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Medical students must be taught to deal with mistakes ethically

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Picture: Karin Retief – Medical student Matete Mathobela, left, in training with Dr Shiraaz Shaikjee at G F Jooste Hospital. Medical students must be intentionally taught how to face difficult situations such as admitting making errors in treatment of patients, the writer says.

By Dirkie Swinfen

A family member of mine took her baby girl to the doctor with a weeping birth mark. The treatment given made the birth mark a lot worse and they went back to ask advice. The doctor became defensive, insisting that the correct treatment had been given. There was an attempt to shift the blame to the parents. They were troubled by the way they were treated and felt the doctor did not care. This episode made them cynical towards healthcare professionals in general.

This story caused me to reflect on difficult conversations that doctors regularly face and how to handle situations where treatment did not go to plan. Together with Prof Mathys Labuschagne and Prof Gina Joubert, I asked the question whether medical students are adequately prepared for the daunting task of disclosing medical errors.

Doctors expected to be honest and open

There is a myth that doctors should be perfect and that a good doctor should never make any mistakes (Kling, 2018). However, medical mistakes remain common despite increasing patient safety measures worldwide. These mistakes can have severe consequences for the patient. It can also have profound effects of guilt and self-doubt on the doctor, as well as litigation (Wu, 2000).

According to a study at the University of the Witwatersrand in 2017, the main barriers to error disclosure in South Africa are fear of victimisation by colleagues and fear of litigation (Carmichael, 2017). Dr Larisse Prinsen, a University of the Free State senior lecturer in law, recently explored the reasons for sky-rocketing numbers of medical litigation cases in the South African setting published in The Conversation.

None of us likes making mistakes and it can be very tempting to try and hide mistakes rather than admitting to them. However, doctors are expected to be honest and open even when treatment did not go to plan. Researchers found that patients are less likely to pursue legal action when they have received a clear explanation from the doctor following a medical error (Robbenolt, 2009).

When researchers asked doctors whether error disclosure was the right thing to do, more than 70 percent of them said yes. However, when they were asked whether they had disclosed their last error, only 16 percent replied yes (Ghalandarpoorrattar et al., 2012). There was an apt description of this contrast between beliefs and behaviour in 2013: ‘Ethics says yes, but instinct says no’ (Detsky, 2013).

Admitting errors is difficult and will not come naturally. Medical students must be intentionally taught how to face these difficult situations, but are they? Error disclosure has been included in the UK medical communication skills curriculum for some time. However, in the South African setting, researchers found that specialists and postgraduate trainees reported little training in this complex communication skill (Moodley et al., 2021). In terms of undergraduate students there was hardly any information regarding training in error disclosure.

Review training in disclosure of medical errors

Students at the UFS Medical school were asked to review training they had in the disclosure of medical errors. These findings were interpreted in the light of available literature. This formed part of a wider study in which medical students reviewed the communication skills training they had received as undergraduates.

The study had a cross-sectional, descriptive and quantitative design. Fourth- and fifth-year medical students at the UFS completed anonymous questionnaires to review the doctor-patient communication skills training.

The findings showed that almost three-quarters of fourth-year students (73.9 percent) and considerably more than half of fifth-year students (61.1 percent) reported that training in error disclosure was infrequent. Almost half of the fourth-year students (49.2 percent) rated themselves as novices in this skill, while a little over half of fifth-year students (53.3 percent) rated themselves as average in this skill.

This is an area where there is a huge need and an opportunity for professional growth through learning and teaching. Role modelling of the right behaviour is essential. Medical educators should nurture honesty and humility in medical trainees so that patients can trust medical graduates.

Training in error disclosure is just one thread in the tapestry of patient safety. Making use of the simulation unit can equip students to become skilled in procedures prior to performing these procedures on patients. Training in patient safety measures such as safe prescribing, good note-keeping and clear interprofessional communication are other aspects of paramount importance.

Furthermore, system factors that could increase errors such as insufficient staff to deal with the workload and inadequate resources should be addressed. Most importantly, the myth of perfection should be debunked. In that way, errors can be reported and prevented, rather than hidden and lamented.

Dr Dirkie Swinfen is a lecturer and medical officer at the School of Biomedical Sciences, University of the Free State. Her research paper won first prize in the Best Educational Paper in the Junior category at this year’s Faculty of Health Sciences Research Forum.