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Forgiveness. Is there anything more difficult to do than ask for forgiveness? Is there anything more powerful to enable a healing process to begin than asking for forgiveness? Like many physicians, I have struggled with my imperfections in a world where perfection is expected – and imperfection is punished. Once we come to acknowledge the Alexander Pope quote (and the title of the first Institute of Medicine Report in 1999), “To Err is Human”, the next step is to remember that he also noted, “To Forgive, Divine”1.
Take a journey with me to the foundation of improvement in health care: forgiveness. It is safe to talk about what organizational change needs to occur to spur improvement in the high risk, high consequence environment of health care. It is much harder to talk about individual changes among health care professionals (clinicians and managers) that might lead to safer and more professionally satisfying roles in health care. This commentary will explore both types of changes, because organizations are fundamentally about people – their behaviors, beliefs, hopes, and conflicts.
In peeling the onion of health care dynamics, the layers that come off before forgiveness include high error rates, unanticipated adverse outcomes, compassion, high liability costs, service problems, and a failure to make patients and families the center of the health care universe. Before outlining the forgiveness connection, let me share a story.
At the National Patient Safety Foundation annual meeting last year, I chose to attend a small breakout session on “The consumer perspective of safety”. During that session, as a nationally known patient safety advocate generated group discussion about her experience in losing her mother more than a decade earlier, one of the audience members had a profound comment. He is a well known figure in the health care industry. His wife was the victim of medical error several years ago that left her brain injured and in a long term care facility. His life has been forever altered by this tragedy. This is what he said:
“People want to forgive, but we (health care professionals) don’t make it easy for them to do that.”
He and others in that session spoke about the silence that they encountered when trying to learn what happened. Wanting to prevent someone else’s loved one from a similar fate, they described the frustration and anger that arise when no one talks with them. Worse yet, many related the unwanted and unpleasant experience of having to speak through attorneys in a highly adversarial situation.
After thinking about the importance of allowing forgiveness to occur in these tragic, unanticipated, and unintentional situations, I began to realize the power of forgiveness in my own life as a physician – and how difficult it is for physicians to forgive ourselves in these situations. (It is even difficult to write about it – I want to make it less personal by using the term “themselves” instead of “ourselves”, but have resisted the temptation.)
Organizational Reasons for Forgiveness
The reasons for health care organizations to focus on allowing victims of medical error to forgive are numerous. First and foremost, it is the right thing to do. Medical ethics teaches that Respect for Persons includes telling the truth, and Beneficence calls for acting with charity and kindness. Telling the truth, apologizing, and expressing remorse uphold the time-honored principles of medical ethics.
Second, if health care organizations are serious about their missions of healing, it is impossible to ignore the healing that must occur after a tragedy if all participants (including health care professionals) are to regain physical and emotional health. Victims tell us consistently that the anger and vengeful feelings that come when truth, apology and remorse are missing is an unhealthy situation. We know from our experiences as physicians that the angry and vengeful heart is an unhealthy heart. The Dalai Lama, in his book “The Wisdom of Forgiveness”, says:
“But revenge…..this creates more unhappiness. So think wider perspective: revenge no good, so forgive. Forgiveness does not mean you just forget about the past. No, you remember the past. Should be aware that these past sufferings happened because of narrow mindedness on both sides. So now, time passed. We feel more wise, more developed. I think that’s the only way.”2
Sister Diane Traffas, a dear friend and former colleague, wrote this about saying “I’m sorry”:
Christ is our model for how we are to behave when confronted with vulnerability. Jesus always illustrated trust by offering hope, courage, and a caring presence to others that said, “I am with you.” We who say we want to be His hands and ears and eyes for the healing profession betray our calling if we do any less.”3
Third, a growing body of evidence suggests that liability costs of health systems can be reduced by full disclosure and apology. The early experience of the Lexington, KY Veterans Hospital outlining reduction in claim costs4, and more recent reports from the University of Michigan Health Systems of 50% reductions in claims and more than 50% reduction in attorneys fees are encouraging signs of the power of apology.5
Personal Reasons for Forgiveness
But now it’s time to get personal. Why should an individual, particularly a physician, make him/herself vulnerable to a brutal legal system, critical colleagues, or angry patients by asking forgiveness for a mistake? Physicians’ personality characteristics have been studied for years by several authors. Some of the findings make it especially difficult for physicians to acknowledge error, and to express responsibility. For example, physicians typically are very sensitive to criticism, are perfectionistic and compulsive, and often have low self esteem6. Many are “alpha males”, who tend to be uncomfortable showing vulnerability, and take high performance for granted7.
With this background then, it will be difficult – but not impossible – to change patterns. Based on my own personal experience as a physician – and more importantly as a human being with all my wonderful flaws and imperfections that come with that designation – here is how I see forgiveness applying to each one of us as health care professionals.
- Think of yourself as a human being first, a physician second. We are no different in our ability to make mistakes than other humans. Forgive yourself for making unintentional mistakes because you are not perfect – and never will be. If necessary, forgive yourself for being human. Get off that pedestal that has been built (sometimes with our own sweat) for physicians.
- Realize that errors are not usually your fault alone. It generally takes a series of circumstances lining up in just the right way for a catastrophe to occur- the “Swiss Cheese” model of error8. Don’t personalize the error – look for what can be fixed in the system that allowed the error to occur.
- Understand that admitting error, and apologizing for it, is a characteristic of great people. It takes strength of character to acknowledge responsibility, and to show compassion for victims of medical misadventure.
- Trying to keep quiet about our accountability will affect our own health because we know our Hippocratic instinct is to tell the truth. Asking forgiveness for our humanness, and allowing patients or families to forgive us, can begin the healing process for ourselves – as well as for our patients.
- If we acknowledge our human frailties as physicians, then we should be able to realize that we can create work processes that include communication techniques with other human beings to minimize the opportunity for human error. For example, we can learn from aviation, from deck hands on aircraft carriers, from companies outside of health care that produce products or services with few defects how to build safety into our work. In my case, I learn from my oldest son, a young pilot who is willing to quit his job if his concerns about flight safety are not addressed by his superiors. He has helped me understand the communication techniques that allow dangerous situations to get handled without challenging someone’s competence, or resulting in punitive consequences for the individual raising the concern. Another source of ideas for health care is Toyota, specifically the Toyota Production System, which stresses minimization of errors, and recognizes the creativity and good intentions of the people closest to the problem. Other industries or organizations may be of more interest to you. What is important is that we recognize the vulnerability of our health care system to error, and begin to search for solutions.
- Finally, I believe it is possible for us to recapture the excitement and promise of a career in medicine by becoming leaders for patient safety improvements in our organizations. We are lifelong learners. The body of knowledge on safety is huge, and just now being explored in health care. We have a sacred responsibility as healers, and as advocates for our patients, to do nothing less on their behalf.
Barry Silbaugh MD
Senior Healthcare Partner
Creative Management Group
bsilbaugh@swcp.com
President, American College of Physician Executives
1 Alexander Pope. Essay on Criticism. 1711.
2 His Holiness the Dalai Lama and Victor Chan. The Wisdom of Forgiveness: Intimate Conversations and Journeys. p. 109.
3 Sr. Diane Traffas, personal communication, June 2005.
4 Kraman S, Hamm G. Annals of Internal Medicine, 21 Dec. 1999, pp. 963-967.
5 Tanner L. “Doctors Eye Apologies for Medical Mistakes.” AP Medical Writer, Nov. 6, 2004.
6 Linney B. American College of Physician Executives, from presentation in June 2004.
7 Erlandson E. “Coaching the Alpha Male”, Harvard Business Review. May 2004.
8 Reason J. Managing the Risks of Organizational Accidents, p. 9.
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