Medical Mistakes and Disclosure: The Role of the Medical Student

“TO ERR IS HUMAN,” DECLARES THE TITLE OF THE RECENT, well-publicized report by the Institute of Medicine. According to this study, errors cause between 44000 and 98000 deaths annually in hospitals in the United States. While these figures have gained much attention, this is not the first examination by the medical community of its mistakes. Since 1990, several studies have also scrutinized medical error. These publications mark a break from the traditional secrecy surrounding mistakes by physicians. A new approach in medicine encourages physicians to acknowledge mistakes, both to themselves and to others. Physician error commonly affects patients, physicians, and other health care providers. A 1998 study of registered nurses, for example, showed 33% were aware of at least 1 incident of patient harm caused by physician error in the previous month. Those surveyed reported a troubling dilemma in deciding when to report other health care providers’ mistakes. Similarly, some medical students will witness physicians’ medical mistakes. The student must then reconcile conflicting desires to ensure patient welfare through truthtelling with those to protect and remain loyal to the teaching physician. Facing this dilemma, the medical student will find many reasons to facilitate disclosure of the error. A physician has a multifold ethical duty to admit mistakes to the patient. As the American Medical Association Principles of Medical Ethics states, “A physician shall . . . be honest in all professional interactions.” Moreover, in cases in which “a patient suffers significant medical complications that may have resulted from the physician’s mistake . . . the physician is ethically required to inform the patient of the facts necessary to ensure understanding of what has occurred.” This ethical requirement to inform the patient of the mistake can be concluded from both deontological and consequentialist perspectives, that is, both by considering the ethical value of the action alone and by considering the possible consequences of the action. The patient-physician relationship is fiduciary in nature; as such, it relies on principles of autonomy, beneficence, nonmaleficence, justice, and fidelity in all actions. The physician must act in the patient’s best interest at all times. Most often, disclosure of mistakes would benefit patients. For instance, to gain patient cooperation, it is often necessary to explain exactly how a condition arose. In some cases, knowledge of a mistake could affect the patient’s current and future decisions regarding care. Thus, to maintain autonomy and to give true informed consent, the patient must know of relevant errors. Also, understanding that a mistake occurred may relieve patients’ anxieties about slow recovery or complications. Even knowledge of an iatrogenic cause could allay fears that a worse problem exists. Providing such relief is an important example of beneficence. To knowingly allow continued anxiety would constitute maleficence, as the physician would consciously impair the patient’s well-being. Furthermore, if the physician’s error resulted in increased costs to the patient, justice would dictate disclosure to ensure patient compensation. Indeed, some cases may require monetary reimbursement to the injured patient. Finally, fidelity demands truth-telling at all times. A recent survey of patients found that 98% desired acknowledgment of even minor mistakes. This refutes the assertion that nondisclosure “protects” patients by maintaining an image of physician infallibility; patients want physicians to disclose their errors. For all these reasons, and because a physician must always act in accordance with the principles of the patient-physician relationship, disclosure is clearly the ethical action after a medical mistake. In addition to reasons arising from these principles, consideration of future consequences also compels the physician to disclose errors. Accurate information could improve the patient’s subsequent treatment. Other caregivers can then work with better facts, while the cooperation of the informed patient greatly facilitates recovery. Additionally, disclosure could aid in relief of the physician’s own emotional stress while fostering a stronger patient-physician bond. These practical results alone suggest disclosure is the best course of action. While it is relatively clear that a physician has the ethical obligation to admit medical errors, what should the medical student do when the physician refuses to disclose a mistake? In determining a course of action, the medical student must consider duties to the patient, physician, and himor herself. It is inappropriate for the student to unilaterally disclose the error, yet the student must not allow the patient to be deceived. Although the student’s responsibility to the patient does require acting to facilitate disclosure, the same responsibility precludes responding to patient queries by accusing the physician of error. In clinical situations, the medical student has a unique relationship with the patient. The student often accepts the description “student doctor” and thus is obligated to maintain ethical conduct appropriate for a physician. As such, all of the reasons for physician disclosure considered above also apply to the medical student. However, there are also reasons a medical student should not independently tell a patient of a physician’s mistake. The student’s limited medical knowledge may make it difficult to explain the nature of the error adequately. Also, a small number of patients specify before treatment that they do not