The Power of Apology

When we were children, we often heard our parents say something to the effect of “Just tell me the truth and I won’t be angry.” And as parents ourselves, how many times have we said something similar to our own children?

It is interesting how we have either forgotten this lesson or simply don’t believe it applies when we are adults. That is a real pity. In addition to any psychological or spiritual benefits afforded to the person admitting to having performed in a less than perfect fashion, not being truthful can cost an erring individual or business a great deal of money, tarnishing a good name and reputation in the process.

A good example to illustrate this point is the medical profession in general, and doctors in particular. Whenever I work with doctors or a medical management group, the subject of liability is invariably raised. One has only to pick up a newspaper to realize that medical malpractice insurance premiums have soared, with some physicians actually leaving their practices because insurance has become cost prohibitive in an environment of shrinking reimbursements.

I will typically address this issue by first stating the obvious: Insurance premiums are continuing to rise because more doctors are being sued by their patients, and the dollar value of settlements awarded to plaintiffs is increasing faster than the national debt.

Next, I ask a question: “What are you doing to address the problem?” The responses run the gamut from self-insuring to requiring patients to agree to arbitration in lieu of litigating prior to their even being evaluated. The former poses the hazard of capital risk, and the latter is not likely to pass legal muster. The responses are revealing. They expose an expectation of being sued by patients, with the concurrent strategy to limit the financial exposure of a judgment favoring the plaintiff.

Curiously, in my consultations, no doctor or practice manager has ever talked about strategies to prevent being sued in the first place. Therein lies a tremendously expensive problem.

At this point I look at my audience and say,“You know in your heart of hearts that if you make an error in the treatment of a patient and the patient learns of your mistake, you are likely to be sued.” And heads all nod in agreement. They are appreciative that I understand their anxiety.

And then I say, “Of course, that often depends on how the patient learns of the mistake. If your patient sees another doctor who determines an error was made, and you never mentioned it (or perhaps tried to cover up the error in hopes they would never find out), you will likely be calling your attorney and your insurance company. But if you make a mistake and you have a relationship with your patient, and you (gasp) admit your mistake, explain your thinking in arriving at the course of treatment you chose, and apologize sincerely, you will significantly reduce your risk of litigation.

This statement draws significant skepticism, and it becomes necessary to explain to these protectors of life and limb what a powerful tool a humility-tempered apology can be. People do not hesitate to sue impersonal entities and businesses. They will sue a person they perceive to be arrogant, unfair or uncaring in a heartbeat. But in spite of the impression made by reality television courtroom dramas, people are hesitant to sue their friends. So I offer a simple, yet possibly life altering suggestion: be a friend to your patients.

What characteristics do we look for in a friend? First and foremost, I believe we want someone who is our friend to be worthy of our trust. We want our friends to be honest with us. We also want someone we can talk with. Not someone we can talk to, not someone who talks to us, but someone we can talk with. We communicate with our friends, and communication implies a two-way conversation flow.

All too often I have encountered doctors who refer to their patients not by name but by their condition: “I have a kidney stone in room 3,” or “Send the swollen ankle to the lab for x rays.” Patients hear these conversations, and are dehumanized by them. And friends don’t refer to friends in that fashion. Friends have names, families and stories.

The absolute biggest mistake a doctor can make is to lie to a patient or to be less than forthcoming regarding an error in treatment or judgment, and failing to apologize sincerely. This premise is contrary to popular wisdom, which all too often suggests the biggest mistake a doctor can make is to admit a mistake. It is not, however, contrary to the philosophy of treating patients as people, not as a procedure or source of revenue.

I am not attempting to make the case that absurd negligence can be overlooked. When a surgeon removes the wrong limb, there is a near 100% chance that he will pay a claim. I’m not talking about those instances of gross or criminal negligence. The courts are clogged with a continuum of cases of varying severity, and there is a point on that continuum at which a patient decides to litigate. I am talking about ways to move that point much further down the road, away from the decision to sue.

Let me provide an example: A few years ago, a young woman, ten weeks pregnant, exhibited symptoms of experiencing a miscarriage of the pregnancy. She called her obstetrician’s office and was told her doctor would meet her in the emergency room.

Upon arriving, he put her on an examining table, did an ultrasound, and announced that she had indeed had a miscarriage: the fetus was gone, with only fragments remaining. He advised a surgical solution (D & C) the next morning to ensure the process was complete.

The procedure was performed the next day (also the patient’s birthday) Following the outpatient surgery, the doctor spoke to her husband, saying everything went well, and that bleeding for a few days was normal and cramps could be expected to last for a week or more.

After grieving the loss of her baby for four days, the woman received a call from the hospital requesting that she come in immediately for another ultrasound (sonogram). She naturally asked why it was necessary. “Well, the lab results came back a little weird.”

This is probably a good time to mention that the patient is a Ph.D. level Registered Nurse. She educated the person calling to this fact, and asked for specifics. The reply was not at all what she expected.

“The sample from your surgery that was sent to pathology for analysis contained no fetal material.”

Thirty minutes later the woman was lying on the ultrasound table, and was able to see that in fact, a live fetus was clearly visible. Hard copy images were made, and the woman was advised to see her doctor immediately. That instruction was hardly necessary.

The woman (let’s personalize her and call her Tess) went immediately to the practice office and was quickly shown into the doctor’s private office. What the doctor didn’t know, and what I will demonstrate, was that this meeting was the defining moment in his treatment of this patient, and he had arrived at a most critical juncture. The manner in which he handled this situation would determine the future course of action Tess, his patient, would take.

The doctor had a few choices. His first choice was to be honest and forthcoming with an explanation of how his clinical findings and judgment had led his decision making; then to offer a sincere apology with an earnest commitment to the highest level of follow up care to maximize the viability of the pregnancy.

His second choice was to attempt to minimize his mistake and attempt to limit his culpability by being evasive and less than forthcoming about what had happened and why.

Sadly, he chose door number three. He outright lied.

The doctor told Tess, “Well, it seems you were having a miscarriage. You were carrying twins, and you lost one of them. It’s fortunate we cleaned out the debris from the baby you miscarried or infection would have caused you to lose the second baby too.”

The heroine of the story looked at him coolly and said, “If that is true, explain two things to me. First, why didn’t you know I was carrying twins, and second, why was there no fetal material in what you removed from my uterus?”

Defining moment number two. Admit the error, or say nothing more in an attempt to avoid self-incrimination? He again decided on the wrong plan B. Conventional risk management wisdom might agree with his choice, but truly, in matters of life and death, it is rarely if ever the right thing to do.

“Well, because you had a D & C and you continue to carry a fetus, you are now a high-risk patient. I’m sorry, but this practice cannot continue to treat you.” And with those two sentences, he walked out of the room.

After sitting in stunned disbelief for a few minutes, Tess went to the front desk and asked what she was supposed to do. The receptionist, obviously acting on orders from the doctor, said, “I really can’t offer any suggestions. When you find a new doctor, have him request your records and we will forward them.” And that was the last conversation that took place directly between the patient and her OB/GYN practice.

This might seem like an extreme case of patient and crisis mismanagement, but that is unfortunately not the case. Doctors have been instructed by both their insurance carriers and by counsel not to say anything that admits liability or could cause a patient to litigate. While this might be sound advice under some circumstances, it is precisely the type of behavior that will increase a doctor’s risk of losing his shirt and his lab coat. The irony is that it is precisely this type of impersonal response that will send a patient running to an attorney. And this isn’t just a business transaction on the part of the patient as it might be for the doctor. It is personal. Patients trust their health and lives to doctors. I believe that all too often physicians fail to credit their patients as thinking people. Patients want good outcomes, but they can understand and accept risk when they feel their doctors are being honest and including them in the decision making process. Not only are patients thinking people, they are feeling people. Failure to attend to this part of the patient/provider relationship is arguably the biggest risk a physician can take.

In the aforementioned case, the anguish for Tess was just beginning. No local OB/GYN practice wanted to take her case. Traumatic days went by before she found a practice that would see her, and it was in another city over an hour from her home. She was in a state of high anxiety (read an emotional wreck) over the health of her baby and the state of her pregnancy. During the remaining seven months of the pregnancy, she worried constantly about losing the baby (the risk of miscarriage had, because of the unnecessary surgical procedure, increased a hundredfold ); she had concerns about the health of her unborn child; and she was concerned (obsessed) with the implications for his postpartum health. Would he be deformed? Developmentally delayed? Have other health issues caused by the surgery to her womb during the critical days of his development? Those concerns can be summed up in three words: “pain and suffering.” And she is determined to extract payment for her pain and suffering from the person who treated her so badly.

I have spoken with Tess at great length regarding her experiences with this doctor and the manner in which she was treated. There is one theme that has been consistent in all our conversations: if he had been honest about what had happened, apologized sincerely, and then did everything in his power to help her through the remainder of her pregnancy (including finding a high-risk practice to handle her case), she would not have sued him. “Mistakes happen, and people are human,” she has said. “He didn’t misdiagnose a miscarriage and then (thankfully) botch a D & C on purpose. But he lied to me. He put his financial security ahead of my needs as his patient. And then he turned his back and walked away. He treated me like I was not worth his time after he broke me. And I want him to know that is not ok.”

Had he apologized, there would have been no need for pre-trial discovery. And through the discovery process it was learned that Tess’ surgery was performed without the benefit of ultrasound. The doctor requested the ultrasound equipment, but decided to proceed with the surgery without it, rather than wait for its arrival. The desire to save a few minutes and not put himself behind in his surgical schedule took precedence over his patient’s well being. (Tess is convinced he had a tee–off time booked at his country club that he didn’t want to miss.)

I often advise clients to be guided by a variation of the “Golden Rule.” Treat your patient, client or customer the way you would want your spouse, child or parent to be treated in the same situation. One could only hope that Tess’ doctor wouldn’t want his wife, mother or daughter to receive this kind of (mis)treatment. And if that is the case, why would it be acceptable to treat someone else’s wife, mother and daughter in this way?

What would you advise your client to do in this situation? Duck and cover? Or be truthful, apologize sincerely and help in any way possible?

Tess gave birth to her son in November of 2006. The child was born with a number of birthmarks: on his ear, his back, his foot. He has a hearing deficit, and his speech has not developed normally: he is difficult to understand and the words he uses to form sentences are atypical of normal speech patterns and commonly seen language pathology in a child his age. His intelligence, as best as can be determined, is above average, but he experiences extreme frustration in making himself understood. The case has not yet gone to trial.

Lest the reader think that Tess and her husband would have sued even had the doctor admitted his error, sincerely apologized and acted in a caring, compassionate fashion befitting status as a human being, I can categorically state that is not the case. I am Tess’ husband. The child is my son.

Here is totally different example. The industry shares few similarities with medicine, but the theme is the same: When you mess up, ‘fess up.

Some years ago I worked with a large manufacturer of frozen dairy products. As is the case with most companies that manufacture products which contain different ingredients or components, this company did business with a number of suppliers.

They issued product specifications to each of their vendors, and performed inspections at those suppliers’ facilities, confirming good manufacturing procedures (GMPs). Still, sub-standard product sometimes managed to slip through the most stringent quality assurance checks. The result was that foreign objects (nutshells, fruit pits, small stones) sometimes found their way into product that was manufactured, shipped and ultimately sold to the consumer.

The original procedure for handling foreign object related injuries (most often broken teeth) was to refer the customer to a claims adjuster who would in turn file a claim on behalf of the injured party with the supplier of the contaminated ingredient. At that point, the dairy product manufacturer usually had no further contact with the customer. I say usually, because sometimes they did hear from the customer again, or the customer’s attorney.

What caused the customer to retain counsel? Upon investigation, I found that once the claim was handed off by the manufacturer to their supplier, the injured customer received less than stellar service. Frankly, the supplier was unconcerned with whether or not the dairy manufacturer lost a customer, and had little or no interest in spending any time resolving the customer’s problem. Often the only indication of customer dissatisfaction was the arrival of a demand letter from the customer’s attorney at the dairy company’s corporate offices. Many billable hours later, the manufacturer often paid thousands of dollars to settle claims that could have been resolved for a few hundred if handled differently.

I approached this problem the way I do all challenges: Not with a “What should we do?” mindset, but rather, “What is the end result we wish to achieve?” The first approach fights fires while the second facilitates the development of systems that will achieve the desired end result.

In this instance, the goal was twofold. We didn’t want to get sued, and we wanted to convert unhappy customers into fiercely loyal supporters.

Accomplishing that goal required a total system redesign, beginning with how customers were handled upon initial contact. The procedure in place was impersonal and conveyed concern for the company, not the customer. If someone called and said, “I was eating your ice cream and I broke my tooth on a nutshell.” the immediate response was, “Give me your name and phone number and I will have our independent claims adjuster contact you.” That response did nothing to convey any sense of concern for the customer. It did communicate to the customer that they were in for a time consuming, frustrating experience by giving the (correct) impression that the company was mustering in “cover your butt” mode.

The new system we implemented was very different. Upon receiving a call of that nature, the very first thing the person receiving the call would say was, “I am so sorry to hear that. Are you ok?” And after hearing the customer’s response, “How can I help?”

The difference between the two responses is worlds apart. The first approach does nothing to connect with the customer. The second approach disarms them; they called expecting a bad experience, and instead reached a sympathetic and caring real person who wanted to help them. First impressions are lasting ones, so it was critical to make an excellent first impression.

It has been shown that the number one thing that improves how a customer views a business is knowing someone who works at that business. We made sure than anyone contacting our company would have a friend there. That action, being a friend to our customers, paid huge dividends.

The “back of the house” systems changed dramatically as well. Working with our insurance carrier, I was able to negotiate a change in claims procedure. Instead of sending our customer to a claims adjuster, the caller was told, “I am the person who is going to help you get this taken care of. Let me give you my toll-free number. And by the way, are you calling us on our 800 line now?” If the customer was not (and that was usually the case), the next response was, “Let me take your number and I’ll call you right back at our expense.” This accomplished three things. First, it provided us with the customer’s phone number. Second, it told them we really were interested in making the process as easy and painless as possible for them. And third, a callback meant the customer was speaking to the person at the company a second time. The first time he was a stranger on the other end of the phone line. This time he was the customer’s friend at the company: the person who was helping. Seemingly little things to be sure, but little things are often what shape perception, and perception is a very big thing; often it is everything.

Once the customer was immediately called back and all the necessary information was gathered, i.e. their name, address, product information, etc., they were told, “I am going to give our insurance company a call. You should be hearing from Mary Jones at XYZ insurance company within the next thirty minutes. Is that convenient? She will need your permission to contact your dentist. I will call you later today to make sure she was in touch, and to see how you are doing. Is there anything else I can do for you right now?” And almost always the response was something to the effect of, “Wow! No, I think you have covered everything Thank you very much.” The conversation would end with, “You have my toll-free number. Don’t hesitate to call if there is anything at all I can do for you.”

The next step was to call the insurance company and speak to Mary Smith, our personal adjuster. We requested the insurance company assign one adjuster to us, and when a client is paying over a million dollars in annual premiums, requests are taken seriously. This was important: we needed to have an excellent relationship with our adjuster, and in order for that to happen, the folks involved need to know each other. Mary would take the information we had already gathered, contact the customer, obtain a medical release, and run a check on the claimant (there are scam artists out there who earn their living or supplement their income by filing fraudulent claims against businesses). Assuming everything was as presented by our customer, Mary would then call their dentist, authorize treatment and guarantee payment. She would then fax the info to us, and we would call the customer. That conversation went something like this: “Hi Mrs. Jones. This is Bob at Ice Cream Central. I just spoke with Mary Jones at our insurance company. She has spoken to your dentist, and everything has been taken care of. You can make an appointment to have your tooth repaired, and you won’t need to pay anything out of pocket. We have handled everything.” After giving Mrs. Jones a few seconds to pick herself up off the floor, we would then say, “We are really sorry this happened, Mrs. Jones. We will of course be sending you a refund for that ice cream that caused the problem, as well as a bunch of free ice cream as a token of our appreciation for having a customer as nice as you. Is there anything else I can do to help?” And believe it or not, the answer was always, “No. Thank you.”

So what happened here? It’s pretty simple really. From the point of initial contact, the customer was treated like a real person. She didn’t get the runaround. She didn’t encounter a cold, impersonal corporation that was more interested in protecting their bottom line than helping her. And she didn’t need to do anything. Everything was arranged for her. And further, she didn’t need to wait. The entire issue was resolved almost immediately. In fact, our goal was to have all claims resolved within 24 hours, so overwhelming the customer with caring, stellar service delivered so quickly that the customer didn’t even think about taking legal action.

Our insurance company subrogated the claim back to our nut supplier’s insurer for repayment. We had negotiated a clause in our supplier agreements that said our insurer would handle all claims made against our product using standard adjusting criteria. We expected reimbursement from the supplier’s insurer within 30 days, or the monies paid by our carrier would be deducted from the next invoice the supplier presented to us for payment.

There were also instances where we clearly didn’t have any legal liability, but we decided to pay the claim anyway, because it was the right thing to do. An example would be a 90 year old customer eating our product and breaking a denture on a piece of candy that was a listed ingredient in the product. In this case, the customer (or one of his adult children) might call and explain what had happened. Sometimes, upon learning the customer was living on social security and unable to afford a denture repair, we picked up the tab. The criteria we used to make the determination to pay was simple: if this was my parent, how would I want him to be treated? And it was a win/win situation. The customer was happy, continued to purchase our products, told all his friends how well he was treated by those wonderful people at the ice cream company, and the company acquired more customers.

How well did the system work? In the first year, we reduced the amount of money paid out in claims by over 75%. This was in spite of a 400% increase in claims (caused by a shipment of ingredients contaminated by an inordinately high number of foreign objects). The number of incidents that resulted in legal action dropped to zero. Our insurance carrier actually lowered our product liability premium. And best of all, our customers loved us, continued to purchase our products and told their friends about us. We treated them like the important people they were.

If only physicians thought their patients were as important as the ice cream company knows their customers are, many medical malpractice lawsuits would never see the light of day.

Never underestimate the power of apology. In a business climate that depersonalizes the customer experience, a company that can demonstrate true partnering with their clients will set themselves above the competition. Best of all, they can save money in the process, thus increasing their bottom line. Saving money and making money by treating people well? It isn’t a gimmick and it’s easier than it sounds. Business doesn’t get much better than that.