(Originally published on Bedside Manner at Everyday Health)I’d like to introduce this week’s guest blogger, Sigall Bell, MD. Dr. Bell is a member of the Division of Infectious Diseases at Beth Israel Deaconess Medical Center in Boston and is an Assistant Professor of Medicine at Harvard Medical School. Her medical education activities focus on the narrative experience of illness, communication after harmful events, and promoting humanism in both patient care and the training of physicians. I got to know her through a grant the Kenneth B. Schwartz Center gave her for a program she teaches to medical students: Reading, Writing, and Reflection: the New ‘3R’s of Medical Education.” It’s a fascinating program, in which Harvard Medical School students participate in reading groups; write and share pieces about their experiences with patients; and participate in “reflection sessions” and writing workshops, when they ponder the psycho-social aspects of caregiving. Here she writes about medical error, one of the toughest issues that comes up in the patient-caregiver relationship. Twenty-five years ago, David Hilfiker, a family practitioner who dedicated his career to care of the poor and underserved, published his then controversial piece in the New England Journal of Medicine “Facing Our Mistakes.” The article takes a stark, honest look at medical error, and the human consequences of mistakes. Here’s an excerpt:
“Most people – doctors and patients alike—harbor deep within themselves the expectation that the physician will be perfect. No one seems prepared to accept the simple fact of life that physicians, like anyone else, will make mistakes… The medical profession simply seems to have no place for its mistakes.”
I suspect the publication was controversial in its day, 1984, because few doctors were talking openly and publicly about mistakes. Today, we have a whole new language for medical error, owing largely to the 1999 Institute of Medicine report “To Err is Human,” which brought medical error squarely into public and national view. “Patient safety” and “quality of care” have become household terms and cornerstones of American healthcare. We speak of “systems issues” and work hard to develop myriad patient safety initiatives to prevent mistakes. Electronic orders, double identity checks, allergy alerts, checklists, and other interventions have been important system-level changes.
But when things go wrong, it is individuals who are harmed. Medical error can be devastating for each of these individual patients, families, and clinicians. There is a notable absence of a safe forum for discussion, healing, and perhaps even forgiveness. The guilt, fear, and isolation experienced by all involved parties after a mistake can be equally or more damaging than the error itself.
Physicians are routinely socialized into the expectation of “physician infallibility,” but error remains an inescapable reality in the human practice of medicine. The pressure to perform perfectly is so deeply ingrained that physicians often view an error as a character flaw… “If only I had tried harder,… I wasn’t careful enough,” even though most errors are involuntary. Even worse, the negative perceptions cast by fear of malpractice and litigation impede physicians’ volunteering of information regarding errors or “near misses”—potential mistakes that are caught before they are transacted. Other high stakes industries like nuclear power and aviation have long known that investigation of such events yields the greatest opportunity for learning and system improvement. In medicine, only a tiny minority of errors or near misses are reported through hospital reporting systems—the veritable tip of the iceberg. While quality improvement efforts are focusing more on learning from mistakes, we may still be missing the boat. Without learning about these potential problems, systems remain at risk of imminent failure, and individuals remain at risk of their subsequent harm.
It’s the summer, which in academia means a fresh influx of new interns. I can’t help but wonder how they would react if we told them outright what we tell them in less explicit terms: “Thou shalt not err.” The intern held under this doctrine is part of a health care system that stills holds tenaciously to the covenant of physician infallibility. It sends the message “You have to be perfect and cannot make mistakes” and subsequently can lead to hiding, denying, or concealing error. It breeds shame and distrust.
Contrast this to the young pilot who is told by the aviation industry, “You are human, and we recognize that you may make mistakes. Your job is to stay vigilant, and to speak up whenever you see something that looks wrong.”
Medicine needs more realistic expectations, ones that recognize the “paradox of error” while we can perfect techniques to avoid mistakes, we can’t perfect the human beings who use these techniques.
A quarter-century since Hilfiker’s courageous statement, how much have things really changed? We’ve come a long way with developing systems to prevent errors, but what do we do with the ones that remain? Is the perfection standard reasonable? How can we be better poised for healing our patients and our doctors after medical error?
What do you think — when it comes to modern day medicine, does the profession have a place for its mistakes? Have you or a loved one been affected by a medical error?
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