Wednesday, January 17, 2007

The art of apology

Recently I admitted a patient whom I told I was going to give a blood transfusion, but didn’t. You see, when his repeat blood count came back, it showed that the transfusion probably wasn’t necessary. I canceled the order pleased that I was sparing him an unnecessary transfusion, but unfortunately, I never told him that. He lay in bed all night wondering where the heck his blood was, just waiting for the transfusion to start. When I popped into his room for morning rounds, he understandably was irritated. I brightly announced that he wouldn’t need a transfusion after all, to which he responded sourly, “it would have been nice if somebody would have told me that last night.”
“Oh, sorry, didn’t the nurse tell you?” I asked uneasily.
“No, nobody told me.”

I left the room not only feeling guilty about having been remiss in updating him the night before, but professionally embarrassed because I was now going to have to pass off a grumpy patient to the day team. I also felt ashamed at having tried to blame his nurse, and enough so that before leaving the hospital I went back into his room.

“Hey, I just wanted to say I’m sorry for leaving you in the dark last night. I should have been the one to tell you that the transfusion was off, not the nurse. I'm the one at fault.”
His mood shifted completely.
“That’s all right,” he said smiling warmly. “Say, it’s shaping up to be a mighty fine day, do you think I’ll be able to go home by this afternoon?”
I grinned. “We’ll see what we can do.”
I was forgiven, and I felt so much better.

Sometimes I feel like I’m the only one who has noticed that it can feel really good to apologize. Not that the apologizing itself is so great – you do after all have to admit that you were wrong – but the potential for forgiveness can make it very appealing. Think about it – you injured somebody, but through apologizing you have a chance to restore relations and make amends, even to wipe the slate clean. That’s powerful. Yet, we live in a society that is loathe to apologize. Our celebrities and leaders rarely apologize, and when they do it is done so cautiously that it hardly seems like an apology at all. Any admission of wrongdoing is removed, and the blame is often placed on the offended party for misinterpreting the well-intentioned words of the apologizer.

Consider the Pope. Back in October, in a move that probably wasn’t his wisest, the Pope quoted 14th century Christian Byzantine emperor Manuel II on Islam in a speech at the University of Regensburg in Germany:

Show me just what Mohammed brought that was new, and there you will find things only evil and inhuman, such as his command to spread by the sword the faith he preached.

Afterwards, he issued the following ”apology”:

At this time, I wish also to add that I am deeply sorry for the reactions in some countries to a few passages of my address at the University of Regensburg, which were considered offensive to the sensibility of Muslims. These in fact were a quotation from a medieval text, which do not in any way express my personal thought.

I’m sorry for your over-reaction? If that’s not heartfelt I don’t know what is. For some reason people seem to think that if they can include the word “sorry” somewhere in a statement, it then becomes an apology. Pope Benedict’s apology only deepened the initial insult by affirming that he stood by his original statement, and by insinuating that those who were offended were actually the ones in the wrong.

To me, explaining what exactly you are sorry for is one of the key elements to a good apology. An ex-girlfriend of mine used to refuse to do that. She said that if I didn’t know what she was apologizing for, I probably didn’t deserve the apology in the first place. To her, an apology was a three-word phrase, spit out as if it was some despicable thing: “Fine, I’m sorry!” Unfortunately, besides obscuring the apology’s meaning and making me question its sincerity, this also left me in the position of doubting whether she knew what she was apologizing for herself. (e.g. that she wrongly accused me of forgetting to take the car in for repairs, that she refused to talk to me for two hours afterwards, or that she called me an incompetent idiot during the ensuing fight)

Apologizing can be difficult, though, and sometimes we’re not sure exactly how we hurt somebody. If, as someone who was wronged you are able to explain your feelings and don’t insist completely on the other person figuring them out on his or her own, you are going to receive much better apologies. Asking for (not demanding) an apology can be a great way to resolve a conflict. A good discussion can often also lead to a double apology – after you apologize the other person both accepts and apologizes back, usually for over-reacting or handling the misunderstanding ungraciously. With a double apology, you really know you are forgiven. I think that might have been what Pope Benedict was going for when he got the parts mixed up: he was supposed to apologize for what he said, and the Muslim leaders were supposed to apologize for the over-reaction, not the other way around.

As physicians we’re really bad at apologizing, for multiple reasons. We’d like to blame it mostly on the lawyers, but the truth is that most of us (66% in a large study published by the Archives of Internal Medicine) believe that apologizing to patients actually reduces our medical liability. Even if the legal climate doesn’t prevent us from apologizing, though, I think it does negatively impact the language that we use. When pronouncing people dead, for example, we commonly tell family members, “I’m sorry for your loss.” To me this just sounds cold and detached, and I think the reason we say it that way is because we want to be clear that we aren’t accepting any liability for the death. Expressing sorrow for death, though, is a benevolent apology that doesn’t naturally imply accountability. I prefer the more simple, “I’m so sorry,” which I think shows family members that I’m on their side.

I suspect that what we’re really afraid of in apologizing and admitting medical mistakes to patients is losing their confidence. Without the trust of our patients, we are worthless as doctors, and that is a frightening proposition.

The art of apology is tricky and filled with potential pitfalls and misunderstandings, but I wish that our leaders would be more ready to put themselves on the line with higher quality apologies. A person willing to apologize is a person whom I’m willing to trust, but someone who withholds apologies is either weak or mean-spirited. The difficulty and fear involved are not reasons to back away from apologies, but are what make them refreshing and meaningful in the first place. Without them, forgiveness can simply not be granted. And I would suggest that when you’ve hurt somebody and feel bad about it, there’s nothing better than to be forgiven.