Interview and survey based research works conducted among specialists and trainees from a variety of medical disciplines, such as: Anatomic and surgical pathology, surgery, obstetrics, pediatrics, family medicine, emergency care, internal medicine; and also from diverse geographical backgrounds such as South Korea, China, Iran, Saudi Arabia, Canada, USA, Italy, Spain and Turkey, point to the fact that inadequate disclosure of medical errors is a universal, specialty – overarching problem[1]. Medical errors can be defined as "an injury or illness caused by medical management, rather than by the underlying disease or condition of the patient (adverse events), or an event that could have resulted in an injury or illness, but did not (near misses), either by chance or through timely intervention"\cite{Grepperud_2005}.

The problem of getting the distinguish between medical complications and errors seems to be connected to an inherent problem of biomedicine: How can medical standardization be reconciled with the big diversity of bodies and pathologies? How can doctors standardize diagnosis and therapy, in the midst of variation in work conditions, training and education, and also, experience and personal background? Connected to the problematic issue of a technically correct definition of an expert - induced error comes the social problem of communication: How are doctors supposed to tell patients and patient relatives, that they have to suffer the consequences of his-her own professional shortcomings or work overload?

Evaluating the efficacy and accuracy of clinical reasoning is a difficult task. The two primary models developed to investigate reasoning in diagnostic and therapeutic tasks in clinical medicine are the decision-analytic approach and the information-processing or problem-solving approach[2]. While the decision – analysis is based on comparing a doctor’s diagnostic accuracy with a mathematical model, the information – processing analysis describes cognitive processes in reasoning tasks, based on case protocoll analysis and observational techniques[3]. Research on understanding accurate diagnosis methods and figuring out the most effective expert tools for developing therapy plans support efforts to reduce medical errors in clinical practice.

“The health care delivery system is rapidly evolving and undergoing substantial redesign, which may introduce improvements, but also new hazards…As health care and the system that delivers it become more complex, the opportunities for errors abound. Correcting this will require a concerted effort by the professions, health care organizations, purchasers, consumers, regulators and policy-makers. Traditional clinical boundaries and a culture of blame must be broken down.”[5]

The report points to the immediate need for constructing a medical error reporting system in all stages of healthcare delivery. This approach was further supported by the 2005 evaluation report of two authors of "To Err is Human", stating however, that progress in matters of safer care delivery and improved communications was slow. The authors expressed hope in the introduction of "pay for performance" incentives: " The pace of change is likely to accelerate, particularly in implementation of electronic health records, diffusion of safe practices, team training, and full disclosure to patients following injury. If directed toward hospitals that actually achieve high levels of safety, pay for performance could provide additional incentives."\cite{Leape_2005}. Yet, inspite of improvements in electronic record keeping, more training in team work and doctor - patient communication and increased awareness about the need to disclose errors to patients, the question about how to avoid putting institutional or team-based mistakes on the account of the direct service providers, especially nurses and physicians, seem to remain largely unanswered. Also, the debates about if to compile data on errors anonymously or not, and if to make data on medical errors accessible to the public, are topics which seem to be hard to resolve, as they point to the conflicting interests of patients, physicians and healthcare facilities\cite{Blendon_2002}.

The WHO, in 2009, called for the global development of national health information systems, designated as " country health systems surveillance (CHeSS) platforms", to "electronically monitor performance, efficacy and increased patient safety in healthcare"\cite{who2009}. The surveillance platforms serve the synthesis of data from direct care providers, and so allow for better planning of services, joint ventures and efforts to reduce inequalities in work load, infrastructure and access to information for the health care professionals. Although electronic surveillance systems definitely would support full disclosure of medical errors to patients based on concrete data, it seems to be difficult to implement surveillance networks connecting the diverse structures of healthcare facilities: Public hospitals, university clinics, private clinics, doctor's offices and pharmacies. Developing standards for care and building in filter mechanisms to detect practices deviating from standards becomes more difficult, as financing, governing and controlling healthcare slips government control in most parts of the world, and as patients increasingly are consumers, customers and regulatory actors in their own healthcare \cite{Healy_2017}.

In a web - based survey from 2010 carried out among 2194 Turkish physicians from diverse backgrounds, 41,4% of survey participants concluded that the transformation of the doctor - patient relationship towards a consumer - service provider approach leads to increasing patient mistrust \cite{pala2011}. The authors of the study point to another shortcoming of the pay for performance system with regards to avoiding medically induced harm: In the performance based evaluation of healthcare services, what counts as success is hardly the quality of care provided, which is difficult to assess in numbers, but the number of patients served and interventions completed. This pressure of serving as many patients as possible, with the lack of adequate numbers in co-workers, clinical infrastructure and technological know-how, combined with the pressure to commit no medical mistakes, put the doctors in an almost unsolvable dilemma. The number of private-run healthcare facilities, where the doctors work under the pressure of profit accumulation, increase in many countries, including Turkey \cite{2014}.

Under these conditions, it becomes harder to avoid medical mistakes in clinical encounters. This may be one of the reasons why, an increasing number of articles in a variety of specialist journals today deal with the problem of disclosing medical failures to patients. A number of studies suggest teaching methods and tools in assisting medical students and interns to improve professional skills in: Explaining why and how the medical error happened, giving informed assurance that the mistake will be avoided in the future, and offering sincere apologies to patients and families \cite{Berlinger_2005}, \cite{Rathert_2010}, \cite{Appelbaum_2017},\cite{Han_2017}.

The increasing role that the patient plays as a partner in regulating therapy requires strong communication skills from the sides of the medical professionals, especially nurses and doctors. As Healey discusses, situating patients as active agents in the therapy process poses challenges with regards to: Providing patients access to support and sanctioning mechanisms; Providing patients with sufficient information to regulate their healthcare; Providing transparency in diagnosis and therapy, making it possible for patients to know when things go wrong; Building therapeutic confidence between patient and doctor, so that genuine cooperation is possible\cite{Healy_2017}. From the perspective of doctors however, co-regulating therapy and informing patients about risks, side effects, possible alternatives and the possible outcomes of a treatment is not only time-consuming and difficult, but also includes the problem of explaining unforeseeble events, which in most cases, may lead to misunderstandings and unneccessary anxiety.

The changing expectations of patients from the medical professionals, especially in matters of transparency in disclosure of complications and medical errors, may strongly undermine the medical authority of doctors. This change of position is not only problematic in relationship with patients, but also with regards to other medical professionals and the institutional framework. The hierarchical structure of the profession within itself may undermine any efforts to share medical authority, and hinder aceptance of medical fallibility. On the other hand, authority not only means making decisions, but also carrying the consequences. This is somehow expected from the traditional doctor, and leads to increasing problems of dealing with self-blame and feelings of insufficiency. As demonstrated by a study carried out among obstetricians and midwives in Denmark, even in an institutional context regulated to promote non-judgemental recognition of mistakes, and even in cases of not doctor-induced adverse events, medical profesionals suffer from guilt and have problems with self - forgiveness \cite{Schr_der_2017}. It seems that, one possible way of reforming a doctor's acceptance of limitations and fallibility may be introducing methods of self - reflection and transparency already during the undergraduate education and also during internship. As pointed out by Berlinger and Wu, role models, senior physicians should play a major role in instructing prospective doctors how to " disclose errors, apologise to injured patients, and ensure that these patients' needs are met, while honestly confronting the impact of error upon oneself" \cite{Berlinger_2005}.

As stressed by Martinez et.al. in their study on dealing with surgical mistakes, a hierarchical work environment in medical care does not serve well, when it comes to disclosure[7]. Unfortunately, a rapid transformation of power structures in the medical profession does not seem to be immediately achievable. Doctors may fear to appear professionally incompetent, having to suffer malpractice punishments, and be harshly treated by collegues, especially by senior doctors, and may try to ignore, cover up and silence medical mistakes Here too, discussing frankly with medical students about the power inequalities among doctors and patients, and also among members of the medical profession, and encouraging students to develop a critical approach towards power disparities in the system, may prove fruitful. One basic argument in favor of less hierarchical relations in the hospital environment may be, that rigid power structures may hinder the open flow of information: One example is given by Pynton in his discussion of the communication patterns of nurses with doctors, who perceive to have less power in the hospital context and hence, use informal mechanisms to have more say in the decision making processes \cite{paynton2009}.

Turkey: Badir and Herdman interviewed 150 critical care nurses concerning their perceptions of patient safety standards in a selecion of private, public, and university hospitals in Turkey. Quality management and patient safety programs were more prevalent in private hospitals. Private hospitals were also more likely to encourage reporting, have error/adverse event reporting systems, and less likely to have a punitive response to reported errors. However, respondents who work in private hospitals work both more hours per week and more hours per day \cite{Badir_2008}.

There is no doubt that disclosing medical failures to patients and also to collegues and institutions should not be a burden that individual doctors should carry by their own. There should be best practice guidelines, training and instruction available for medical professionals at all levels of their education, starting from the undergraduate level[8]. In the Turkish context, doctors and medical ethics professionals stress the need for less ambigious medicolegal regulations, special courts for the evaluation of malpractice cases and a public malpractice insurance system \cite{Pakis_2009}, \cite{_zdemir_2005}, \cite{_zkara_2003},

As Ghalandarpoorattar et.al. state, gaps between doctors best intentions and clinical practice can be huge, when it comes to talking with patients about professional shortcomings, flows in the healthcare system and the consequences of their errors, that the patient has to bear[9]. Training in how to analyse all steps and components in a patient’s treatment that went wrong, and working for the needed institutional change for transparency at the work place, would be a part of such educational programs[10]. Doctors should also learn to how patients hear what they are saying[11].

A literature survey of the Turkish body of work on medical errors and their disclosure reveals that there is rich material discussing legal and medical implications of physician induced errors, how they can be reported to healthcare institutions and the related state agencies, and how hospital systems can be improved to learn from them. Although one study has been conducted there is not one single study on how to disclose mistakes to patients, and not any study or review article on how to apologize from patients for mistakes undergone.

It seems that while acknowledging professional, institutional, political and economical shortcomings in the delivery of healthcare services, medical professionals in Turkey do not yet recognize the role patients play in the web of healthcare delivery. The missing agency of the patient and patients’ families in the intellectual universe of Turkey’s doctors and nurses may be interpreted as a hidden, ignored paternalistic approach yet prevalent in Turkey’s healthcare system.

Although reliable numbers on medical mistakes in Turkey are not available, Turkey already has an anonymous mistake reporting system for healthcare professionals. Along with the increasing number of patients’ rights centers in hospitals and civil advocacy groups for patients’ rights, it may be that a pressure from the sides of patients for transparency and open communication can make doctors think about how to talk about medical mistakes, not only to hospital administrators, lawyers, law makers, ministery of health officers and to each other.

The inadequate nature of the Turkish “Professional Safety Insurance”, the mandatory private insurance intended to protect doctors against malpractice cases, may support the need to find other methods of dealing with medical mistakes, rather than meeting the patients and families at court. Here, the Scandinavian system of “Patient safety Insurance” may provide a good example, where standing on a legally and financially safer basis, also Turkey’s healthcare professionals would start to consider having honest conversations with patients about personal and institutional guilt, shortcomings and potentials for improvement.

[1] For ex.: \cite{Dintzis2011}, \cite{White2011}\cite{Coffey2010}, \cite{Cole_2013}, \cite{Ghalandarpoorattar2012}, \cite{Leung2010}, \cite{2017}, \cite{Blendon_2002} \cite{Parzeller_2014}, \cite{Leung2010}, \cite{Lee2012}, \cite{Leone_2015}, \cite{Fein_2007}, \cite{Wu_2009}, \cite{Hammami_2010}, \cite{Raemer_2016}, \cite{Anwer_2014}, \cite{Varjavand_2012}, \cite{Mazor_2006}, \cite{Giraldo_2016}, \cite{Badir_2008},