Ethics check: When your colleague makes a mistake

Medical errors: They’re one of the most troubling aspects of medicine. And unfortunately, they’re commonplace. A 2016 British Medical Journal analysis found that medical error is the third leading cause (after heart disease and cancer) of death in the US, killing more than 250,000 people each year.^[]

But what’s a doctor supposed to do if they discover a colleague’s mistake? Medical ethical codes—and a medical ethicist—offer answers.

AMA guidance

The AMA defines an error as “an unintended act or omission or a flawed system or plan that harms or has the potential to harm a patient.”^[]

This must take place regardless of legal liability.

Even if an error doesn’t affect treatment or therapeutic options, doctors should:

• Disclose the error, explain it, and give the patient what they need to make an informed decision.

• Acknowledge the error and express “compassionate concern” toward the harmed patient.

• Explain what was learned from the error and what’s being done to prevent it from happening again.

• Maintain care continuity for the patient. Facilitate a transfer if the patient has lost trust in the original physician.

The AMA also offers guidance on what to do if a doctor catches a confirmed or potential error committed by another HCP. They should:

• Encourage the HCP to tell the patient about the error.

• Report colleagues who may be impaired or incompetent.

American College of Physicians guidance

The ACP offered additional directives on reporting colleague errors in a case study.[3]^[] The organization noted that “disclosing errors to patients presents physicians with a situation where the principle is clear but the practice is difficult.” That difficulty, however, does not eliminate a physician’s obligation to address the error.

According to the ACP, important considerations for dealing with a colleague’s error include:

• Timing: The urgency of the patient’s condition and the error should dictate how quickly the discovering physician informs the colleague and patient.

• Mitigation: What systems led to the failure, and how might they be improved?

• Legal implications: “Physicians' ethical responsibility to tell the truth always trumps any concerns they have about legal action,” the ACP wrote. The organization noted that it would be appropriate for the clinician who committed the error to notify their liability insurance carrier.

• Challenging emotions: A medical error—whether a colleague’s or your own—is bound to stir up some unpleasant emotions. Discuss them with trusted friends, colleagues, or family, and seek professional counseling if you need additional support.

Core virtues

The ethical guidance offered by the ACP and AMA is clear, but its application can be challenging. MDLinx turned to Lydia Dugdale, MD, director of the Center for Clinical Medical Ethics at Columbia University, for practical insights on real-world scenarios.

“Honesty and integrity are core virtues for the physician," she continued. "Having said this, there are, of course, circumstances in which a patient might ask not to be told something.”

For example, Dugdale said that a patient facing a potential cancer diagnosis may ask that the physician tell their spouse, not themselves. Or, a doctor might be asked to respect their cultural belief that a person shouldn’t be told when they’re dying.

“These scenarios are different from one in which a patient was harmed and a doctor attempts to disguise, obscure, or deny responsibility for the doctor's role in causing the harm,” Dugdale said.

An ethics case study

Exploring another hypothetical situation, MDLinx asked Dugdale to consider an American Family Physician case study in which one physician discovers another’s error.^[] The error is a misdiagnosis: tuberculosis instead of early-stage lung cancer. An earlier diagnosis could’ve saved the patient’s life.

According to Dugdale, in this situation, the doctor who missed the diagnosis is obligated to tell the patient. Things get a bit murkier for the physician who discovered the error.

“This is largely because the second doctor wasn't present at the conversation about tuberculosis, and thus it becomes a matter of ‘he said, she said,’” Dugdale acknowledged.

How the second doctor approaches the situation may or may not yield any benefit. Even a gentle query, never mind a more direct confrontation, could cause the culpable physician to become angry. On the other hand, being found out could compel that physician to take responsibility for the error.

“The second doctor would have to exercise practical wisdom to know which course to take,” she added. “Regardless, the second doctor might suggest to the patient that she find a new primary doctor.”

Experience and errors

Dugdale said that experience and competence have little impact on a physician’s ethical obligations.

“If, for example, a new doctor makes an error due to inexperience, that error still must be reported and the consequences addressed,” she said. “But if the physician is incompetent, then that doctor's supervisors have a duty to provide additional oversight until the young physician can practice medicine autonomously and competently.”

And if a physician cannot achieve competence, then they can’t continue in the job, she added.

This dynamic can also create a thorny scenario. What if, for example, it’s the junior resident who discovers the senior attending’s error? What are the ethical implications there?

“Those in junior positions should seek counsel from an ombudsperson, program director, supervisor, or department chair,” Dugdale added.