Remember the quote from the old Love Story movie, "Love is never having to say you're sorry"? The unfortunate part is that apologies are critical to the survival of all relationships.

Believe it or not, medical professionals have been trained to never say they are sorry, even if they made a serious error in treating their patients. The whole thing began with a belief that admitting culpability was the first step to a lost malpractice lawsuit. Heaven forbid would you tell a patient or family of an error when they weren't already aware of it! That would invite a suit where none would have been!

To the contrary, it's a common experience for families to speculate about medical errors when a member suffers a surprising complication from medical treatment. And the result of family discussions often is exploring legal options. The drive for such painful discussions is often a feeling of betrayal and deceit by the medical professional.

Now it seems the issue is coming full circle, insurance companies, anxious to prevent lawsuits are encouraging medical providers to say they're sorry. It seems that it has resulted in fewer lawsuits!

Much of the time, there is something uncommonly right about common sense. Why is it we pay so little attention?

Insurance Journal

Some of Harvard Medical School's top teaching hospitals may add a lesson for their doctors: how to say sorry. A national specialist on patient safety, Dr. Lucian Leape, has led a group of physicians, patients, and hospital executives in drafting the policy for physicians to acknowledge and apologize for medical errors to their patients. The group has circulated a 50-page draft among hospital leaders, the Boston Sunday Globe reported.

The policy, if adopted, would create a uniform response to some of medicine's most difficult situations at Massachusetts General Hospital, Brigham and Women's Hospital, Beth Israel Deaconess Medical Center, Dana-Farber Cancer Institute, and Children's Hospital Boston. The hospitals would join a growing number of U.S. medical centers and malpractice insurers that embrace medical disclosures and apologies to patients. "I'm trying to get all the Harvard hospitals to adopt the policy,'' said Leape, a professor at the Harvard School of Public Health. "The time has come to be open with our patients.'' He declined to discuss details, saying the policy has not been completed.

[..]"Fifteen to 20 years ago coming through medical school and residency, we were implicitly, if not explicitly, told, 'Don't ever admit a mistake,' because it will come back to haunt you if you get sued.''

This is a very interesting article for several reasons. First of all, it supports my point of view about what makes treatment effective. Second it shows how misleading even technically academically correct research can be. The complete research manuscript can be found here.

Desire To Stop Drinking Could Be More Important Than Therapy

The positive outcomes of therapy for alcoholism may have less to do with the therapy itself and more to do with participants' determination to quit. These are the findings of a study published today in the Open Access journal, BMC Public Health, which provides a new analysis of previous data from Project MATCH, a clinical trial of three common forms of therapy used for the treatment of alcoholism. This analysis shows that the participants in the trial who attended all sessions did scarcely better than those who received no treatment. This contradicts previous analyses, which concluded that all three therapies for alcoholism were very effective.

First of all, one's commitment to treatment outcomes always has been the most important component in the success of treatment. Motivation in common usage refers to the energy it takes to follow through on a decision. My experience is significantly different. A major portion energy needed for change is invested in the decision and the commitment to follow through. Then the energy it takes to follow through is committed from the time of the decision and one is duty bound by honor to follow through, whatever it takes.

But then of course, people have various challenges they must meet to make the decision and follow through. Making a decision and commit to follow through takes a certain amount of self-knowledge and self-discipline. Then successful follow through requires skills to cope with emotions, crisis and interpersonal relationships. These skills become the essense of treatment and aftercare.

Then there is the issue of bad research. While technically, it's academically acceptable research, the problem is that it creates a misleading impression. The conclusion the authors make is based on the assumptions of the research. They assume that not drinking is the ideal outcome and a sufficient measurement of the effectiveness of treatment. It's reasonable to propose abstanence as an outcome in alcohol treatment research, but they sought no other measure that might tap some of the more complex outcomes that are more difficult to measure. Then the authors conclude that the treatments they used were roughly equivalent to each other and to no treatment. This seems like a reasonable conclusion. The problem is that the conclusion has very little value. The treatment they describe is merely the skeleton of what it takes to provide quality treatment and without the necessary aftercare regime. This minimal effort at treatment is certainly not what it takes to provide successful treatment. So they have measured the effectiveness of inadequate treatment and concluded it was little better than doing nothing at all! No surprises here.

Another key issue here is what is a reasonable measurement of treatment outcome for alcoholism. Traditionally, abstanence is the measurement of success. However, recent research suggests that some alcoholics can cut back and improve their quality of life. So the authors included drinks per day for one of the measures. However, that was not a sufficient measure.

The outcome that truly measures the effectiveness of treatment is the quality of life that it produces. This research follows the clients treated in a traditional "primary" CD treatment basically in the skills of avoiding drinking over a relatively short time, weekly sessions for 12 weeks. A critical element of treatment, aftercare, is omitted. There is no documentation that they were taught the skills of putting their lives back together, those skills they would need to make the choice not to drink and follow through possible. Then there was no follow up on the clients' quality of life after treatment through the follow up period. Did they have and keep a job? Did they have successful relationships? Did they manage life without requiring hospitalization or further treatment? What sorts of difficulties and successes did they experience during the follow-up period?

In my experience, people drink to manage what they feel about what has been missing in their lives. Therefore, once the client stops drinking, they need treatment on how to live their lives without alcohol. The research treatment taught clients how to not drink, not how to live. Then they checked with clients for 15 months after treatment to find out if they were still not drinking or how much they were drinking. Not surprisingly, the outcomes were not very good.

The real shame is that many people are going to conclude that CD treatment is useless. That is a real tragedy. Fortunately, CD and MH treatment is much more comprehensive than that which was offered to the clients in the study. People generally are treated for their symptoms and offered an opportunity to learn how to better live their lives. And outcomes in my experience, are much better.

Here is a more academically oriented comment I submitted to BioMed Central.

Did you know that almost all insurance companies require your therapist and your doctor to negotiate a mutually agreed upon treatment plan with you? I'd bet there are a few of you out there who will say it's not happening that way.

Counseling can easily go astray without an active discussion of your goals. Your counselor may have some good ideas, but if you don't agree, you will not make progress and may drop out of treatment pre-maturely. If you and your counselor haven't had a good discussion of goals, you maybe expecting results for which your counselor isn't helping and your counselor may be spending valuable treatment time on goals you don't think are that important.

Just like all relationships, good communication is essential. The same is true for your relationship with your doctor. If he doesn't understand what you want from your medication, he can't make the decisions you need to meet your goals. If you haven't talked to him about your goals, be sure you jot down a few ideas before your next session with him and bring them up. Both you and your doctor will be more comfortable with the results of a discussion of goals.

Enlightenment Bulletin Board :: The Relationship with Your Doctor is Important

...in a recently published study, commissioned by Janssen Pharmaceutica Products and co-authored by Dr. Diamond,.. psychiatrists and people with schizophrenia were asked to rank their treatment goals. The 199 consumers surveyed and the 291 doctors who participated have many of the same broad goals: improved overall happiness and mental health are at the top of the list of shared goals. Other similar rankings between patients and doctors included improved ability to express oneself to others, reduced depressive thoughts, improved family relationships, less agitation and irritability, fewer suspicious thoughts about others, less dependency on others, fewer sexual side effects and less frequent visits to the psychiatrist or counselor.

But the study also highlighted some differences between the goals of physicians and patients. Doctors valued minimizing the side effects of medication more highly than the patients did. And patients cared more about social activities than the doctors did.

The survey revealed that physicians have higher treatment goals than their patients. It suggests that patients may not have high hopes for the success of their treatment, and are not freely discussing their own unmet treatment goals with their doctors. Because of the survey’s findings, physicians are urged to discuss treatment goals and progress toward these goals with individual patients in order to increase their satisfaction.