Michael Rowe1 and Antonella Surbone2

1 Department of Psychiatry, Yale School of Medicine, USA 2Department ofMedicine, New York University, USA KEY POINTS

• People (patients or family members) who do not sue following a medical error may nonetheless believe a harmful medical error occurred.

• People may refrain from suing due to not wanting to lose their physician's care, exhaustion related to the medical error, or relief at eventually having the error corrected.

• People who do not sue have often considered suing for reasons similar to those of people who sue.

• Whether or not a lawsuit follows medical error, patients and family member tend to lose trust in physicians and medical institutions: understanding their experiences is important for maintaining and enhancing trust and communication in patient-doctor relationships.

• When a medical error occurs, oncology professionals partners might benefit by sharing the truthful story about what happened and why from the outset, rather than hiding behind silence or each telling a partial and impoverished story in court.

• Oncologists can address medical errors with honesty and humility, with attention to their patients physical, psychological, and spiritual needs, and with respect for the patient-doctor fiduciary relationship.

Introduction Understanding the motivations of people who initiate or do not initiate malpractice lawsuits may help us to identify effective alternatives to litigation that address not only financial compensation, but the psychological and existential consequences of medical errors for patients and family members and members of the medical team. Such understanding may also help in identifying ways to restore trust in patient-doctor relationships in the aftermath of medical errors and other iatrogenic harm.

A number of studies, along with patient and family member narratives, have examined reasons for pursuit of medical malpractice lawsuits. These include doctors and medical institutions ignoring patient or family member requests for information or treating them disrespectfully, and patients' and family members' desire to assure that similar errors will not occur with future patients. Researchers and scholars have also considered problems inherent in our litigious medical system, such as the impact of doctors' fears of malpractice lawsuits on limiting open dialogue with patients following harmful medical errors. Ironically, such defensive responses can lead patients or family members to pursue lawsuits based, in part, on the need to gain some form of satisfaction when other avenues have been closed off or in response to what they perceive, as above, to be disrespectful treatment. [1-7] Institutional use of other approaches, such as timely apology and restitution, are also being studied. [8-14]

Medical error is defined clinically as the unintentional use of a wrong approach or failure to carry out a correct approach with usual skill. [15] The odds against successful malpractice lawsuits are high and there is little correlation between their merits and their outcomes. [15-18] Little research has been conducted, however, on the motivations and experiences of patients and family members who do not sue when they believe a harmful error occurred. We do so in this chapter, based on findings from in-depth qualitative interviews we conducted with family members that suggest additional responses to medical errors. Following our report on these findings, the first author discusses his experience as a family member who decided not to pursue a malpractice lawsuit with regard to his son's care. The second author then draws on her experience as a clinical oncologist to discuss the need to build reciprocal trust and respect among patients, family members, and the physician in the aftermath of medical errors, and to deepen our understanding of patient and family member experiences of medical error and the potential long-term impact of these experiences on all parties.

Study: why people do not sue Study description We conducted 26 interviews with patients and family members, 24 in Connecticut and 2 in Canada, who believed that they or a family member had been the recipient of a harmful medical error. We employed a purposive sampling method in which recruitment is based on subjects' common experience. [19] Of the 26 participants, 18 were patients of whom 16 were female, 10 were family members of whom 4 were female, and 2 were female patients who also spoke as family members. Twenty-four participants were Caucasian. Females and Caucasians were strongly overrepresented and professionals and academics appear to be overrepresented as well.

Interviews were audiotaped and transcribed. The first author conducted all interviews. The interview began with a request for the participant's description of the perceived medical error, called "medical error" or "error" for the remainder of this report, reflecting both the fact that participants were not required to provide evidence of error and our understanding that medical definitions of error are not objectively neutral, but are shaped by disciplinary perspectives that exclude non-clinical definitions. [20]

Additional questions were:

• "At some point, you experienced what you think may have been a harmful medical error. Can you talk about what you were being treated for and what happened, as you see it?"

• "Did your doctor talk to you about this situation? Was there other follow up, treatment or otherwise?"

• "What were your thoughts and feelings during all this?"

• "Did you consider taking legal or other action? Why or why not?"

For each question, the interviewer asked follow-up questions as appropriate. Only one study participant had initiated a malpractice lawsuit at the time of the interviews.

Analytic methods followed an empirical phenomenological framework for identifying common themes across individual narratives. Both authors, and a third collaborator whom we acknowledge at the end of this chapter, reviewed and analyzed transcripts independently, then compared, contrasted, and ultimately reached consensus on common themes. We then selected participants and relevant quotes. [21] Names and some details are changed to protect participants' identities.

Study results We identified three main themes for non-pursuit of malpractice lawsuits that have received little or no attention in the research literature: (i) liking, or needing to maintain relationships with, doctors; (ii) mental and physical exhaustion or experiencing wellness; and (iii) complications of treatment and life, unexpected positive outcomes over time, and achieving some form of validation or satisfaction other than through pursuing a malpractice lawsuit.

1. Liking, or needing to maintain relationships, with one's doctors Patients' reluctance to sue was sometimes related to their fear of being shunned by doctors from whom they needed, or thought they might need, ongoing care. A female in her 60s, a writer and editor, was diagnosed with a benign tumor in her thigh. Her surgeon, she said, did not realize that her form of tumor could degenerate into a malignant one and so did not thoroughly clean its margins. As a result she underwent two additional surgeries, since the entire tumor was not removed during the first. The woman, who appeared to identify with her surgeon based on their professional and educational accomplishments, expressed ambivalence toward, but not condemnation, of him during the interview. She also spoke of her dependence on him:

He's the only surgeon in the area who could have done the second surgery, so I needed him ... It didn't serve my best interests to alienate him.

She spoke of her friendship with the surgeon, as well, although not without a sense of the politics of their relationship:

We became friends. He respects me. We talked about a lot of things ... he doesn't normally talk about with his patients. He felt, I think, that he had committed an error of some sort, so I think he had an interest in jollying me along and making sure I was an ally rather than an enemy. And we just naturally got along well together.

Another woman reported having suffered a missed diagnosis of pancreatitis, of surgical and procedural errors including bowel perforation during surgery to remove her gall bladder, of punctured lungs from chest tubes to drain an infectious pleural effusion leading to sepsis, and of late repair of a leaking bile duct. Her husband, speaking of their consideration of a lawsuit, expressed concern for his wife's ongoing medical care in the rural area where they live:

This is where we want to retire. It's a small community. There aren't a lot of doctors or physicians, surgeons that wouldn't know what transpired . . . And so if we start attacking the people responsible for this, ultimately is that going to impact her ability to get good care?

Other patients spoke of their decision not to sue based on concern about damaging their relationships with current physicians whom they liked and saw as having minor roles in the medical errors they experienced. This reluctance could involve protective feelings, as with a female patient who had bleeding during pregnancy for which, she felt, her Ob-Gyn was mainly at fault for being too slow to address. She thought her primary care physician, too, was partly at fault. The baby was delivered prematurely and was stillborn. The woman considered a lawsuit, but decided against it because she liked her primary care physician and her attorney told her that she would have to sue him as well as her Ob-Gyn:

It would be a shotgun lawsuit. I'd have to sue my primary, and I like him. I really do.

Another patient, a physician in her early 50s, experienced a host of cognitive difficulties following a long surgery. These included forgetting her patients' medical problems following 14-hour breast reconstruction surgery. Separate rounds of neuropsychiatric testing identified permanent damage. Eventually she retired from practice. She believed her cognitive deficits were caused by a lack of repositioning of her head during an eight-hour surgery, a task, she said, that fell to her anesthesiologist:

I had a huge necrotic area on the back of my head. I'd clearly not been repositioned during the entire surgery. He certainly could have moved my head back and forth. I think if I hadn't had the pressure necrosis on the back of my head I might have been more willing to say, "I had a very long surgery, maybe this stuff happens."

She chose not to sue for several reasons. Her friendship with and empathy for the other doctors involved in her care, especially her surgeons, were among them. "I love them," she said. "I knew them to be good men, ethical."

2. Mental and physical exhaustion, and recovery Perhaps the most surprising yet simplest reasons given for not suing were, on the one hand, patients' physical exhaustion or illness directly related to the perceived medical error and, on the other, a new lease on life they gained by the return of health following correction of the original error or missed diagnosis. In the first case, a graduate student whose diagnosis of endometriosis was made only after years of misdiagnoses considered a lawsuit related to a drug she was prescribed prior to being given the correct diagnosis. She relented, however, because she was "too tired, too sick" and needed to "put my energy into taking care of myself." Other patients echoed this feeling, sometimes focused simply on their physical exhaustion and sometimes on the compounding demands of work or other obligations in the face of compromised health.

Regarding "regained wellness," a sociologist in her mid 30s who suffered from Cushing's syndrome for years before it was diagnosed said that, while she recognized the difficulty of detecting the syndrome, she still felt her doctors' failure to detect it was related to biases regarding her youth - she was "too young" to be so ill - or her gender - she "must be depressed." Once diagnosed and treated, though, she abandoned any serious consideration of a lawsuit. She didn't want to spend time dealing with the past, she said, or spend the good energy she had now on a negative project:

I was just so relieved about feeling better. Once my cortisol went down it was night and day. I was on such an emotional high that it just didn't matter anymore. It had almost been ten years that I hadn't felt like myself.

Later she felt tempted to sue to prevent others from going through a similar ordeal. Ultimately, however, she returned to her original conclusion that she "just couldn't go back." The physician with memory loss discussed above spoke on the same theme:

I'm alive and I still have a rich life . . . I don't want to spend the time I have left on this earth blaming people. I want to appreciate the fact that I survived this, because there was quite a while when I wasn't sure I would ... I just wanted to move on.

Too sick to sue or emotionally exhausted from of dwelling on negative things when well, there was no space or time in some patients' lives to pursue a lawsuit.

3. Complications of treatment and life, unexpected positive outcomes over time, and achieving some form of validation or satisfaction short of pursuing a malpractice lawsuit Decisions not to sue were sometimes related to the number of doctors involved and the complexity of diagnostic and clinical issues in play over a considerable period of time. This is often the case in oncology, as many cancer patients receive multidisciplinary treatments over long periods of time and are followed by different teams that specialize in different aspects of cancer care.

A young academic living in an area in which Lyme disease was common had typical symptoms of the disease including a bull's-eye rash and extreme fatigue. She saw several physicians who, she felt, were misled by negative Lyme Disease titers. In her own online research she had learned, she said, that the CDC did not recommend using titers alone to diagnose Lyme Disease:

[The CDC says] you should diagnose it based on clinical features. . . The test [the Lyme Disease titer] is for confirmation, but it shouldn't be used as a diagnosis.

Ultimately, this woman was properly diagnosed and treated, but the long period of illness put her academic career at risk:

I considered suing somebody, but I didn't know who I would sue. I like my neurologist, so I didn't want to sue him. If I could've found some way to pin it on my primary, I would have. But I don't know if I would have. I thought about the lawsuit thing, but I was just ... I can't.

The complications and "messiness" of day-to-day living, further compounded by the medical, psychological, and social impacts of a medical error, were factors in some participants' decisions not to sue. One female patient was inadvertently kept awake during gall bladder surgery, a fact she later confirmed with her skeptical surgeons by reciting parts of their conversations during the operation. "I felt like I was on fire," she said. She also reported that she woke up gasping every night for a year from nightmares of reliving the surgery. She wrote to the hospital asking them to look into her case for the sake of future patients, but never heard back. She wondered if she could force a response by filing a lawsuit, but this consideration paled before her grief over her daughter's recent death following abdominal surgery, her need to care for her surviving children, and other medical issues she was experiencing that were unrelated to the gall bladder surgery.

Finally, a few patients experienced unexpected positive outcomes following their medical ordeal. These seemed to contribute to turning their energy away from lawsuits. The patient with Cushing's syndrome spoke on this theme:

Most of the things I love about myself now happened because of Cushing's - studying the recovery process and ways in which spirituality enters into the recovery process. So in some ways it almost feels like it was part of a journey I was supposed to be on, and that rotunda [named after Dr. Cushing] almost feels like sacred space, part of what my journey is supposed to be about.

First authors' experience My experience of the aftermath of my son's death following complications of liver transplant surgery led me to consider a malpractice lawsuit. Ultimately, though, I did not sue, for reasons including an aspect of the third primary reason for "non-pursuit" that we identified in our study: "achieving some form of validation or satisfaction short of pursuing a malpractice lawsuit." My suspicions of possible error in my son's death concerned the amount of time - four days - between his liver transplant and getting him back into surgery to repair what his surgeons described as the surgical accident of an intestinal perforation during liver transplantation surgery. My suspicions, however, rose to the level of considering a malpractice suit only after my experience of the silence of my son, Jesse's, doctors after his death, along with months of dunning letters for payments when all allowable costs had been agreed upon in advance and paid by my health insurer, and delayed or incorrect responses to my correspondence with hospital representatives. These, combined with my grief, ultimately led me to wonder if what I was experiencing as insensitivity on the part of Jesse's doctors and the hospital may, rather, have been a "circling of the wagons" out of fear that I would sue. Thus did I come to think about suing. [7-22]

At the end of my investigation, based on reviewing Jesse's medical records with experts, a senior gastroenterologist's agreement with my basic analysis of the delay in getting Jesse back into surgery gave me a sense of relief and validation of my reason for investigating his care. My attorney acknowledged the gastroenterologist's opinion, but ultimately decided not to take the case, since the law still regarded organ transplantation as an experimental procedure and thus entitled to additional legal protection, that is, benefit of the doubt. I could have continued pursuit of a lawsuit by trying to find another attorney to take the case, but decided not to for two reasons. First, I felt that I had "stayed the course" in memory of my son in finding out the truth. Second, I wanted to witness his story by writing about it, which I did.

Second author comments For Dr. Rowe, receiving confirmation of his suspicion that a medical error had contributed to his son's death and knowing that he had "stayed the course" in memory of Jesse by finding out the truth were important factors in his decision not to continue to pursue a lawsuit. In line with the "complications of life" theme of this section, he also recognized that his first priority, even before he began to suspect medical error, was to tell his son's authentic story. In my experience as medical oncologist, I further believe that when a medical error goes unrecognized or denied or is poorly communicated without a sincere apology, not only is the patients' authentic story lost, but the authenticity of everyone involved is compromised, leaving patients, families, and medical staff deeply impoverished.

Conclusion One contribution of this research, we think, is to reveal the extent of injury, the number of corrective procedures, and, in some cases, the chronic pain or disfigurement that patients experience after a medical error, qualifying their recovery and suggesting a subgroup of patients who refrain from suing but nonetheless experience significant harm from medical errors.

Our study has some inherent imitations, the first being that people spoke retrospectively about their reasons for not suing rather than at the time they were engaged in coming to this decision. Such a posteriori assessments are subject to varying degrees of reinterpretation, memory loss, or discomfort in remembering certain aspects of one's experience and thus favoring others. Second, our participant group was overrepresented by women and Caucasians and in part by professionals and persons with advanced education as well. Further qualitative study might explore whether gender or race-ethnicity are factors in participants' decisions about whether or not to pursue a malpractice lawsuit, or in attorney interest in their cases that might lead them to make a different decision. Employed males, for example, are more attractive clients for malpractice attorneys than stay-at-home females, as the payout for similar injury would likely be greater for the male. [23] In our study, however, the majority of female participants were employed as professionals or academics. Regarding the likelihood of pursuing a lawsuit based on income, available evidence is that poor people are less likely to sue than the wealthy, in part due to the incentive structure by which lawyers decide to take on malpractice cases. [24] Participants in this study did not appear to refrain from suing on the basis of income, however, but on other factors that we have discussed above.

Limitations notwithstanding, we think this study sheds some light on the complexities of patient and family member experiences in coping with medical errors. The experiences of persons affected by medical harm who decide not to sue offer a view of relatively unexplored aspects of the physical and psychological damage of medical errors and of how different persons react while, at times, still respecting and liking their doctors.

Understanding the motivations of people who do, or do not, initiate malpractice lawsuits may help us identify effective alternatives to litigation, beyond compensation, that address the psychological and existential consequences of medical errors. Our study suggests commonalties of experience and emotion among people who do and do not sue. Many of our participants who did not sue had considered it, and their reasons for considering litigation mirror those of people who do sue, according to the research literature and narrative testimony. These include anger over silent or otherwise disrespectful treatment, lack of full disclosure from doctors and medical institutions, and hope that legal action will deter repetition of similar errors for future patients. [1-9] Reasons not to sue were related to self- or other assessment of the chances of success, but also to subjective factors, individual coping strategies and circumstances, and life situations and priorities.

Our findings further suggest that medical errors have an impact on patients' and family members' lives that may be long-lasting and of no lesser gravity in those who do not sue as in those who do. Efforts aimed at restoring faith in doctors, medical institutions, and medicine must take into consideration the large group of patients and family members who do not sue, but continue to experience prolonged suffering from their experience of medical error. In addition, while the focus in the study was personal experiences of medical error, participants' experiences took place in social contexts that shape attitudes toward people who initiate medical malpractice lawsuits. They were responses, in part, to institutional-disciplinary contexts that push clinicians to deflect patient and family member questions about the degree, the causes, and the consequences of harm resulting from medical errors. [20]

After many years of collaboration on the experience of medical errors for patients, families, and physicians, our work on this study has deepened our understanding of the aftermath of medical errors on all partners. We conclude with some reflections on our different personal experiences.

First author I wrote above about my experience of investigating the possibility of harmful medical errors in my son's care and of finding some satisfaction that my layman's analysis of error was supported by a senior gastroenterologist. Here, I want to follow up and conclude my personal reflections by talking about a different kind of error, one that is implied in my earlier comments.

I have written elsewhere of a sense of excommunication that my wife and I felt in the silence of Jesse's doctors after his death, and of how our sense of excommunication was deepened not by insensitive treatment from the medical team during Jesse's hospitalization, but in contrast to the closeness and common cause we felt with them, and nurses, while we were all struggling to save Jesse. [7-22] I was aware, in the aftermath of Jesse's death, of wanting and needing to witness his life. Not having been able to bring him home as he had hoped, I wanted to bring him home symbolically, to redeem him, in a sense, from a less true, because poorer, story of his life - an unfortunate young man with ulcerative colitis and early-stage cirrhosis, recipient of a surgical accident during liver transplant surgery leading to an intestinal perforation, sepsis, and death.

It's not that his doctors were trying to impose any such limited narrative upon Jesse or us. They were not. Yet their silence after his death erased a different story of caring and community in which Jesse was the protagonist, and left no other story to be told, unless someone told a different, and truer one. That true story would now have to include the poverty of silence that followed Jesse's death, but it would also tell of the tenderness that his doctors and nurses felt toward him, the hopes and fears they shared about his recovery, their seemingly genuine wonder at his resilience through operation after operation and a second liver transplant . . . Without that part of the story, Jesse was buried in his hospital bed more than he was in the cemetery off Route 63 on my commute to and from New Haven.

The truest, most inclusive story, then, was the one about trust and care and dozens of highly trained physicians and nurses trying to save a young man's life, and his family members there with them and with Jesse. This is partly a story of medicine, too, but the other medical story, the one that remained behind in the silence that followed Jesse's death, was a squeezed, dried, flattened, unimaginative, and impoverished one. Jesse's doctors tried to save him. What was killed in the silence that followed his death was his, his family members,' and his doctors' and nurses' true story. Many of his nurses, in fact, attended attended Jesse's funeral. That story could not continue in the same way, of course, but it could have been rounded out, through and past death, by witnessing the value of his life and the healing community that had come together around him. This was the story that a lawsuit would have hidden, and is the one I turned to when I decided not to continue down that path of forgetting.

Second author's reflctions As a medical oncologist practicing both in the USA and Europe, I have had the immense fortune never to cause (or to know to have caused) a major or fatal medical error over 30 years of clinical activity. Yet I certainly have not been immune from committing errors of different types and degrees and from experiencing deep regret and desire to repair the error and mend the damage that it may have done to my relationship with a few of my patients and their family members. I also experienced shame and guilt, as well as the foolish wish to go back in time and do it right.

With the exception of one case, something always struck me: that even after I had committed, or contributed to committing a medical error, my patients and their families continued to trust me and my team. I always reported my errors in a clear open way and apologized. This certainly contributed to maintaining reciprocal trust and respect. Yet, reflecting more closely on my experiences with cancer patients, as well as on my personal experiences as a recipient of medical errors during long hospitalizations, I have come to the conclusion that what makes it possible for the recipient and perpetrator alike to "accept" a medical error is that physicians not run away from the true story about the error and about the patient. As Dr. Rowe said, hiding behind an impoverished account serves only our impulse to achieve maximum legal and psychological protection. Yet it leaves us smaller.

The practice of clinical oncology, based on both distance and intimacy at physical, psychological, and spiritual levels, entails attention and solicitude for the sick person entrusted to our care. Yet, at times, medical acts or procedures can be very painful for the patient, and errors occur, generating tremendous tensions between the tender and the brutal side of medicine. Brutality is reflected in crude actions or behaviors that may be incisive and accurate but always are harsh, not only physically painful or invasive but devoid of human mercy or compassion. Tenderness is defined as a quality of being moved to compassion and of being warmheartedly responsive to others, always expressed in delicate manners. Tenderness in response to patients' suffering reveals, through soft gestures, a posture of the mind that cannot bear to witness others' anguish or humiliation.

If we could reconcile these two extremes, the brutality of any error and the tenderness that underlies most of our care, we could also allow ourselves and our patients and relatives to share the same narrative and to try to mend the devastating effects of the truth about a medical error. Can we find tenderness also in dealing with something so painful? The technological interventions of modern oncology come with their own specific forms of physical intrusion, and these may be exacerbated or mitigated by the conduct of doctors, nurses, and others. Often, the severity of our cancer patients' illnesses requires multiple and difficult interventions, with side-effects that may put their lives at risk, or long or repeat residency in hospital wards, where medical errors tend to occur and multiply, often resulting in a cascade effect of multiple errors of various degrees and consequences mixed with communication errors. [25] These can also be mitigated by not losing the caring tender attitudes that define our profession as a healing one.

In the one case in my personal experience where trust was forever lost, the patient was a young, brilliant woman at the end of her illness course and I was the Attending on ward. Together with the whole team, I inherited several errors of the kind that we define as both individual and systemic, which, compounded with each other, added to the pain and distress of the patient. While my team and I tried to fix the various errors, I now recognize that we acted more from a too much from a medical perspective and without sufficient understanding of the suffering that past and present medical errors caused to the patients. We looked at each error individually, thus underestimating its gravity within the context of many others, and we comforted ourselves with the conclusion that many of them were system errors. Yet never is an error a "lesser one" for the patient.

Our patient was at her last hospitalization, which lasted a few weeks after my rotation was over. The word "hospital" has roots in the "hospitality" of ancient cultures, where welcoming into one's home foreigners who were lost or in need of refuge and making them feel "at home," that is, respected and loved, was a sacred act. Yet in that case we did not treat the patient with sacred respect. By contrast, as we unsuccessfully tried to improve her care, often missing something or adding another layer of complexity to existing errors, we became increasingly frustrated at our failure to do better, rather than focusing on improving our relationship with our patient and her family. Toward the end of my rotation, we had grown more and more distant from her and the true story - that her disease was rapidly progressing and she needed good palliative care, delivered with tenderness and respect in an atmosphere of trust, where errors of drug prescriptions, nurse delays in administration, or inadequate communication, would be minimized if not totally eliminated. I felt guilty and powerless as I watched her talking to her primary Attending in the evening or during weekends. I saw her in all her strength, beauty, fierceness, and frailty, as she talked to her trusted doctor, sharing her true story with her. By contrast, my team and I chose a partial story of difficulties, errors, and silence to cover our inadequacy. Maybe, if we had courageously faced her about our inadequacy and apologized for every single error, we might have being able to communicate about the errors, but also about her feelings, emotions, and needs. We might have learned from her own words how to best respect her at that stage in her life, enriching ourselves in the process of delivering better care.

Breaking the silence surrounding the possibility and occurrence of errors in its practice, and rising above it is a major ethical challenge in today's oncology practice. [26] Communicating with honesty and humility with our patients and their families, sharing the same true story when an error has occurred and apologizing for it, gives all parties the opportunity to restore reciprocal even in the context of the right of any patient or relative to pursue a lawsuit and the duty of any oncologist to prevent, admit, and repair each medical error. To err is human, and so is our desire to overcome the deep emotional wounds of errors in favor of the tenderness that we feel toward our cancer patients and strive to show in our words and acts.

In this chapter, we have explored the question of why some patients and families who have suffered clinical medical errors and might have a strong legal position, do not sue. We would like to close by suggesting that medical culture, law, and the judicial processes can admit only a partial, and largely impersonal, account of medical error. They have their place, but cannot host the more human and stories that might lead to restoring the trust so essential to clinical medicine. By contrast, all involved partners might benefit by sharing the more truthful story about medical errors from the outset, rather than each telling a partial and impoverished story in court. [27]

Acknowledgment The authors wish to thank Erica Stern for her contributions to data analysis for this study.


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PART II Improving patient safety in clinical oncology practice CHAPTER 5