Français

Disclosure


Maintaining trust

Communicating honestly


  • What if the patient doesn't know an adverse event (accident in Québec) happened?
  • What should physicians do when the clinical care in question was delivered by another provider?

Case: A 64-year-old with syncopal episode
Two male physicians discussing x-ray image

Background

A 64-year-old woman is admitted to hospital following a syncopal episode. She is diagnosed with heart block and treated with a pacemaker. Prior to discharge, a chest X-ray is done to investigate her chronic cough. You perform the discharge summary.

One year later she is diagnosed with advanced lung cancer. The chest X-ray, done during the previous admission, had revealed a nodule in the left upper lobe of her lung. The chest X-ray report was present in the medical record at the time you did the discharge summary but you did not see it. As a result, it was not followed up.

The thoracic surgeon believes this nodule could have been resected if it had been diagnosed at the time of the previous admission. The patient would have had a better prognosis and would have required less invasive treatment.

Think about it

  • Would you consider this to be an adverse event?
  • Should the patient be told of the reason for the delay in the diagnosis of the lung cancer?
  • Who should disclose this to the patient?
  • What would you say if you were disclosing this to the patient?
  • Would you apologize?

Suggestions

This delay in diagnosis is an adverse event and should be disclosed to the patient.

The thoracic surgeon should notify your attending staff or the most responsible physician at the time of the patient's previous admission.

Your attending staff should have the disclosure discussion with the patient.

You are encouraged to offer to attend the meeting(s) to learn and to provide your own apology for your part in what happened.

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Case: Young woman with black irregular nevus
Upset-looking young female

Background

You are working as a locum in a family physician's clinic. A young woman presents with a black irregular nevus which she says has been increasing in size over the past year.  She hadn't been too concerned about it as the family physician had reassured her it wasn't anything to worry about.

You biopsy the nevus just to be certain there is no malignancy. Unfortunately the pathology shows a malignant melanoma arising in a compound nevus.

Think about it

  • Would you consider this to be an adverse event?
  • What will you say if the patient asks why this nevus wasn't biopsied earlier by her family physician?
  • Who should discuss this with the patient?
  • Would you apologize?

Lessons learned

Most often, adverse clinical outcomes result from the progression of the patient's underlying medical condition.

The clinical appearance of this patient's nevus needed to evolve to the point at which a reasonable physician would identify the need to perform a biopsy.

Suggestions

An honest, simple explanation of the variable progression of the pathophysiology from nevus to melanoma should be provided and should reassure the patient.

If the patient has additional questions, she may be referred to her family physician.

It is helpful to alert the family physician of the patient's concerns and the information you have already shared with the patient.

The discussion should be supportive of the other healthcare providers and not judgmental of the care provided.  

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