Perceptions of the general public and physicians regarding open disclosure in Korea: a qualitative study

Background Experience with open disclosure and its study are restricted to certain western countries. In addition, there are concerns that open disclosure may be less suitable in non-western countries. The present study explored and compared the in-depth perceptions of the general public and physicians regarding open disclosure in Korea. Methods We applied the COREQ (Consolidated Criteria for Reporting Qualitative Research) checklist to this qualitative study. We conducted 20 in-depth interviews and four focus group discussions with 16 physicians and 18 members of the general public. In-depth interviews and focus group discussions were performed according to semi-structured guidelines developed according to a systematic review of open disclosure. We conducted a directed content analysis by analyzing the verbatim transcripts and field notes in accordance with the predetermined guidelines. Results Open disclosure perceptions were summarized in terms of the “five Ws and one H” (who, what, where, when, why, and how). All physician and general public participants acknowledged the normative justifiability of open disclosure. The participants mostly agreed on the known effects of open disclosure, but the physicians had negative opinions on its expected effects, such as decreased intention of the general public to file lawsuits and increased credibility of medical professionals. Generally, the participants thought that open disclosure is required for medical errors causing major harm. However, the physicians and general public had conflicting opinions on the need for open disclosure of near misses. Most physicians did not know how to conduct open disclosure and some physicians had bad experiences due to inappropriate or incomplete open disclosure. Conclusion Physicians and the general public in Korea acknowledge the need for open disclosure. Guidelines according to the type of patient safety incident are required to encourage physicians to more readily conduct open disclosure. Furthermore, hospitals need to consider organizing a dedicated team and hiring experts for open disclosure. Electronic supplementary material The online version of this article (doi:10.1186/s12910-016-0134-0) contains supplementary material, which is available to authorized users.


Background
An understanding of the perceptions of medical professionals and the general public, including patients, regarding medical error is required to improve patient safety [1,2]. Furthermore, medical professionals and the general public should discuss patient safety incidents caused by health care delivery and develop measures to prevent and manage them together [3]. However, there may be gaps between the perceptions of medical professionals and the general public regarding patient safety incidents, such as the causes of patient safety incidents and their prevention. In particular, when patient safety incidents occur, there may be a marked discrepancy between medical professionals and patients regarding the communication of the incident [4]. Patients and their caregivers want to know what has occurred, why it occurred, and how it will be handled. However, medical professionals are reluctant to openly communicate with patients and their caregivers after such incidents [2,5]. These gaps in communication could diminish patient trust in medical professionals and patient satisfaction and may increase the likelihood of medical lawsuits [6,7].
To promote the communication of patient safety incidents to patients and their caregivers, open disclosure programs and policies are being adopted in several countries [8][9][10][11]. The definition of open disclosure may differ among researchers and institutes, but key components of open disclosure usually include "an acknowledgement; an expression of regret or an apology; an investigation into the incident; providing a factual explanation of what happened and explaining the steps being taken to manage the incident and prevent recurrence" [12]. The known benefits of open disclosure include reduced intention of the general public to sue and punish medical professionals, increased trust in medical professionals, increased intention of patients to revisit and recommend hospitals or physicians, improved quality of care scores, and ameliorated feelings of guilt of medical professionals [13].
However, the experience with open disclosure is restricted to certain western countries [12]. Furthermore, there are concerns that open disclosure may be less suitable in non-western countries [14]. Therefore, in this qualitative study, we explored and compared the in-depth perceptions of the general public and physicians regarding open disclosure in Korea. In the case of Korea, open disclosure policies have not yet been adopted, but there is growing interest in patient safety including open disclosure due to the introduction of a new patient safety act that requires the establishment of a patient safety reporting system at a national level in 2016 [15]. The key findings from this qualitative study will help in the introduction of open disclosure programs and policies in non-western countries such as Korea.

Methods
We performed 20 in-depth interviews (IDIs) and four focus group discussions (FGDs) to explore and compare the in-depth perceptions of study participants regarding open disclosure. A total of 34 individuals participated in this study (Tables 1 and 2). We thought that data saturation would be achieved with this sample size [16]. We applied the COREQ (Consolidated Criteria for Reporting Qualitative Research) checklist to this qualitative study as much as possible [17].

Organization of the research team
The research team consisted of four members. Three of the team members (MO, MWJ, and SIL) had previously participated in other studies into patient safety. Two of the team members (MO and HJK) had repeated experience in conducting and publishing qualitative studies.

In-depth interviews
IDIs were conducted with 10 members of the general public and 10 physicians. We operationally defined the general public as persons with no license or certificate in the medical area. We recruited members of the general public with a college diploma in their 30s or 40s, considering comparability with the physician participants. At the beginning of recruitment, IDI participants were

Focus group discussions
We conducted four FGDs. The participants of the first FGD were the general public, whereas physicians participated in the second FGD. The participants of the third and fourth FGDs were a mixture of the general public and the physicians from the first and second FGDs. Six to eight participants were involved in each group. We selected physicians with experience of patient safety incidents, as in the IDIs, to participate in the FGDs, but Gallup Korea recruited the general public participants of the FGDs by selecting individuals who were interested in medical accidents and aged in their 30s to 50s.  (5) failure of open disclosure in the case of apparent medical error causing severe harm. By assuming no harm in our third hypothetical case, we determined the participants' perceptions regarding a near miss. We expected that the hypothetical cases would help participants to readily express their opinions on open disclosure, but we did not just focus on these hypothetical cases.

A definition of terms
Before conducting the IDIs and FGDs, we clarified a definition of terms related to patient safety to the participants. We defined patient safety incident as "an event or circumstance that could have resulted, or did result, in unnecessary harm to a patient and medical error as "a failure to carry out a planned action as intended or application of an incorrect plan", in accordance with "Conceptual Framework for the International Classification for Patient Safety" from the World Health Organization [18]. We also defined adverse event as "an injury resulting from a medical intervention, or in other words, it is not due to the underlying condition of the patient" and near miss as "medical errors that resulted in no harm", in accordance with the Institute of Medicine [19]. The term of open disclosure were from the Australian open disclosure framework [9] and open disclosure was defined as series of process as follows: "When a patient safety incident occurs, medical professionals preemptively explain the incident to the patients and their caregivers, express sympathy and regret for the incident, deliver apology and compensation appropriately if needed, and promise to prevent recurrence."

Analysis
The audio recordings from the IDIs and FGDs were transcribed verbatim. Transcripts were not returned to participants for comment or correction. We applied a directed content analysis by analyzing the verbatim transcripts and field notes in accordance with the predetermined guidelines of IDIs and FGDs [20]. One author (MO) first read the transcriptions and field notes repeatedly and coded them according to the categories. Another author (HJK) reconfirmed the results of the analysis. Data saturation was confirmed by two coders when no additional codes were identified. If there were disagreements, two coders conducted a reiterative analysis together and reached an agreement. The research team also examined the codes and their categories. We used NVivo 10 software for the analysis [21]. We did not get feedback from participants on the results of the analysis.

Results
A total of 34 individuals participated in the IDIs (n = 20; Table 1) and FGDs (n = 14; Table 2). Analyses of the transcriptions identified 474 codes and the codes were categorized into nine groups according to the "five Ws and one H". The structure of the analysis results and the main content is shown in Table 3. Further details are provided below.
Why should medical professionals conduct open disclosure?
All of the participants in this study, both the physicians and the general public, acknowledged the need for open disclosure. In essence, many suggested that open disclosure is required in its own right, regardless of its impacts or benefits. That is, they felt that open disclosure is a physician's moral responsibility and that patients' and their caregivers' have a right to know this information. Therefore, physicians with a • Open disclosure is an imperative, especially for the healthcare field because it deals with matters affecting life and death. • The well-known benefits of open disclosure, such as reduced number of medical lawsuits and improved level of patient trust in physicians, were generally accepted by participants.

When
When should open disclosure take place? When should open disclosure be initiated?
• Participants from the general public group wanted open disclosure to take place as promptly as possible.
What What should be delivered through open disclosure?
• Incident description and sympathy expression were considered essential elements of open disclosure. • The general public mainly argued that if harm occurs due to medical error, the apology should come before compensation and will bring about emotional relief.

Who
Who should practice open disclosure?
• Physicians thought that implementation of open disclosure itself depends on the superior involved, that is, the professor in charge of the department.
Who is subject to open disclosure?
• Many participants believed that not only patients, but also caregivers are subject to open disclosure.

Where
Where should open disclosure take place?
• All physicians insisted on a separate place, for instance, a quiet counseling room, as a venue for open disclosure.

How
How should open disclosure be carried out?
• Physicians did not know how to conduct open disclosure.
• The general public felt offended by inadequate apologies and consequently felt neglected in other medical areas as well.
How should open disclosure be promoted?
• Most physicians acknowledged the importance of open disclosure education.
• Not only most physicians, but also considerable numbers of participants from the general public showed support for improving the medical environment, that is, the organizational culture of hospitals.  The well-known benefits of open disclosure, such as reduced number of medical lawsuits, improved level of patient trust in physicians, increased willingness to revisit the physician/hospital, higher patient satisfaction, and lessened physician guilt were generally accepted by participants. However, some were skeptical. In particular, physicians were cynical of the effect of open disclosure on reducing lawsuits; they forecasted that the fall in the number of medical lawsuits would be hindered by Korean laws and the healthcare milieu. When should open disclosure take place?
In deciding when to conduct open disclosure, there was discordance among participants according to the characteristics of the patient safety incident. First of all, physicians and the general public agreed on the need for open disclosure in the event of medical errors that cause severe injuries. A medical error leading to severe harm is an indisputable event. Therefore, many suggested that such a trait leaves physicians no choice but to conduct open disclosure. Meanwhile, others pointed out the possibility of concealing, rather than disclosing, medical errors resulting in severe injuries. On the other hand, comparative comments were made for medical errors that resulted in minor harm. For such errors, open disclosure could be practiced without much stress, so the likelihood of implementation is high. However, one physician mentioned that s/he would inform the hospital patient safety reporting system of medical errors resulting in minor harm but would not practice open disclosure with the patient and the caregivers; another participant voiced concern over such a comment, stressing that it will decrease the patient's trust in medical staff and reduce their willingness to revisit the hospital. In particular, physicians mostly assumed that patients would not want to know about medical errors causing minor problems.
Pessimistic perspectives of physicians on the need for open disclosure of apparent medical errors causing minor harm Focus 6 (Physician): I suppose medical errors causing minor harm will be even more problematic. Interviewer 2: Because patients will know nothing of it if the physician keeps quiet? Interviewer 1: You know you should say something, so you are facing a dilemma as a doctor? Focus 3 (Physician): Hmmm. I'd rather not say. This is a matter of preference, I think. The patient might not feel the need either. Telling the truth is the right thing to do, but since nothing really happened, I guess doctors would be inclined not to do so.  Need for an apology for inapparent medical errors Focus 14 (Layperson): Whether the doctor admits it or not, an apology is a must. The mind and the body are not separate, you know. The mind is actually connected to the body and directly affects it, so the patient ought to have been extremely confused and troubled. I mean, the least you could do is to admit that they're liable and apologize. Say, "I've tried my best as your doctor and I am sorry for the unintended consequences." In particular, certain physician participants admitted that there is a gap between the perspectives of the general public and physicians about which particular adverse events are subject to open disclosure and whether a medical error has occurred or not. Moreover, they required a proactive approach when dealing with open disclosure of all patient safety incidents.
Differences between the perspectives of physicians and the general public on patient safety incidents Focus 5 (Physician): To bring our attention back to this issue, as you have seen here, the major premise is that a patient safety incident had occurred. But the thing is… the standpoints of seeing this as a patient safety incident vary. Doctors do not consider it such an incident.

What should be delivered through open disclosure?
The four elements of open disclosure-providing explanation, showing sympathy and guaranteeing future investigation, offering an apology, and promising adequate amount of compensation and effort to prevent recurrence-were reviewed in this qualitative study. Firstly, most participants, including several physicians, and particularly the bulk of participants belonging to the general public group supported the early stages of open disclosure, such as providing explanation, showing sympathy, and guaranteeing future investigation. The emphasis was on the importance of reassuring the patient, providing emotional comfort, and promising investigation of the matter when a patient safety incident occurred. Particularly, incident description and sympathy expression were considered essential elements of open disclosure. Thus, omitting them would tarnish the meaning of the other elements. In addition, there were opinions on the need for an explanation despite the ambiguity of the medical error.

Need for incident explanations in open disclosure
In-Depth 8 (Physician): Whatever the case, you should give an explanation to the caregivers. On why you did it and how things can go wrong.
Interviewer: And what makes you think you should inform them? In-Depth 8 (Physician): Well, isn't it natural for them to want to know? All of a sudden, a patient dies after a surgery. Sure, the odds of death from surgical complications, one in a million and whatnot, are well known. But they probably wouldn't have imagined anything like it happening in their own life, not in a million years.
Interviewer: Then, it's for appropriateness? Because you ought to or is it out of some sort of ethical conscience? In-Depth 8 (Physician): It's designated in medical ethics, and aren't we mandated to inform the caregivers because it's just right?
Secondly, many participants showed emotional support for an apology, which is the second element of open disclosure. The general public mainly argued that if harm occurs due to medical error, an apology should come before compensation and will bring about emotional relief. However, for fatal accidents, some participants from the general public group mentioned concerns regarding the acceptance of apologies because their power was limited.
Importance of delivering an apology in open disclosure Focus 7 (Layperson): The main target of open disclosure seems to be obtaining sincere apologies from physicians. Apart from money, as a human being, one-on-one… When a patient is harmed or dies, we want a wholehearted apology. Medical disputes come later. Money and whatnot comes second. Interviewer 2: I'd like to speak on behalf of physicians because they found that "it all comes down to money". Focus 7 (Layperson): Not all people are like that. A good tongue is a good weapon, you know. With a heartfelt "sorry"… Focus 1 (Physician): But let's say your father had passed away. He was the one providing for the family. So, now you are all of a sudden out of money. Will an apology do? Your mother died so now you need to hire a housekeeper. Will it do? It goes the same for a child too. A kid does not even support the family, but most people seem to consider financial compensation a sincere way of apologizing. Focus 10 (Layperson): Money is not the best policy. Focus 7 (Layperson): Money is not a cure-all. Father's gone. The only source of family income is gone now and no sincere apology or whatsoever will replace him. But if doctors take responsibility and apologize for my loss, I would take it on my own shoulders even when I have to earn a living for myself. Because I accepted the apology.
In addition, not only the physicians, but also the general public insisted on an apology only when a medical error occurred. However, there were few opinions from the general public on how they would emotionally prefer an apology, with some admitting that it is rationally unnecessary. Most participants distinguished between sympathy and an apology but had trouble defining them. One of the participants who belonged to the general public group suggested that an apology cannot be considered an admission of medical error or negligence, depending on the expressions used and underlying context.
Apology not regarded as admitting negligence In-Depth 19 (Layperson): When such a case arises, it's saying sorry for what's happened and any wrongdoing possibly caused by the medical staff, for example. And it doesn't necessarily mean you are admitting negligence. At first, when people are in a fury or are upset, they may take it as an admittance [of guilt]. But after they cool down and think about it, I don't think they will take it that way. And, personally, I wouldn't.
Thirdly, most participants from both groups urged a guarantee of adequate compensation if the medical error was clear. When the medical error is not apparent, physicians need not promise compensation. Furthermore, some thought that an adequate amount of compensation for adverse events would prevent disputes. However, there were worries about how the ambiguity of the word "adequate" could cause difficulty in determining the amount of compensation.

Compensation unnecessary for inapparent medical errors
In-Depth 12 (Layperson): I don't see any need for compensation. If it's not an error, an apology will do. Compensation is absolutely unnecessary and saying sorry for the inconvenience caused seems fine. Interviewer: Isn't it unfair for the patients? They came to a hospital in the hopes of getting better, but end up with a longer hospital stay and additional treatment. In-Depth 12 (Layperson): Now that's something we have to work on. "Due to this condition, this rare, probability of one or two percent, complication occurred. That is why you need further treatment and I am sorry for the inconveniences caused." Good enough. You do not need to provide compensation.
Fourthly, discordance between the perspectives of physicians and the general public became apparent in the fourth element of open disclosure, promising to prevent recurrence. Several physicians did not feel the need to promise prevention. Furthermore, similar to apologizing and assuring adequate compensation, they refused to accept the fourth element when the medical error is not apparent.
Skeptical perspectives of physicians on a promise to prevent recurrence Interviewer: Do you think promising to prevent recurrence is a different matter? In-Depth 2 (physician): I think education is a prerequisite if we were to jump into that. But in this situation where everyone's growling at each other… I think it's better not to… Interviewer: Even if it's for future recurrence prevention? In-Depth 2 (physician): That's a promise you have to make for yourself, not to the patient or the caregiver… However, many participants from the general public insisted on a promise of recurrence prevention to the patient and the caregiver, because they thought that prevention itself should be our ultimate aim. In addition, despite the ambiguity of the error, prevention was deemed important to identify the hidden factors behind the incident. How should open disclosure be carried out?
Generally, physicians were aware of the significance of successful implementation of open disclosure. However, they did not know how to carry it out. Furthermore, they shared their experiences on how inappropriate or imperfect open disclosure either provoked negative responses or turned out to be ineffective. They also seemed to have acquired certain coping skills, such as avoiding bringing up words or phrases that might trigger hostile reactions from patients. Meanwhile, some could not practice open disclosure even under compulsory circumstances.
Physicians' styles in carrying out open disclosure Focus 6 (Physician): I don't literally bring up the word "regrettable", but I do it eventually. Interviewer 2: How do you express it without actually saying [the word]? Focus 3 (Physician): Like, "You won't be able to go home, unfortunately". Focus 6 (Physician): "We need further tests". Interviewer 1: Without using the word "sorry"? Focus 3 (Physician): It's a Korean thing that you don't really need to put into words to… Focus 6 (Physician): "We need more tests". However, the general public felt offended by inadequate apologies and consequently felt neglected in other medical areas as well.
Offended by inadequate delivery of apology Focus 14 (Layperson): The apology did not make me feel any better. 'Cause I knew how inattentive the head nurse at that floor was. I kept my eyes on that child 24/7, except for that 30  In particular, most participants could not present a clear-cut means to deliver empathy and apology, the two elements of open disclosure, in a cordial way. However, they expected that sincerity would be expressed through the following: precise and detailed explanations, use of charts and data, and investing time in counseling. Additionally, one physician felt that more time spent with the patient reinforced the persuasiveness of his/her explanation. One participant from the general public group pointed out that a sincere apology can be intuitively distinguished from an apology that is feigned. Focus 1 (Physician): Not only that, but also IV fails, tapping fails, bone marrow (aspiration) fails in the ER… These days, I am affiliated to an online club of moms of pediatric cancer patients as an observer. They talk about all kinds of things there. One of the things that grabbed my attention was how moms were upset after repeated failures and no apologies from doctors. Moms were very upset. Failed procedures were making their kid suffer in pain, but doctors would smile and walk away. We can imagine why doctors would smile in such situation. They were embarrassed and that's probably why they smiled awkwardly. Moms get furious because their babies are sick. But, in fact, we are extremely sorry, but we just don't know how to express or convey it.
Secondly, not only most physicians, but also a considerable number of participants from the general public showed support for improving the medical environment, that is, the patient safety culture of hospitals. In reality, even with hospital approval, it is not easy to perform open disclosure, and the hierarchical hospital culture that involves apprenticeship and the traditional "blame Finally, participants were asked how they viewed the apology law and open disclosure law in light of the legal reform. Many agreed on the purpose and the need for an apology law to facilitate open disclosure. In other words, the apology law could dispel concerns among physicians who worry about having an apology used against them in court. Meanwhile, several others doubted the likelihood of the introduction of an apology law and its usefulness. Some physicians even suggested the possibility of an increase in medical lawsuits filed by patients informed about patient safety incidents that would have been overlooked without open disclosure. In addition, some participants from the general public expected an increased number of patient-doctor conflicts in Korea upon the introduction of open disclosure compared with the United States. One participant from the same group thought that empathy or apology expressed under the apology law would hardly be sincere. Moreover, several physicians predicted that open disclosure would be practiced only in incidents that are distinct to the patients or the caregivers.
A participant from the general public group supporting an apology law In-Depth 20 (Layperson): For now, it will definitely invigorate open disclosure. But, now that I think of it, patients might not consider open disclosure sincere in severe cases. It won't feel like doctors are being 100 % frank. It'll give the impression that they are trying to duck out of responsibility and say sorry at the same time, so I guess it won't make patients any happier. Interviewer: Okay. In-Depth 20 (Layperson): Nevertheless, it's a necessary evil. When such a system is nonexistent, these things will never be disclosed to begin with. It's like a necessary evil.
Participants expressed doubt about the adoption of an apology law because of the differences between the legal systems in the United States and Korea. However, despite the probability of weakening a patient's ability to prove medical malpractice in court, most people from the general public were still in favor of an apology law. However, some insisted on imposing limitations on the starting time of open disclosure in order to enact an effective apology law. Therefore, they suggested protecting open disclosures that have been carried out within a certain time after the occurrence of the patient safety incident or when it is acknowledged by physicians.
Participants from the general public group supporting an apology law even when patient's admissible evidence can be tainted

Discussion
We conducted 20 IDIs and four FGDs with 16 physicians and 18 members of the general public to explore and compare their in-depth perceptions of open disclosure. We found specific findings under the various aspects of open disclosure in terms of the "five Ws and one H". We also compared the differences and similarities between physicians' and the general public's perceptions of open disclosure. The key findings from this qualitative study will help to promote a more positive view of open disclosure and to develop open disclosure guideline policies in hospitals. In particular, this study will broaden the understanding of open disclosure in non-western countries because studies on open disclosure are often scarce in non-western countries.

The need for open disclosure
Although there are concerns that open disclosure is less suited to non-western countries [4], all of the participants in this Korean study acknowledged the need for open disclosure. In particular, many suggested that open disclosure is required in its own right, regardless of its impact or benefits. They thought that open disclosure is an imperative for the healthcare field because it deals with matters of human life. Furthermore, open disclosure is valuable, in terms of not only patient safety, but also patient-centered care, emphasized by the Institute of Medicine as one of the goals for healthcare improvement [22]. We need to pay more attention to what is right and wrong based on the views of patients and their caregivers.
The well-known benefits of open disclosure, such as a reduced number of medical lawsuits, improved level of patient trust in physicians, increased willingness to revisit physicians/hospitals, higher patient satisfaction, and ameliorated guilt in physicians, add value to open disclosure [13]. These benefits were generally accepted by participants in this study but some participants provided skeptical responses. In particular, physicians were cynical of the effect of open disclosure on reducing lawsuits and related costs. According to previous studies, some found that open disclosure does not increase the likelihood of lawsuits from the general public [23][24][25], although one study showed that a fair number of physicians disagreed with its effects on medical lawsuits [26]. Furthermore, two studies of observational data reported that open disclosure reduced the number of medical lawsuits and their related costs [27,28]. We need to disseminate the known medical lawsuit-related benefits of open disclosure to physicians to improve their understanding of the situation. However, more research is needed to evaluate the medical lawsuit-related effects of open disclosure in non-western countries because most previous studies were conducted in western countries [4].

Objectives of open disclosure
Another remarkable issue concerns when open disclosure should take place. Most importantly, there were discrepancies between physicians and the general public on the objectives of open disclosure according to the characteristics of the patient safety incidents. First of all, the participants generally agreed on the need for the open disclosure of medical errors causing severe harm. However, some physicians mentioned that they would not conduct open disclosure for medical errors causing minor harm. Furthermore, some physicians expressed marked negativity toward open disclosure of near misses, similar to the findings of previous studies [5,29]. In particular, we expected that there would be controversy about whether open disclosure is required for near misses. However, as the participants from the general public and some physicians mentioned in this study, a more persuasive argument is that open disclosure of near misses is necessary for the patient's future reference and to prevent similar medical errors. Gallagher et al. also reported that knowledge of a near miss could alert patients to what medical errors they should be aware of.
Almost all physicians had negative views on open disclosure of inapparent medical errors. However, we believe that these perceptions were caused by the physicians' misconception that open disclosure only involves apologies for mistakes. When we divided open disclosure into four key elements, namely, providing explanation, showing sympathy and guaranteeing future investigation, offering an apology, and promising adequate amount of compensation and effort to prevent recurrence, providing explanation and showing sympathy and guaranteeing future investigation were also necessary in inapparent medical error cases. Although most of the general public insisted on an apology only when medical error occurred, incident description and sympathy expression were considered essential elements of open disclosure, even for ambiguous medical errors. Medical professionals, including physicians, therefore need to be educated about the key elements of open disclosure. Furthermore, guidelines for open disclosure according to the type of patient safety incident are required to encourage physicians to more readily conduct open disclosure.

Methods for carrying out open disclosure
In this study, almost none of the interviewed physicians knew how to successfully conduct open disclosure and some reported bad experiences, namely, that inadequate or imperfect open disclosure either provoked negative responses or turned out to be ineffective. Consequently, many physicians seemed to have acquired certain coping skills and they did not practice open disclosure even in situations requiring open disclosure. On the other hand, the general public felt offended by the inadequate open disclosures and felt neglected in other medical areas as well. Therefore, help is required so that physicians can effectively and appropriately carry out open disclosure.
In order to successfully perform open disclosure, a systematic approach, including the development of education programs and guidelines, should be emphasized rather than an individual approach treating open disclosure as an entirely private matter [30][31][32]. Etchegaray et al. [31] reported that training and education on open disclosure were correlated with a more positive attitude to open disclosure and its benefits in terms of patient trust. Most physicians interviewed in this study also