Issue 34 / 9 September 2013

THERE is something about the medical profession that nobody talks about — doctors make mistakes. All the time.

Dr Brian Goldman, an emergency physician in Toronto, Canada, champions openness about medical errors and changing the culture of medicine. His fabulous TED talk “Doctors make mistakes. Can we talk about that?” is a breath of fresh air.

Society’s expectation of doctors is that they quite simply shouldn’t make mistakes. And the culture of medicine goes along with this.

Of course, mistakes happen every day (those of us who work in hospitals know this), but we certainly don’t talk about it.

Our mistakes are considered shameful — either to be kept just between us and the hospital management, or simply our secret we hope nobody will ever find out about.

But how does that help other doctors or patients?

In his TED talk, Goldman tells of one tragic case of misdiagnosis in the emergency department. The patient was breathless with crackles on auscultation, and was diagnosed with congestive heart failure. He gave her diuretics and aspirin, she started to improve so Goldman discharged her.

Later that day he heard those terrible words from a colleague — “Do you remember that patient you sent home?” His patient died in the intensive care unit a few days later after she had been rushed back to the hospital in severe shock and barely breathing.

His observation is so right — that phrase is one we all dread. It is more likely to be followed by a devastating follow-up sentence rather than exciting news that the patient has turned up with a box of chocolates.

Goldman describes his feelings of “beating himself up” and of feeling alone and isolated by his failure at making the mistake, and others since. It was not an option to discuss this with his colleagues because of this feeling that it’s “not that what you did was bad, but that YOU were bad”.

He reconsidered why he went into medicine and why he ever wanted to become a doctor in the first place.

Eventually he started to feel better about himself and was able to move on. Until the next mistake when he discharged a man with a sore throat who actually had epiglottitis (this patient survived the misdiagnosis).

He became aware of the frequency of mistakes — “twice in one shift I misdiagnosed appendicitis. Now that takes some doing”. In both of these cases, the patient was properly diagnosed before discharge.

He admits that it’s not just in his first few years as a doctor that these mistakes happened. They happen to senior doctors too.

However, we can’t just talk about our mistakes. Goldman asks, when was the last time you heard someone talk about failure after failure? It’s simply not acceptable in our professional sphere to recognise that we make mistakes.

He describes the health system as having two kinds of physicians — “those who make mistakes and those who don’t”.

Goldman proposes the model of the “redefined physician” — who is “human, knows she is human, isn’t proud of making mistakes but strives to learn one thing from what happened that she can teach to someone else… She is supportive when other people talk about their mistakes. She works in a culture of medicine that acknowledges that human beings run the system and they will make mistakes”.

His view is trailblazing, but how far is he from reality?

We all know that open disclosure is an intrinsic part of medicine, and every hospital and indemnity organisation supports doctors in being open about their errors to patients. But it is a different matter entirely when the issue is talking publicly about mistakes, as Goldman has done.

When I contacted some medical indemnity organisations to ask them their advice on this, the response was clear — don’t talk about your mistakes in public. That’s it. It’s not an option. There was no need for elaboration.

Clearly we are still a long way away from Goldman’s vision.

I have interviewed those in the health system who have been involved in errors — a doctor who did go public about a medical mistake; a doctor whose child was subject to medical error; and a medical leader who has dedicated himself to a culture of openness. Their stories are available on Life in the Fast Lane.

Each doctor involved has made moves to reform the current culture of shame around errors. Each offers a unique view on what the current attitude towards medical mistakes means to those who use and work in the health care system.

Dr Tessa Davis is an emergency medicine trainee originally from Glasgow and now living in Sydney.
 

12 thoughts on “Tessa Davis: Making mistakes

  1. Huw Davies says:

    Why are doctors afraid of admitting to making mistakes?  Fear of getting sued in the vast majority of cases & fear of professional humiliation in a few.  

  2. Joe Moloney says:

    Is this woman KIDDING??  Has she EVER had to negotiate the issues even internally when perceived mistakes are made?  The fear of being sued is a constant factor in admitting mistakes.  No matter how important it is to the families of the deceased (or morbidly damaged), the most innocently gentle families often come back armed by second-thoughts and “ambulance chasers” never seeking revenge (oh no!), but keen to make a clear point so that the same mistake never happens to someone else…(It’s NEVER about the money!).  Added to that, the internal investigations are often carried out by career medical administrators or nurses with an axe to grind, and when it comes down to it, if you counter-sue for the real truth to come out…then goodbye promotion prospects!…….The worst of it is that you never know when such an action may be taken, and you live with the fear for years……(e.g. the “damaged” baby who now needs help at school)…..I’m staggered at the idealism displayed here.  

    One extra thing: whenever a colleague of mine was under investigation, I always made a point of ringing and reassuring him(/her) that I would stand by my high opinion of him(/her), and that I knew medicine was a hard task-master that we all negotiate with extreme difficulty…And in all cases, I was the only one to ring with support!

  3. prof don moyes says:

    most professions do not admit mistakes!!. Having been involved in a civil case (nothing to do with medicine!) where the advice of three solicitors was wrong in law. We were put to the misery of a supreme court action because a judge in a lower court made a simple error! No adverse event became these lawyers!!  Indeed they did well financially out  of their mistakes.  I should add that we won all the cases eventually. No one apologised or sent us for counselling although the stress was considerable.                                                                                

  4. Sue Deacon says:

    It’s disappointing to find that doctors are still in fear of being human, and humans make mistake. It takes more than 10 years to change culture, but that time is nearly up!

    I have been one of those dreadful administrators (ex-clinician) who have conducted investigations, but never with the intention of pointing the finger of blame. Ironically, those doctors who fully particpate and don’t try to hide the obvious have a geater likelihood of finding out how systems of work and communication are the usual culprits. Be open, be honest, say you are sorry (pretty sure it was never intentional), look at what could be done better next time and move on. Not as easy as that I know, but it helps to ease your conscience if you can genuinely say that you have learned from the error…

  5. Helen Robertson says:

    Long ago in the 1970s I was at a major teaching hospital where all neonatal deaths and near-misses were presented in detail and discussed with all medical staff of the obstetric unit present; the doors were locked at the start of the meeting; it was a very good learning experience and changed practices. There was also the deaths and near-misses study in anaesthetics done in the UK many years ago that led to significant changes in practices in anaesthesia. These types of studies can lead to improvements in practice to the benefit of patients and doctors but they can only happen when the doctors reporting are safe from legal repercussions and other deleterious effects. It seems in recent years that these events have become impossible because of the call for “openness”.

  6. Hasina says:

    We all know medical errors cause unnecessary deaths each year and many injuries. While physicians correctly perceive an ethical duty to disclose an error to a patient, deterrent factors like lawsuits and other punitive actions cause a “disclosure gap.” Although most patients want their physicians to disclose harmful medical errors, this is somewhat rare.

    “To err is human”, “Learn from your mistake”- are very expensive in this setting. Therefore to learn from mistakes, doctors need a forum where they can tell their experiences of horrors and warning others not to fall into that situation is of paramount importance to medical education. This forum should then be able to identify the necessary changes to the procedure and check list that are required to improve/arrest such situations from repeating.  However if a doctor/or team member continues to have bad judgements he/she should be guided extensively without shame. Identify a medical error made by a professional colleague, and discuss the factors they must consider in determining when to disclose the error and to whom. No one wants an overconfident doctor with God factor in their gene!! In hospital setting everyone in that team is to be blamed not a single person. But blame shame will not improve-taking appropriate actions and teaching young ones will.

     

  7. carpus@amamember says:

    Of course all humans make mistakes.

    But in the operating theatre (or ED) it is as in the drama theatre, where the audience has a suspension of disbelief. The playwright may allude to the reality eg Shakespeare’s “this wooden O” of the Globe theatre, or have a character speak an aside directly to the audience, but most of the time we willingly forget that the merchant of Venice is speaking English, not Renaissance Italian.

    We all know pilots are not immune to mental illness, that government buses lack seatbelts and are therefore less safe, that food poisoning may occur in a restaurant, and that every Sydney taxi driver has had an accident. But to remind us of this does not help the situation. What is the benefit of ‘open disclosure’ to assuage your conscience, if it terrifies your patient?

    Dr Goldman’s mea culpas are illustrative, in that they are all ‘I was young/ overworked/ inexperienced, and other people rescued me’. He may well feel different if his attending had told the Drucker family: “Your mother’s death was Dr Goldman’s fault. To ensure it never happens again, I have called AHPRA to have him deregistered, and called the police to have him charged with manslaughter.” Yet that deregistration and imprisonment is the standard we all expect if a negligent taxi driver had run over Mrs Drucker.

    We cover up our faiings, and our patients tacitly ignore our errors and suspend their disbelief. No police run onto the stage in Hamlet’s final scene, and equally our manslaughters are not pursued as they would be if we were driving negligently.

    Perhaps Dr Davis can tell us whether she feels Dr Goldman should have gone to prison for his admitted manslaughter.

  8. Sue Ieraci says:

    The difference between the ED and the taxi victim, Ian Hargreaves, is that the patient starts off with an illness. The vast majority of medical error is not fatal, and the vast majority of people end up better than they started, erros notwithstanding. Clinicians should be – and are – charged with manslaughter if their action is demonstrably and seriously outside that is considered acceptable. Just like in traffic, health system adverse events can and do happen without anyone being negligent.

  9. Department of Health Victoria Clinicians Health Channel says:

    When I was a Departmental Director, trying to introduce a culture of admitting mistakes in M&M meetings, with an aim to educate and minimise future errors, I found the best method was to illustrate each of the presentations with a story of my own, similar error. (and there were plenty of those!) Although I often felt embarrassed at having to admit to so many mistakes, I considered that if the boss couldn’t own up, why would my staff? The method seemed to work, but did require a lot of humility on my part, and sometimes left me wondering what my staff thought about my competence!

  10. carpus@amamember says:

    My interest in this open disclosure article came because two weeks ago, an anxious patient asked my anaesthetist :”Have you ever lost anyone?”, to which the anaesthetist honestly replied :”Yes”. 

    He went on to clarify that he was recalling major road trauma patients, not elective carpal tunnel patients. The patient asked an apparently reasonable question, got an open disclosure, and was terrified by the answer.

    It had me thinking that perhaps the reason patients are happier to pay cash to chiropractors rather than GPs is that they want reassurance, not scientific fact. The road accident analogy suggests this is a community response. Every single road death is investigated independently by the police, often by Coroners or public courts. Not by the RAC or motorists’ associations. Deaths as a result of medical misadventure/ negligence are rarely investigated as thoroughly. In traffic accidents which cause injury, blame is always apportioned and criminal charges frequently laid. Hitting two pedestrians after a busy shift is never “considered acceptable” in the way that Dr Goldman’s presentation treats his missing appendicitis twice in a busy shift.

    In-house investigations are imperfect, but no doubt the Medical Defence insurers’ advice against public airing of mistakes, is based on the logical premise that if the voting public thinks rationally, there is no difference between the lasting effects of medical and traffic injury, from the patient’s viewpoint. Ask Cyril Karabus about what happens when alleged medical negligence comes before the courts. I think I would rather have patients regard me with the trusting awe they reserve for chiropractors, than the cynicism they have for politicians!

  11. Sue Ieraci says:

    Good points, Ian. I suspect that the ”trusting awe” that is held for many non-science-based providers is the same awe in which doctors were previouly held, but which is now discouraged (and rightly so, I would say). The model of provider and patient in a mutually-respectful therapeutic relationship works for most people, so long as both parties acknowledge the relative skills and knowledge of the other in health care. However, I suspect there is something deep in human nature that likes certainty, reassurance and simple advice. The example of the anaesthetist also reflects the general public’s poor understanding of relative and absolute risk. Most homeopaths could rightfully claim that they hadn’t lost anyone – if, for no other reason, because any significant illness is picked up by the medical system. But have they ever diagnosed or cured anyone? Like pharmaceuticals, a treatment has to have some effect in order to have side-effects.

  12. Mia Morocz says:

    The “trusting awe” is well in place, Dr Ieraci. 

    Here is the list of most trusted professions: 2. paramedics, 4. nurses, 6. doctors, 7. pharmacists, 14. dentists, 25. cleaners, 26. builders, 27. alternative health practitioners 

    http://www.readersdigest.com.au/most-trusted-professions-2013#sthash.c5G

    The latest Roy Morgan “Image of Professions” survey: Nurses came out on top, with 90 per cent of respondents rating their profession as the most ethical and honest. Doctors (88 per cent), pharmacists (84), engineers (76) and school teachers (76) followed. 

    http://www.smh.com.au/business/the-most-trusted–and-the-least-20130502-2iusc.html#ixzz2fhtrI05y

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