Transparency is now part of providing quality care.

An ophthalmologist is a perfectionist — someone who doesn’t sweat details shouldn’t work in such a vital, delicate space. Unfortunately, it is impossible to avoid undesirable outcomes in the practice of medicine.

Of course, bad outcomes are not always the result of an error. The Institute of Medicine’s (IOM) 1999 landmark report To Err is Human defines an adverse event as any harm from the provision of medical care, while it defines an error as failure of a planned action to be completed as intended, or use of the wrong plan to accomplish a goal. Since then, both doctors and patients have become more aware of the prevalence and impact of medical error.

Two years later, with its publication of Crossing the Quality Chasm, the IOM defined transparency as a critical component of high-quality health care. This includes disclosure of errors, a practice endorsed by the Joint Commission, American Medical Association, American College of Surgeons and many malpractice insurers, including the Ophthalmic Mutual Insurance Company (OMIC).

BENEFITS FOR BOTH PARTIES

Disclosing errors runs counter to many physicians’ understandable instinct to divulge as little as possible. However, many great reasons exist to communicate more openly with patients.

For instance, a study at the University of Michigan showed that a disclosure and compensation program actually reduced claims, lawsuits, dispute length and cost.¹ Physicians who disclose errors may also experience less guilt and emotional distress.² Transparent communication also meets patients’ and families’ needs. They expect honest communication after an error, including a clear statement that an error or mistake occurred, an explanation of what happened and why, discussion of how it will affect them, and an understanding of how they will prevent future errors. They also want doctors to apologize after committing errors; some states protect these conversations from being used against physicians if litigation ensues.

It is also a professional responsibility and a cornerstone of ethical practice to be open and honest with our patients. Of course, any discussion of this type should take place only after discussion with risk management or your malpractice carrier. If you fail to talk to your insurer first, you may be in violation of your obligations under your policy. It’s also helpful to touch base with your carrier, because insurers have coaches who can prepare you for the patient conversation.

DO YOUR HOMEWORK FIRST

I recommend seeking out training in disclosure or similar patient communication skills.³ The need to have an actual error disclosure conversation is fortunately rare, but these skills will improve your ability to communicate in an effective and patient-centered way in all situations.

Communication about medical error and adverse events is just one example of how medical-legal issues impact clinical practice. One reason I decided to pursue a MD/JD is the fact that physicians feel uncomfortable and unrepresented in this area.

As the articles in this issue of Ophthalmology Management demonstrate, some things that concern doctors the most have fewer medical-legal implications than feared, while other areas actually do not elicit enough concern. I’m grateful to all the authors who have contributed their time and experience to this first medical-legal issue of Ophthalmology Management.

Hans K. Bruhn, MHS shares lessons from OMIC’s case database, which is a tremendous resource for the types of issues that have led to claims and caused defense problems. Neil H. Ekblom, Esq., an experienced attorney in ophthalmology malpractice defense, gives guidance on reducing the risk of claims. An ophthalmologist who was sued (and won) shares lessons learned from the experience, while Jennifer B. Cohen, JD, and Mark E. Kropiewnicki, JD, go beyond malpractice to talk about employment and contract issues in ophthalmology.

And, if you have ever wanted to discharge a patient but were unsure of your footing, Cynthia Matossian, MD shows you the right steps to take in The Enlightened Office. OM

REFERENCES

1. Kachalia A, Kaufman SR, Boothman R, et al. Liability claims and costs before and after implementation of a medical error disclosure program. Ann Intern Med. 2010;153:213-221.
2. Yardley IE, Yardley SJ, Wu AW. How to discuss errors and adverse events with cancer patients. Curr Oncol Rep. 2010;12:253-260.
3. White AA, Brock DM, McCotter PI, Shannon SE, Gallagher TH. Implementing an error disclosure coaching model: A multicenter case study. J Healthc Risk Manag. 2017;36:34-45.

Bryan S. Lee, MD, JD, is a cornea, cataract and refractive specialist in private practice at Altos Eye Physicians in Los Altos, Calif. He serves on the AAO Council and Online Education committee as well as the ASCRS Young Eye Surgeons committee and Phaco Fundamentals Classroom Editorial board.