MEDC
— stands for “Medical Error Disclosure Competence.”
The roots of this construct lie in my dissertation, where I combined and triangulated scientific theories from various academic disciplines into one heuristic predictive “Physician Mistake Disclosure” model (2009). In the subsequent years, I validated and tested this model over a long-term systematic scientific study program that was funded by Wake Forest University’s Social, Behavioral & Economic Research Grant (2010) and the Swiss National Science Foundation (2013-2016). I summarized the final result of these studies in a set of thoroughly tested and scientifically validated “MEDC” safe disclosure guidelines (see below).
Premise
My research has evidenced that providers' disclosure skills affect patients' perceptions of disclosure adequacy, and predict beneficial or harmful disclosure outcomes. When patients perceive their physician’s communication as adequate, they experience disclosures as relationship enhancing. When they perceive it as inadequate, they distance themselves from their physician and potentially even harm themselves. Thus, MEDC triggers outcomes that affects the patient, provider, and the provider-patient relationship. Adherence to the MEDC guidelines also reduces financial and reputational risks for individual providers and institutions, particularly in the context of a sentinel event.
Content
MEDC Safe Disclosure Guidelines
GUIDELINE 1: DISCLOSURE PREPARATION
A. CONTEXT
In preparation for the disclosure, take into account the following contextual considerations:
Decide whether the disclosure is beneficial to the patient’s health condition; if not, consider disclosing the error to a family member instead or disclose it later when the patient is stable.
If possible, the patient should bring a care companion to the disclosure.
Invite a neutral (external) third party to the disclosure (as a person of trust for the patient).
Be prepared to send the patient a written account after the disclosure so the patient can revisit and better understand the communicated information (if desired by the patient).
Make sure you schedule plenty of time for the disclosure (no time limit would be ideal).
Recognize the disclosure as a gradual, sequential conversation (there will be more than one meeting with the patient, the patient will need time to process and revisit the information).
DO NOT invite too many care participants to the disclosure – the number of clinicians should not outnumber the patients’ side.
DO NOT disclose an error over the phone.
B. MOTIVATION
Enter the disclosure with the motivation to…
establish a close, trusting relationship with the patient (as a foundation for mutual empathy).
maintain a relationship with the patient (opening the door for the patient to return in the future).
invest into the relationship with the patient (“paying for” the error in relational terms).
demonstrate relational sincerity (take the patient seriously, convey genuine respect).
straighten things out for the patient (e.g., in light of the error’s impact on the patient’s life).
alleviate the implications of the error for the patient’s personal and professional life.
DO NOT appear avoidant, distant, or defensive
C. KNOWLEDGE
Enter the disclosure with informed knowledge about the patient’s…
informational preferences (i.e., participatory or authoritarian care style).
medical history/records.
personal preferences (e.g., what type of person the patient is, what the patient [doesn’t] want).
DO NOT enter the disclosure unprepared.
GUIDELINE 2: DISCLOSURE SKILLS
During the disclosure, demonstrate the following communication skills:
Attentiveness (i.e. sit in front or next to the patient; directly face the patient; occasionally lean toward the patient; make appropriate eye contact with the patient; look at the patient while s/he talks; show the patient that you are listening to him/her; show the patient that you have made it a priority to be here with him/her; seek personal contact with the patient and take his/her comments seriously; demonstrate a certain devotion to the patient’s needs; show the patient that you truly care for his health and well-being).
Composure (i.e. humbly try to calm down the situation; use a calm voice; calmly explain what happened; talk with calm confidence).
Coordination (i.e. pause occasionally/appropriately to give the patient an opportunity to react).
Expressiveness (i.e. display a small smile when you enter the room; use a kind tone of voice; talk to the patient very clearly; try to talk in simple terms; be empathic but do not get too emotional – remain informative and clear).
Interpersonal adaptability (i.e. embrace any cognitive, linguistic, informational and/or emotional needs/expectations that the patient expresses, verbally or nonverbally, during the disclosure conversation; feel out the patient and see how s/he reacts; for example, be sensitive to the patient’s needs to decide something on his/her own; adapt to the patient’s language, check whether the patient understands what you are saying; try to get inside the patient’s head and skin; get a feel of how much information the patient needs so s/he does not get overwhelmed; see whether the patient needs a hand on the shoulder).
DO NOT introduce physical barriers to the conversation (e.g. a desk in between you and the patient, stacked-up charts, a ringing phone or beeper).
DO NOT use technical language or medical terms that the patient cannot understand.
GUIDELINE 3: DISCLOSURE CONTENT
During the disclosure, make sure to explicitly state the following contents:
Always maintain your communication skills! Give the patient opportunities to ask questions; keep your calm voice; stay attuned and adapt your informational contents to the patients’ needs and expectations; pay close attention to the patient while you explain things; keep your own nonverbal displays in mind and be careful not to overwhelm.
Be as open, honest, transparent, and authentic in your communication as possible.
Admit and assume responsibility for the error (if applicable, a statement of responsibility should also be conveyed by your supervisor).
Make sure to express remorse.
Provide an explanation of (a) what happened to this point in time (chronologically), (b) why the patient is there, (c) why and how this could happen, (d) what should have been done, and (e) if applicable, what the patient needs to do now as a consequence of the error (e.g., adjusted behaviors/medication intake etc.). Succinctly and clearly discuss the (a) consequences of the error and (7) corrective steps that will be taken.
Discuss what you will do / suggest do to next to correct the situation and/or repair the consequences of the error.
Discuss how you intend to repair the patient’s health (so that the patient feels better).
Offer the patient psychological support.
If applicable, offer the patient financial reparation (that any extra costs will be covered).
If applicable, discuss how you intend to repair the patient’s professional life (e.g., inform the patient’s employer).
Ensure future forbearance by stating that you will actively engage in an investigation to reflect and draw consequences from this experience to prevent such errors in the future (conveying that the error didn’t happen for nothing, but that it led to improve things).
DO NOT ramble around.
DO NOT ignore or deny the error.
DO NOT downplay the situation / make seem everything half as bad.
DO NOT display any arrogance whatsoever.
Scientific Background
Hannawa, A.F. (2019). When facing our fallibility constitutes “safe practice”: Further evidence for the Medical Error Disclosure Competence (MEDC) guidelines. Patient Education & Counseling, 102(10):1840-1846.
Hannawa, A. F. & Frankel, R. M. (2018). “It matters what I think, not what you say”: Scientific Evidence for a Medical Error Disclosure Skills Model. Journal of Patient Safety. doi: 10.1097/PTS.0000000000000524.
Hannawa, A. F. (2017). What constitutes "competent error disclosure"? Insights from a national focus group study in Switzerland. Swiss Medical Weekly, 147:w14427.
Hannawa, A. F., Shigemoto, Y., & Little, T. (2016). Medical errors: Disclosure styles, interpersonal forgiveness, and outcomes. Social Science & Medicine, 156, 29-38.
Hannawa, A. F. (2014). Disclosing medical errors to patients: Effects of nonverbal involvement. Patient Education & Counseling, 94, 310-313.
Hannawa, A. F., Beckman, H., Mazor, K., Paul, N., & Ramsey, J. (2013). Building bridges: Future directions for medical error disclosure research. Patient Education and Counseling, 92, 319-327.
Hannawa, A. F. (2012). Principles of medical ethics: Implications for the disclosure of medical errors. Medicolegal and Bioethics, 2, 1-11.
Hannawa, A. F. (2012). Die Kommunikation nach einem Zwischenfall – Die Bedeutung des nonverbalen Verhaltens. Therapeutische Umschau, 69(6), 363-366.
Hannawa, A. F. (2012). "Explicitly implicit": Examining the importance of physician nonverbal involvement during error disclosures. Swiss Medical Weekly, 142, w13576.
Hannawa, A. F. (2011). Shedding light on the dark side of doctor-patient interactions: Verbal and nonverbal messages physicians communicate during error disclosures. Patient Education and Counseling, 84, 344-351.
Hannawa, A. F. (2009). Negotiating medical virtues: Toward the development of a Physician Mistake Disclosure (PMD) model. Health Communication, 24, 391-399.