins University Press, Baltimore, 2011
- Number of chapters: 11
- Pages: 172
- ISBN: 978-0-8018-9804-4
- Price: £15.50
- Rating: 5 stars