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565
Articles
How
House
Officers
Cope
With
Their
Mistakes
ALBERT
W.
WU,
MD,
MPH,
Baltimore,
Maryland;
SUSAN
FOLKMAN,
PhD;
STEPHEN
J.
MC
PHEE,
MD;
and
BERNARD
LO,
MD,
San
Francisco,
California
We
examined
how
house
officers
coped
with
serious
medical
mistakes
to
gain
insight
into
how
medical
educators
should
handle
these
situations.
An
anonymous
questionnaire
was
mailed
to
254
house
officers
in
internal
medicine
asking
them
to
describe
their
most
important
mistake
and
their
response
to
it;
45%
(N
=
114)
reported
a
mistake
and
completed
the
questionnaire.
House
officers
experienced
considerable
emotional
distress
in
response
to
their
mistakes
and
used
a
va-
riety
of
strategies
to
cope.
In
multivariate
analysis,
those
who
coped
by
accepting
responsibility
were
more
likely
to
make
constructive
changes
in
practice,
but
to
experience
more
emotional
dis-
tress.
House
officers
who
coped
by
escape-avoidance
were
more
likely
to
report
defensive
changes
in
practice.
For
house
officers
who
have
made
a
mistake,
we
suggest
that
medical
edu-
cators
provide
specific
advice
about
preventing
a
recurrence
of
the
mistake,
provide
emotional
support,
and
help
them
understand
that
distress
is
an
expected
concomitant
of
learning
from
the
experience.
(Wu
AW,
Folkman
S,
McPhee
SJ,
Lo
B:
How
house
officers
cope
with
their
mistakes.
West
J
Med
1993;
159:565-569)
M
any
studies
document
that
house
officers
experi-
ence
considerable
stress
due
to
mistakes.'-4
Little
is
known,
however,
about
the
strategies
employed
by
physicians
to
cope
with
their
mistakes
and
the
extent
to
which
these
coping
strategies
affect
their
psychologi-
cal
well-being
and
subsequent
medical
practice.
Infor-
mation
about
the
relationships
among
mistakes,
coping,
psychological
well-being,
and
subsequent
medical
prac-
tice
would
help
medical
educators
assist
house
officers
to
respond
constructively
when
mistakes
occur.
Research
on
other
kinds
of
stress,
including
daily
has-
sles,
major
life
events,
and
chronic
illness,
suggest
that
some
types
of
coping
promote
adaptive
outcomes
while
other
types
of
coping
do
not.5-8
The
judgment
as
to
what
constitutes
adaptive
or
maladaptive
coping
in
a
given
context
depends
on
which
outcomes
are
important
in
that
specific
context.
Context
must
be
taken
into
account
be-
cause
a
particular
coping
strategy
can
be
adaptive
in
one
setting
but
maladaptive
in
another.
For
example,
choos-
ing
not
to
think
about
a
problem
can
be
adaptive
if
noth-
ing
can
be
done,
such
as
while
waiting
for
test
results,
but
can
be
maladaptive
if
problem
solving
and
action
are
ap-
propriate,
as
when
a
symptom
appears
that
calls
for
med-
ical
attention.9
In
this
study,
we
examined
two
outcomes
that
are
important
in
understanding
the
consequences
of
residents'
mistakes:
the
residents'
changes
in
practice
and
psychological
well-being.
These
outcomes
reflect
the
two
major
functions
of
coping:
a
problem-focused
function,
in
which
coping
is
directed
at
the
problem
that
is
causing
distress,
and
an
emotion-focused
function,
in
which
cop-
ing
is
directed
at
managing
the
emotional
distress
caused
by
the
problem.9"10
We
previously
reported
how
residents
changed
their
practice
following
serious
mistakes."
In
this
study
we
fo-
cused
on
the
ways
residents
coped
with
their
mistakes
and
how
different
ways
of
coping
were
related
both
to
resi-
dents'
subsequent
changes
in
practice
and
to
emotional
distress.
These
analyses
controlled
for
variables
previ-
ously
shown
to
be
related
to
residents'
reactions,
includ-
ing
causes
of
the
mistake,
severity
of
the
outcome,
and
institutional
reactions.
Methods
In
May
1989
we
mailed
an
anonymous
questionnaire
to
254
house
officers
in
three
internal
medicine
training
programs.
Programs
were
located
at
large
(greater
than
From
the
Department
of
Health
Policy
and
Management.
School
of
Hygiene
and
Public
Health
and
the
Department
of
Medicine,
School
of
Medicine,
Johns
Hop-
kins
University,
Baltimore,
Maryland
(Dr
Wu):
and
the
Department
of
Veterans
Affairs/Robert
Wood
Johnson
Clinical
Scholars
Program
(Drs
Wu
and
Lo).
Department
of
Medicine
(Dr
Folkman),
Division
of
General
Intemal
Medicine
(Dr
McPhee).
and
Program
in
Medical
Ethics
(Dr
Lo),
University
of
Califomia,
San
Francisco,
School
of
Medicine.
Presented
in
part
at
the
14th
annual
meeting
of
the
Society
of
General
Internal
Medicine,
Seattle,
WA,
May
1-4,
1991.
Reprint
requests
to
Albert
W.
Wu,
MD,
MPH,
Johns
Hopkins
University,
Health
Services
Research
and
Development
Center,
624
N
Broadway,
Baltimore.
MD
21205.
566
-
W
Nom
1993
--
-
19
N
5
500
beds),
academic,
tertiary
care
hospitals.
The
proce-
dures
and
development
of
the
questionnaire
have
been
de-
scribed
previously.'
Measures
Coping
was
measured
using
a
shortened
version
of
Folkman
and
Lazarus's
"Ways
of
Coping"
Scale.'2
The
shortened
version
included
six
of
the
eight
scales
that
make
up
the
scale,
and
each
comprised
three
items
from
the
original
scales.
Scales
measured
the
following
kinds
of
coping:
accepting
responsibility,
planful
problem
solv-
ing,
seeking
social
support,
emotional
self-control,
es-
cape-avoidance,
and
distancing.
Two
scales,
confrontive
coping
("I
tried
to
get
the
person
to
change
his
or
her
mind")
and
positive
reappraisal
("I
found
new
faith")
were
excluded
because
they
did
not
seem
relevant
to
medical
mistakes.
House
officers
were
asked
to
indicate
the
extent
to
which
they
had
used
each
strategy
to
cope
after
they
made
their
mistake.
An
example
of
an
item
from
the
accepting
responsibility
scales
is
"I
criticized
or
lectured
myself'
(Table
1).
Possible
responses
were
"not
used,"
"used
somewhat,"
"used
quite
a
bit,"
and
"used
a
great
deal."
Each
type
of
coping
was
measured
by
sum-
ming
responses
to
the
three
items
in
its
scale.
A
higher
score
indicated
a
greater
use
of
each
strategy.
The
possi-
ble
range
of
scores
for
each
type
of
coping
was
0
to
9.
The
development
of
scales
to
describe
residents'
reac-
tions
to
the
mistake,
institutional
response,
characteristics
and
causes
of
the
mistake,
and
residents'
subsequent
changes
in
practice
has
been
described
previously."
Emo-
tional
distress
in
response
to
the
mistake
was
measured
with
four
items.
Residents
were
asked
to
what
extent
the
mistake
made
them
feel
remorseful,
angry
at
themselves,
inadequate,
and
guilty.
A
mistake
was
defined
as
having
a
serious
outcome
if
the
house
officer
reported
that
it
re-
sulted
in
a
prolonged
hospital
stay,
a
specific
procedure,
a
change
in
therapy,
or
death.
Institutional
response
was
measured
with
two
items
that
asked
residents
how
they
felt
the
mistake
was
handled
by
the
institution.
Causes
of
the
mistake
were
described
by
three
scales:
inexperience
(3
items),
job
overload
(2
items),
and
case
complexity
(4
items).
Changes
in
practice
were
assessed
with
a
scale
of
constructive
changes
in
practice
containing
nine
items
and
a
scale
of
defensive
changes
containing
two
items.
For
each
concept,
scale
scores
were
created
by
summing
responses
to
items.
Because
constructive
and
defensive
changes
measure
separate
concepts
rather
than
polar
op-
posites
of
the
same
scale,
a
house
officer
might
report
both
constructive
and
defensive
changes
in
practice
after
making
a
mistake.
Analysis
We
performed
three
multiple
linear-regression
analy-
ses
to
investigate
how
residents'
coping
strategies
were
related
to
their
emotional
distress
after
the
mistake,
later
constructive
changes
in
practice,
and
later
defensive
changes
in
practice.
These
analyses
controlled
for
variables
previ-
ously
found
to
be
related
to
changes
in
practice:
the
per-
ceived
causes
of
the
mistake,
the
severity
of
the
outcome,
the
degree
to
which
house
officers
perceived
that
their
in-
stitution
was
judgmental,
and
house-staff
gender."
The
analyses
tested
whether
the
extent
to
which
residents
used
each
of
the
six
ways
of
coping
added
significantly
to
the
explanatory
power
of
the
independent
variables.
Results
Characteristics
of
Respondents
As
previously
reported,
of
the
254
residents
sur-
veyed,
114
(45%)
responded
by
reporting
a
mistake
and
completing
the
questionnaire.
The
114
respondents
who
completed
the
questionnaire
made
up
our
study
group.
Because
results
did
not
differ
by
site,
we
present
only
ag-
gregated
results.
Women
comprised
33%
of
subjects.
In
all,
36%
of
respondents
were
interns,
32%
were
junior
residents,
and
32%
were
senior
residents.
The
distribu-
tions
of
gender
and
year
of
training
were
similar
among
respondents
and
nonrespondents.
TABLE
1.-Ways
of
Coping
Scale
Scores
and
Item
Frequency
Scale
Score*
Ways
of
Coping
(Cronbach's
a)
Mean
SD
%
Usedt
Accepting
responsibility
(.45)
.......
4.9
2.0
Made
promise
things
would
be
different
next
time.
76.3
Criticized
or
lectured
self
62.3
Apologized
or
did
something
to
make
up
21.1
Planful
problem
solving
(.62)
.......
4.1
2.3
Concentrated
on
what
to
do
next
52.6
Knew
what
had
to
be
done,
doubled
efforts
to
make
up
40.4
Made
a
plan
of
action
and
followed
it..
38.6
Seeking
social
support
(.69)
.........
3.3
2.2
Talked
to
someone
about
feelings
45.6
Accepted
sympathy
and
understanding
from
someone
31.6
Asked
a
relative
or
friend
for
advice....
22.8
Emotional
self-control
(.67)
.........
3.2
2.1
Tried
to
keep
feelings
from
interfering
with
other
things
51.8
Tried
to
keep
feelings
to
self
22.8
Kept
others
from
knowing
ow
bad
things
were
13.2
Escape-avoidance
(.60)
.............
2.1
2.1
Wished
situation
would
go
away
or
be
over
30.7
Had
fantasies
how
things
might
tum
out
27.2
Tried
to
make
self
feel
better
by
eating,
drinking,
using
drugs
or
medications
1.8
Distancing
(.60)
...................
1.2
1.5
Didn't
let
it
get
to
me
9.6
Went
on
as
if
nothing
had
happened
.
.
6.1
Tried
to
forget
the
whole
thing
5.3
'Range
of
possible
scale
scores,
0
to
9.
Higher
score
indicates
the
coping
strategy
was
used
more.
tincludes
those
answering
'used
quite
a
bit"
or
"used
a
great
deal."
Coping
With
Mistakes-Wu
et
al
566
WJM,
November
1993-Vol
159,
No.
5
WJM,
November
1993-Vol
159,
No.
5
Coping
Residents
indicated
the
extent
to
which
they
had
used
each
of
the
six
strategies
to
cope
after
they
made
their
mistake.
Table
1
shows
responses
for
the
Ways
of
Cop-
ing
items
and
scales,
as
well
as
the
percentage
of
respon-
dents
who
reported
they
had
used
a
strategy
"quite
a
bit"
or
"a
great
deal."
Mean
scale
scores
were
highest
for
ac-
cepting
responsibility
and
planful
problem
solving,
indi-
cating
that
these
strategies
were
most
often
used.
Scores
were
somewhat
lower
for
seeking
social
support
and
con-
trolling
emotions
and
still
lower
for
escape-avoidance
and
distancing.
For
example,
on
the
"accepting
respon-
sibility"
scale,
residents
indicated
they
used
the
following
strategies
"quite
a
bit"
or
"a
great
deal":
"I
made
a
prom-
ise
to
myself
that
things
would
be
different
next
time"
(76%),
"I
criticized
or
lectured
myself'
(62%),
and
"I
apologized
or
did
something
to
make
up"
(21%).
Exam-
ples
of
these
strategies
can
be
seen
in
the
residents'
nar-
ratives
about
their
mistakes.
For
example,
after
failing
to
recognize
the
importance
of
and
initiate
therapy
for
ven-
tricular
tachycardia,
a
resident
wrote,
"I
hung
the
EKG
strip
in
my
room
with
a
sign
saying
"Next
time,
remem-
ber
to.
.
."
One
resident
administered
intravenous
fluids
to
a
patient
with
cardiogenic
shock,
mistakenly
thinking
the
patient
was
septic,
and
induced
congestive
heart
fail-
ure.
The
resident
wrote,
"I
can
occasionally
rationalize
that
I
was
not
the
proximate
cause
of
his
death,
as
the
pa-
tient
was
deteriorating
slowly,
but
I
must
accept
that
I
likely
accelerated
the
course
of
his
demise."
Distress
In
multivariate
analysis
controlling
for
causes
of
the
mistake,
severity
of
the
outcome,
residents'
perception
that
the
institution
was
judgmental,
and
their
gender,
residents
were
more
likely
to
report
emotional
distress
if
they
coped
by
accepting
responsibility.
In
addition,
res-
idents
were
somewhat
more
likely
to
report
distress
if
they
reported
coping
by
seeking
social
support
or
by
con-
trolling
their
feelings.
The
multiple
correlation
coefficient
(total
R2)
for
the
model
for
emotional
distress
was
.47
(Table
2).
As
we
reported
previously,
residents
described
con-
siderable
emotional
distress
in
response
to
the
mistakes,
the
large
majority
describing
remorse,
anger,
guilt,
and
feelings
of
inadequacy.9
For
example,
one
resident
mis-
takenly
ordered
benzodiazepine
on
an
as-needed
basis
for
a
patient
with
respiratory
muscle
weakness.
Subsequent-
ly,
the
patient
suffered
respiratory
failure
and
died.
The
resident
wrote,
"Although
his
private
MD
and
others
as-
sured
me
that
the
'pm'
Ativan
was
not
the
factor
that
tipped
him
over,
I
was
never
sure
of
that.
To
this
day,
I
don't
know
if
he
would
be
alive
had
I
made
sure
that
no
sedatives
were
[prescribed]."
Changes
in
Practice
As
previously
reported,
house
officers
described
mak-
ing
various
changes
in
their
subsequent
practice
as
a
re-
sult
of
the
mistake."
Some
of
these
changes
were
con-
structive,
but
others
were
defensive.
For
example,
72%
of
residents
agreed
somewhat
or
agreed
strongly
that
as
a
di-
rect
consequence
of
having
made
the
mistake,
they
were
more
likely
personally
to
confirm
data,
62%
reported
they
were
more
likely
to
seek
advice,
and
52%
that
they
changed
the
way
they
organized
information.
Other
con-
structive
changes
included
asking
questions
of
peers
or
superiors,
reading,
asking
for references,
paying
more
at-
tention
to
detail,
changing
the
organization
of
data,
and
trusting
others'
judgment
less.
On
the
other
hand,
13%
reported
discussing
mistakes
less,
and
6%
reported
avoid-
ing
patients
with
similar
problems."
In
multivariate
anal-
ysis,
residents
were
more
likely
to
report
constructive
changes
if
they
coped
by
accepting
responsibility,
con-
trolling
for
causes
of
the
mistake,
severity
of
the
outcome,
the
degree
to
which
house
officers
perceived
that
their
in-
stitution
was
judgmental,
and
house-staff
gender.
None
of
the
other
coping
strategies
were
independently
related
to
constructive
change.
The
total
RK
for
the
model
for
constructive
change
was
.49.
Residents
were
more
likely
to
report
defensive
changes
if
they
coped
by
escape-
avoidance.
None
of
the
other
coping
strategies
were
inde-
pendently
related
to
defensive
change.
The
total
RK
for
the
model
for
defensive
change
was
.35
(Table
2).
TABLE
2.-Relation
of
Ways
of
Coping
to
Emotional
Distress
and
Changes
in
Practice*
Constructive
Defensive
Changes
Emotional
Distress
Changes
in
Practie
in
Proctice
Coping
Strategy
P
Value
0
P
Value
0
P
Value
Accepting
responsibility.
.67
Seeking
social
support
.....
.27
Emotional
self-control
......
.
28
Escape-avoidance
.........
.21
Planful
problem
solving
....
-
.11
Distancing
...............
.07
Total
R
2.
.0001
.69
.02
.14
.02
.05
.36
.21
.11
.18
.07
-.26
.13
.35
.46
.07
.28
.25
.33
-.06
.34
-.03
.90
.02
.72
.69 .02
.94
.01
.90
.47
.49
.35
Adjusted
R2
..............
.39
.41
.25
*This
model
controlled
for
causes
of
the
mistake,
severity
of
the
outcome,
the
degree
to
which
house
officers
perceived
that
their
institution
was
judg-
mental,
and
house-staff
gender.
Coping
With
Mistakes-Wu
et
al
567
568
WJM,
November
1993-Vol
159,
No.
5
Discussion
In
this
study,
house
officers
who
coped
by
accepting
re-
sponsibility
were
more
likely
than
those
who
did
not
accept
responsibility
to
make
constructive
changes
in
practice,
but
they
were
also
more
likely
to
experience
emotional
dis-
tress.
These
outcomes
illustrate
the
complexity
of
coping.
The
same
behavior
was
related
to
both
positive
and
nega-
tive
effects,
and
according
to
our
definitions,
such
coping
was
both
adaptive
and
nonadaptive.
Previous
studies
have
examined
how
physicians
cope
with
general
daily
stressors'3-20
and
identified
a
variety
of
coping
strategies.
A
few
qualitative
studies
have
investi-
gated
how
physicians
cope
with
mistakes
and
uncertain-
ty.17"
9
These
studies
did
not
deal
with
responses
to
spe-
cific
mistakes
and
did
not
examine
the
complexity
of
physicians'
coping
responses.
No
studies
have
examined
how
coping
affects
subsequent
adjustment
and
practice,
though
a
few
studies
suggest
that
coping
strategies
may
play
a
role
in
modulating
physician
stress'318'20-22
or
work
satisfaction.'3
In
contrast,
this
study
focused
on
specific
mistakes,
al-
lowing
each
house
officer
to
recall
an
actual
situation
and
his
or
her
response.
Our
study
used
a
multidimensional
approach
to
coping
and
assessed
outcomes
in
terms
of
subsequent
changes
in
practice
and
emotional
distress.
Our
finding
that
the
coping
strategy
related
to
a
desirable
outcome
(change
in
practice)
was
also
related
to
an
unde-
sirable
outcome
(emotional
distress)
has
several
impor-
tant
implications
for
medical
education.
An
important
part
of
residency
training
is
the
acquisi-
tion
of
confidence
and
clinical
competence.
Dealing
with
specific
problems
and
situations
allows
a
resident
to
build
a
general
sense
of
competence
to
deal
with
medical
prob-
lems.
Early
in
training,
many
residents
suffer
from
inse-
curity
about
their
own
adequacy,
and
making
a
serious
mistake
can
add
to
this
insecurity.
It
is
important
that
res-
idents
deal
as
effectively
as
possible
with
mistakes
when
they
occur
so
that
their
general
sense
of
competence
is
strengthened
rather
than
weakened.
What
can
medical
educators
do
to
help
a
resident
deal
effectively
with
a
serious
medical
mistake?
We
suggest
that
educators
provide
specific
advice
about
preventing
the
recurrence
of
the
mistake,
provide
emotional
support,
and
help
residents
interpret
their
distress.
Cases
in
our
study
suggest
how
a
review
of
the
inci-
dent
can
promote
constructive
changes
by
both
the
resi-
dent
and
the
institution.
This
review
can
lead
to
discus-
sions
of
areas
of
uncertainty
in
clinical
decision
making,
for
example,
when
residents
are
faced
with
the
decision
of
whether
to
act
on
an
abnormal
finding.
Reviewing
the
case
can
suggest
areas
where
residents
should
increase
their
knowledge.
Such
reviews
may
also
point
out
signs
that
residents
should
be
more
aware
of,
such
as
agitation
as
a
sign
of
hypoxia.
Reviewing
the
case
may
also
help
attending
physicians
to
suggest
constructive
changes
in
practice.
For
example,
residents
who
misinterpreted
arte-
rial
blood
gases
or
electrocardiograms
should
be
encour-
aged
to
study
more
in
these
areas.
A
resident
who
makes
a
mistake
caused
by
a
lapse
in
routine,
such
as
failing
to
place
a
nasogastric
tube
in
a
patient
with
a
history
of
he-
matemesis,
may
benefit
from
advice
to
resist
the
tempta-
tion
to
forgo
established
routines, particularly
at
the
enid
of
a
shift
or
when
tired.
After
a
mistake,
it
also
may
be
useful
to
discuss
the
potential
for
counterproductive
changes
in
practice,
such
as
avoiding
procedures
after
experienc-
ing
a
complication.
In
this
case,
further
supervised
in-
struction
could
prevent
the
development
of
a
phobia
about
a
procedure.
Case
review
may
also
identify
situa-
tions
in
which
attending
physicians
might
provide
ad-
ditional
back-up.
These
include
cases
where
residents
felt
overwhelmed
by
competing
demands
on
their
time
or
by
too
many
patients.
When
these
situations
arise,
it
is
important
that
residents
be
encouraged
to
call
for
help.
Finally,
a
review
of
cases
may
lead
to
suggestions
to
im-
prove
features
of
the
system
of
care
that
contributed
to
the
mistake.
Such
features
might
include
an
excessive
num-
ber
of
admissions
for
residents,
inadequate
mechanisms
in
the
pharmacy
to
flag
overdoses
of
drugs,
or
an
inacces-
sibility
of
consultants.
Emotional
support
can
be
provided
in
several
settings
including
house
officer
support
groups
and
discussions
of
mistakes
at
departmental
retreats.
Levinson
and
Dunn
have
described
a
model
of
small
group
discussions
of
mistakes
that
has
been
well
received
by
participants.23
Crisis
counseling
can
be
a
model
for
providing
one-on-
one
emotional
support
by
the
attending
physician.24
The
initial
discussion
should
focus
on
the
mistake
and
the
res-
idents'
reactions.
The
attending
physician
should
allow
the
resident
to
express
his
or
her
emotions,
validate
these
reactions,
and
provide
reassurance.
Therapeutic
referrals
should
be
offered
when
needed.
Next,
the
attending
physician
should
assess
how
the
resident
is
coping
with
the
mistake.
The
house
officer
should
be
encouraged
to
accept
responsibility
for
and
discuss
the
mistake
and
should
be
discouraged
from
forgetting
about
or
avoiding
thinking
about
it.
In
doing
so,
the
resident
who
takes
re-
sponsibility
for
a
mistake
cannot
be
expected
to
feel
good
about
it
at
the
same
time.
The
attending
physician
can
help
the
resident
interpret
his
or
her
feelings
of
distress
as
part
of
the
process
of
learning
from
a
mistake.
The
attending
can
also
lessen
distress
by
correcting
mistaken
attributions,
such
as
that
a
mistake
signifies
incompetence
as
a
physician.
Providing
emotional
support
to
residents
who
accept
responsibility
for
mistakes
may
make
it
easier
for
the
residents
to
accept
responsibility
for
mistakes
in
the
future.
For
example,
one
resident
who
inadvertently
ordered
an
overdose
of
levo-
thyroxine
commented,
"This
mistake
sticks
in
my
mind
partly
because
the
patient's
attending
was
so
kind
and
understanding
when
I
called
to
tell
him
of
my
error."
Attending
physicians
can
help
residents
understand
that
other
physicians
who
have
accepted
responsibility
and
experienced
emotional
distress
have
improved
their
subsequent
practice
and
can
convey
the
expectation
that
residents
and
future
patients
will
benefit
from
these
experiences.
Our
findings
also
suggest
that
attending
physicians
Coping
With
Mistakes-Wu
et
al
WIM-
November
-
1NCnt-I1
N
5
CopIn
-k-
need
to
make
a
conscious
effort
to
get
mistakes
out
into
the
open.
The
importance
of
these
efforts
is
underscored
by
the
finding
that
barely
half
of
residents
told
their
at-
tending
physician
about
their
mistakes."
Our
previous
re-
sults
suggest
that
morbidity
and
mortality
rounds
are
not
settings
in
which
information
about
mistakes
is
likely
to
surface.9
Instead,
attending
physicians
should
take
the
lead
in
making
discussions
of
mistakes
a
routine
part
of
training.
In
one
training
program
orientation,
interns
are
given
a
talk
by
a
popular
and
respected
faculty
member
who
candidly
describes
mistakes
that
she
has
made
and
the
general
lessons
they
have
taught
her.
Attending
physi-
cians
can
also
incorporate
a
discussion
of
the
inevitability
of
mistakes
and
the
importance
of
discussing
them
into
introductory
remarks
with
a
new
team
while
attending
on
wards.
Formal
and
informal
sharing
by
faculty
of
their
own
personal
experience
with
mistakes
may
help
make
such
discussions
more
acceptable.
Limitations
Our
findings
may
be
limited
in
several
important
ways.
First,
because
accounts
of
mistakes
and
changes
in
prac-
tice
were
anonymous,
we
have
no
external
confirmation
of
the
data.
Second,
the
limited
response
rate,
the
rela-
tively
small
sample
size,
and
the
surveying
of
only
inter-
nal
medicine
residents
at
three
large
teaching
hospitals
limit
the
generalizability
of
our
findings.
Nonresponse
may
have
occurred
in
a
nonrandom
fashion,
both
among
house
officers
who
coped
by
the
complete
denial
of
a
mistake
and
among
others
who
remained
too
troubled
by
a
mistake
to
confront
the
questionnaire.
Finally,
some
as-
sociations
we
found
may
be
due
to
relationships
between
study
variables
and
unmeasured
confounding
variables,
rather
than
cause-and-effect
relationships
between
vari-
ables.
For
example,
unmeasured
personality
characteris-
tics
of
house
officers
might
cause
them
both
to
cope
by
accepting
responsibility
and
to
make
constructive
changes
in
practice.
Further
research
is
needed
to
determine
whether
efforts
to
improve
residents'
coping
skills
also
promote
constructive
changes
in
practice.
Internal
consistency
reliability
was
only
moderate
for
five
of
the
six
coping
scales
and
was
low
for
one
scale
(accepting
responsibility).
In
general,
coping
scales
have
lower
internal
consistency
than
trait
measures
because
of
the
nature
of
coping:
if
a
person
uses
one
strategy
suc-
cessfully,
he
or
she
is
not
likely
to
turn
to
others.
Because
the
reliability
of
a
scale
is
the
ceiling
of
its
possible
cor-
relation
with
other
variables,
low
internal
consistency
would
lead
to
underestimates
of
the
effects
of
coping
and
does
not
weaken
the
significance
of
the
associations
we
found.
To
achieve
a
greater
precision
of
responses,
re-
searchers
measuring
physician
coping
in
future
studies
should
consider
using
the
original
full-length
scales
in
the
Ways
of
Coping
questionnaire.2'
Also,
although
the
fac-
tor
structure
of
the
accepting
responsibility
scale
has
been
shown
to
be
stable
across
different
populations,
future
studies
might
reexamine
the
constructs
and
their
items.
Conclusion
Physicians
responsible
for
educating
house
officers
need
to
help
them
cope
with
their
mistakes.
They
should
begin
to
think
of
how
to
help
residents
cope
in
ways
that
promote
constructive
changes,
such
as
by
accepting
re-
sponsibility.
They
should
also
be
prepared
to
provide
emotional
support
and
to
help
residents
maintain
their
confidence
and
develop
professionally
as
they
deal
with
their
mistakes.
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1.
McCue
JD:
The
effects
of
stress
on
physicians
and
their
medical
practice.
N
Engl
J
Med
1982;
306:458-463
2.
McCue
JD:
The
distress
of
internship-Causes
and
prevention.
N
Engl
J
Med
1985;
312:449-452
3.
McCall
TB:
The
impact
of
long
working
hours
on
resident
physicians.
N
Engl
J
Med
1988;
318:775-778
4.
Butterfield
PS:
The
stress
of
residency-A
review
of
the
literature
[see
com-
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Arch
Intem
Med
1988;
148:1428-1435
5.
Folkman
S,
Lazarus
RS:
Coping
as
a
mediator
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J
Pers
Soc
Psy-
chol
1988;
54:466-475
6.
Folkman
S,
Lazarus
RS,
Gruen
RJ,
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A:
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Pers
Soc
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1986;
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Aldwin
C,
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Does
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J
Pers
Soc
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1987;
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8.
Folkman
S,
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If
it
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it
must
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a
process-Study
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