Making Mistakes [Revised]

In March 2004, a patient I had sent home from the emergency room (ER) of a Manchester teaching hospital died that same night. He presented with recurrent mild heart failure. I adjusted his medications and arranged for an early clinic visit. What was routine that evening was a fast fading memory by breakfast.

At least until some very upset children arrived to the ER. Years later, I can play it all back, a grainy black and white film clip whose starkness and low quality rebukes me; being paged off rounds, speaking with the family, bringing them to meet my boss, who sat with me and the family and reviewed the chart, EKGs and x-rays. He explained the management was appropriate and yet how he regretted the outcome. We were professional; to them I’m sure we appeared distant, saying the right words, yet not feeling their pain. We resumed rounds.

Privately, I was beside myself. My feelings were a mélange of regret, shame, guilt, embarrassment, humiliation, defensiveness, but shame most of all. My focus was me, not the patient or his grieving family. Such episodes were not meant to happen to young stars. I played the episode over and over, in a fruitless effort to make me feel better. Nothing in my prior life had prepared me for this. To the best of my recollection, none of my teachers had discussed such a scenario.

I drove to my parents’ home that evening. My Dad was reassuring, told me that in the practice of medicine such incidents were unavoidable, and related the story of a man he saw in his private clinic for a routine follow-up visit who fell dead, directly after my father told him he was in great shape and he’d see him in 6 months.

Well meaning as they may have been, the support of my father and my boss did not lessen the emotional impact of the event. Labeling it “unavoidable” was about as much help as telling someone who had lost an aged parent that this was unavoidable. Moreover, while my management might have been considered “appropriate”, the outcome had mistake written all over it. Not in some medico-legal sense, but to both me and the family, and assuredly to the patient if he could have offered an opinion, this was a mistake.

Over the ensuing years, I’ve made lots of mostly trivial mistakes. I say lots but have no true sense of the number. There are those that I know of, others are more conjectural and based on the number of patients I’ve seen in my career. Some have been caught by backup safety mechanisms like a pharmacist questioning a miswritten prescription. Others have been holding on to my initial clinical diagnosis ignoring evidence that the results of investigations or response to therapy should have had me rethinking my impression. Some were gaps in my knowledge, a particular problem for those of us with the sense that we’re above average.

Even in the arcane field of EEG interpretation, where I am considered one of the very best, I made mistakes. None of these were mistakes that led to any lawsuits, but they were mistakes nonetheless. This is not about wearing a hair shirt; rather, a deliberately bald acknowledgement that the best of doctors make mistakes, no exemptions permitted. My choice of the word mistake is also deliberate. The prefix is powerful here; error is softer, and other words (oversight, confuse, inaccuracy etc.) smack of obfuscation, and a degree of denial.

Separate from caring for my own patients, a major part of my professional life has been the education of medical students and residents. As I reflect back on all our interactions, I don’t think I ever had a discussion with any of them about coping with the mistakes they were inevitably going to make. Of course we discussed side-effects of medications, or procedural complications, or avoiding defensive ordering of tests, but I never discussed in depth, and out of the hurly-burly of the clinical environment, the issue of mistakes; that they will happen, how you are likely to feel, how to discuss them with the patient and their family, how to deal with the emotional outcome over the ensuing weeks and months, and how not to let them poison your methods of practice in the future. Is this absurd, and an abrogation of responsibility as a clinical teacher? Absolutely. Am I an outlier? I very much doubt it.

Difficulty admitting to mistakes is human, but the stakes in the case of the healthcare provider are elevated, and require a degree of integrity and self-reflection above what most humans must display. It has become almost reflexive for physicians to cite malpractice risk as the explanation for much that ails US medicine. In reality, the overwhelming majority of our patients and their families are reasonable and see us as fallible human beings too. As a profession often criticized for its arrogance, the admission of mistakes provides us with a great opportunity to display humility. The claim that our difficulty dealing with mistakes is self-protective against the odds of litigation is exaggerated. The wound to our professional pride is more the point. There is evidence that disclosure of errors decreases the likelihood of malpractice suits. Even in the absence of transparency, a very small percentage of errors end up in malpractice lawyers’ hands. It’s when there is a breakdown in the doctor-patient relationship that lawsuits emerge.

Some choose to find refuge in our having Morbidity & Mortality Reports, and Quality Assurance reviews. I’ve attended some M&Ms and been embarrassed by the behavior of colleagues more interested in scoring points and showboating than being constructive and learning. Besides, who isn’t smarter weeks, and a literature review afterwards? As for QA, it is virtually impossible to capture the staggeringly high number of variables that any practice or department will encounter. In my discipline of neurology it is relatively easy to track variables on our inpatient services and in the clinical laboratories, but vastly harder in the outpatient clinic, a major problem when ~ 90% of clinical neurological practice happens in the ambulatory setting.

M&M and QA allows up pass muster when the time comes for review by bodies like the Joint Commission for the Accreditation of Healthcare Organizations or Residency Review Committee. Certainly, organizations like JCAHO and the RRC demand greater accountability than in the past. However, these reviews are still more about jumping through hoops every few years, and having the backup paper trail as evidence that “we’re tracking things”. All individual physicians and healthcare organizations should aim to exceed their minimum standards by a wide margin, and have systems of patient care and education in place that work every single day.

A core problem in dealing with mistakes remains our high opinion of ourselves. Even before physicians enter medical school, we are trying to separate ourselves from the pack. We are smarter, work harder, and postpone gratification more; in sum, we’re above average. Our educational systems reinforce this illusion. We strive (and in fairness often succeed) to instill rigor. We are thorough, scientific, rational, exhaustive in our evaluations, prudent in our recommendations and the assorted caveats with which we discuss matters with our patients. To admit error wounds this self-image. We like the mystique of physician as demi-God. If you read obituaries of physicians written by physicians, you get some sense of this.

We should conquer our need to be omniscient and omnipotent, and acknowledge our vulnerability. We all make mistakes. Sometimes he or she who makes the bigger one is just a little unlucky that it happened to them. Just like we’ve all sailed through a red light and got away with it, while an unlucky one here or there gets nabbed. Greater humility would allow us talk about our mistakes. We would do well to listen in a constructive non-judgmental way to our colleagues who have the integrity and maturity to admit error; to support, and to learn. Those physicians who are humble, less competitive and egotistical are often silenced by being in the minority in a culture that is antithetical to their world view.

We should be concerned about the emotional well being of the physician who has made an error. We all succumb to the trap of denial, but by doing so short-change ourselves by impeding moving beyond the mistake. Denial is also harmful to the patient who is entitled to the unvarnished truth about the error, and to any colleagues who may be unwittingly involved. Many errors result in no long-term harm to the patient, but we should avoid a wait-and-see and then I’ll tell them approach. It’s the patient’s right to know, always.

While silence may be part of denial, it exists as a stand alone phenomenon also, when one considers attitudes at the level of the profession. A lot of human misery is a result of keeping something to ourselves. The culture in our profession is not accepting of error. I’m not convinced a lot of physicians quite know what to do with a colleague who says “I screwed up”.

In a wonderful essay “Facing our Mistakes”, published several years ago in the NEJM (1984;310:118-122), David Hilfiker said: “The medical profession simply seems to have no place for its mistakes. There is no permission to talk about errors, no way of venting emotional responses. Indeed, one would almost think that mistakes are in the same category of sins: it is permissible to talk about them only when they happen to other people”.

If we’ve made any progress in the past two decades, it has escaped me. In a long career, I have no memory of a colleague telling me how they messed up. I have no memory of telling a colleague of errors I made, leaving aside off the cuff comments such as “I should have thought of that; done that sooner; or changed the medication”. This is partly because we mask such mistakes with near-yet so far synonyms like shortcomings. Doing so allows us avoid the self-review that would make us better doctors and help our patients. We do this because this is what we saw our own clinical teachers do. Open acceptance of the limits of our scientific knowledge, the degree to which educated guesswork plays in our clinical practice, and our fallibility as human beings is missing in most clinical teachers. These characteristics pass like some genetic code from one generation of physicians to the next.

There are however, the mistakes that are of a sufficient magnitude that they cannot be swept away easily. Affected physicians need help coping with the emotional fallout from such a mistake. Each hospital or institution should have through its office of clinical affairs a list of colleagues who by virtue of experience and temperament are suited to help. The burden should not be laid at the feet of spouse or family who may not have the professional training to really understand.

My biggest concern remains that of the individual physician who soldiers on after an error but feels burdened and unsupported. Until our profession undergoes a cultural change and facilitates truly constructive discussion of errors, some of our colleagues will continue to go about their professional lives experiencing much unnecessary misery.

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