Five months after coming in for surgery to remove a section of his intestines, Nelson Bailey had come back because he still felt a lot of pain. Festering silently within his body for almost half a year was a sponge the size of a washcloth that the surgeon accidentally left. Stories like this are all too common, as a quick Google search demonstrates with ease. The fact of the matter is that there are a lot of mistakes – including very easily preventable ones – that doctors make, and it is taking a toll on patients’ health (not to mention the economic toll). So why, after years of rigorous medical training, are there still doctors making mistakes, and will we ever be able to receive medical care in an error-less hospital?
Doctors Are Biased
Canadian reporter Erin Anderssen wrote a recent article about her husband, Joel, and their experience in a hospital in June 2011. The article was published in the Globe and Mail, and it began with Joel who became unable to easily drink his coffee one morning. “He looked in the mirror and the right side of his face was drooping, like a one-sided frowning clown,” Anderssen wrote, “and his right eye was frozen into an unblinking squint. This was especially alarming, because he’s been legally blind in his left eye since birth.” She continues:
Joel had seen his family doctor the week before, having woken up one day covered in round, bull’s-eye-like splotches and with a shivering case of the flu. [. . .] A physician friend, after hearing about an unusual “spider” bite on Joel’s stomach, suggested Lyme disease – a potentially serious, relatively rare illness caused by deer-tick bites. He had seen cases before. But Joel’s family doctor had not, and he had not been convinced: He had reluctantly ordered the blood test for Lyme disease, given him some oral antibiotics and sent him home.
The morning of the facial droop, his reaction was no more urgent: He said Joel had Bell’s palsy, a fairly common and benign condition that usually appears for no reason and goes away on its own. We could go to the emergency room, but his attitude was that we were overreacting. At emergency, we saw a polite, professional young doctor. We asked him about Lyme disease. No, he said. It was definitely Bell’s palsy. Joel should not worry, and return to work – even though he could no longer speak clearly and could barely see. [. . .]
When we pressed, the doctor reluctantly referred us to a specialist, but the appointment would be more than six weeks later. [. . .] But finally, our doctor friend told a colleague, and the infectious-disease clinic called the next day.
In the exam room [. . .] in less than 10 minutes, Joel was diagnosed with Lyme disease. [. . .] Joel was lucky to be diagnosed so quickly, he was told later. (We knew we were lucky to know a doctor to advocate for us.) The longer the delay, the harder the infection is to treat, raising the risk of neurological side effects, arthritis or heart complications.
Luckily, this story ended well, but obviously there are many with worse results. Later in her article, Anderssen explains some of the things that may have went wrong:
Psychologists have identified about 100 different cognitive traps people generally fall into – shortcuts to quick decisions that, once upon a time, probably saved us from being eaten. In a medical context, for example, doctors are susceptible to overconfidence bias (relying too much on intuition), diagnosis momentum (accepting a previous doctor’s findings without enough skepticism) and availability bias (concluding that a new patient has the same problem as a recent patient with similar symptoms). Those mental miscues are even stronger when the correct diagnosis is a rare one.
Doctors also aren’t immune to stereotypes. They may judge a patient on appearance, gender or race. They may be misled because someone has come in smelling like alcohol or is snappish in the examining room.
Obviously high-profile cases of medical negligence affect the public opinion of doctors, but in a survey by Maclean’s from 2010 (involving 1024 randomly selected Canadian adults), 92% said they hold physicians in high esteem. It’s important that we can trust our doctors, so obviously this is a good thing; but in the same poll, 40% of respondents also said they thought doctors care less about their patients than they did a decade ago (a mere 6% said they care more). Whether or not that’s actually true is another issue – the point is that many people think it’s true, and this may make it harder to treat patients.
Is The Fear Warranted?
In 1999, the Institute of Medicine estimated that around 100,000 Americans die every year from preventable errors. In 2004, a landmark study on medical errors by Ross Baker and colleagues found that somewhere between 10,000 and 23,000 Canadians died from preventable errors in 2000. Another thing that happened in 2004 was the launching of the California-based doctor-reviewing website, RateMDs.com.
Currently, RateMDs is the 10,000th most popular website in America, and 26,000th worldwide. In fact, it’s around the thousandth most popular website in Canada, which accounts for 45% of the traffic. Evidently, people want to know which doctors they can trust. That’s especially true in the places where the laws are making it harder to sue medical practitioners for their errors. Luckily, in the last few years we have seen that there are indeed simple ways to reduce preventable errors.
In 2009, surgeon and author Atul Gawande wrote the book “The Checklist Manifesto,” which talked about his initiative to bring checklists to eight medical instituations all around the world. They were in Auckland (New Zealand), Afakara (Tanzania), Toronto (Canada), London (England), Amman (Jordan), Manila (Philippines), New Delhi (India), and Seattle, (USA). The checklists dealt with the seemingly obvious tasks such as washing hands as well as the less obvious ones like making sure you introduce yourself at the start of the day to the medical team with which you will be working – sometimes it’s the first time they have ever met each other.
Gawande never expected checklists to be a major part of his career, but after seeing the results of his experiment, it’s clear that they were effective. The rate of preventable errors fell in all hospitals where they were implemented at a rate of 30%. What’s even more shocking is that the death rate fell by 47%. He explained this and more in a TED talk earlier this year.
Those numbers are staggering; death rates fall when measures to curb errors rise. On the other hand, this conclusion suggest that places without the implementation of checklists have a significant amount of preventable mistakes still occurring. If only doctors were more careful, there would be less illness and death. …Right?
The Fault of the Doctor?
Patients Are Guilty Too
It’s easy to say that when a problem occurs, or a doctor makes an error, he or she is negligent. But that’s often disingenuous. The patient has to take some responsibility for certain things that are chalked up as preventable errors. For example, when patients have to recall the drugs they keep in their medicine cabinets, they may either withhold information or simply not remember it properly. Some people take so many pills that they can’t remember the names or properties of each. Gawande says it’s important for people to keep a list of their medicine on them at all times, in which case then they won’t have to worry about recalling such information.
In fact, new research – conducted in the Vanderbilt University Hospital in Tennessee – has shown that out of 851 patients who participated, half of them made at least one error with their medication within the first month. These patients were hospitalized for a heart attack or heart failure, so even such patients who were surely taking the doctor’s advice seriously still made mistakes. But it gets worse. The mistakes were as common among those who had guidance and counselling from a pharmacist as those who had none. Furthermore, this was despite the fact that most patients were highly educated. Of the 50% who made mistakes, 23% of the errors were considered to be serious, and 1.8% were life-threatening.
There’s also the problem that I mentioned almost a year ago, which is that many patients lie to their doctors. Lying is especially dangerous for the patient, but errors made with false information often gets treated as a mistake by the medical professional. Many doctors, for example, will inflate the amount of alcohol they assume they are dealing with when a patient reports how much they have consumed. Patients don’t like their doctors to know how much they drank, but it’s to their own detriment, so doctors learn to take such reports with a grain of salt (“You say you had four drinks? Eight drinks, got it”). Doctors have enough trouble helping those who aren’t withholding information; they shouldn’t have to dig through the info provided by a patient whom the doctor only wants to help.
A great article about the stress of making mistakes as a doctor was written in the New York Times by doctor Pauline Chen in 2009. She watched a colleague of hers go from an aspiring young surgeon-trainee to a burned out, error-laden grump, eventually giving up on medicine entirely. As Colin West and colleagues showed in the Mayo Clinic in Minnesota in 2006, doctors-in-training who thought they had made errors were prone to becoming distressed. That is, self-perceived errors increased their chances of experiencing burnout and depression.
This directly affects the care of patients, because the trainees who believed they made errors in the past felt less empathy toward their patients. Empathy is very important in the relationship between doctor and patient; and doctors who are depressed are twice as likely to make preventable mistakes than those who are not. Indeed, this a serious issue. Chen concludes with some quotes from West:
Greater support for doctors from both the training process and patients could help to improve patient outcomes and strengthen the patient-doctor relationship. [. . . And, according to Dr. West,] “patients need to balance their expectations against the reality of the physician experience. And the medical establishment needs to do a better job of helping patients understand what physician lives are really like.”
“This doesn’t mean that physicians need to be coddled,” Dr. West continued, “but they need to be supported from within and by patients. They need to be supported in developing those relationships that help them to flourish. The reward is a stronger physician-patient bond. And that leads to more effective health care for everybody.”
The Truth About Doctors
There’s one particular fact about doctors that may be so damning, so controversial, and so unbelievable that it may lead to the disintegration of all trust from patients to their physicians. It’s a rumour that cannot be officially confirmed regarding all doctors, but I believe it to be true for everyone who ever graduated from medical school. Without further ado, the secret truth about doctors is:
…Doctors are human.
I know this is a radical statement to make, but it needs to be said. Why? Because humans make mistakes. Even with increasingly productive medical technology and an ever increasing body of knowledge on the ailments, illness, and the human body, errors are absolutely necessary to make us better at what we do. Learning could not take place without mistakes, and you can realistically expect that they’re going to happen in the hospital sometimes.
This is the message of Canadian radio host and emergency-room physician Brian Goldman. In his brilliant and moving TED talk from earlier this year, entitled “Doctors make mistakes. Can we talk about that?” he retells the haunting stories that he experienced at work. He discusses the culture of doctors who – even among other doctors – never speak of errors that they themselves have made.
That’s the system that we have. It’s a complete denial of mistakes. It’s a system in which there are two kinds of physicians - those who make mistakes and those who don’t; those who can’t handle sleep deprivation and those who can; those who have lousy outcomes and those who have great outcomes. [. . .] And we have this idea that if we drive the people who make mistakes out of medicine, what will we be left with, but a safe system?
But there are two problems with that. [. . . ] Errors are absolutely ubiquitous. We work in a system where errors happen every day, where one in 10 medications are either the wrong medication given in hospital or at the wrong dosage; where hospital-acquired infections are getting more and more numerous, causing havoc and death. In this country, as many as 24,000 Canadians die of preventable medical errors. In the United States, the Institute of Medicine pegged it at 100,000. In both cases, these are gross underestimates, because we really aren’t ferreting out the problem as we should.
[. . .] I’m not a robot; I don’t do things the same way each time. And my patients aren’t cars; they don’t tell me their symptoms in the same way each time. Given all of that, mistakes are inevitable. So if you take the system – as I was taught – and weed out all the error-prone health professionals, well… there won’t be anybody left.
With his radio show “White Coat, Black Art,” Goldman is attempting to change the medical culture to give doctors a safe forum to tell their stories of personal mistakes. He has observed that the doctors who come on his show actually want to tell their stories so that they can say “please don’t make the same mistakes I did.”
The Bottom Line
It’s in patient’s best interest to support their physician. That is, to be as honest, open, and positive as they can be. Doctors are medical professionals, but they’re not errorless androids programmed to be perfect. They are people – mostly very intelligent people – who, just like everyone else, make mistakes. I don’t suppose we will ever live in a time where there are no medical mistakes. So the goal for the medical establishment is not to eliminate mistakes, but to identify them so we can reduce their frequency and severity. A world without mistakes will never exist, but perhaps one day they may become trivial to the patient in need.
What should we patients do? We should embrace checklists in medical clinics because it’s clear that they’re very effective. Of course, doctors should be held accountable for those rare cases of negligent malpractice, but essentially, we should support them, because errors are a necessary reality of the human experience.
Kripalani S, Roumie CL, Dalal AK, Cawthon C, Businger A, Eden SK, Shintani A, Sponsler KC, Harris LJ, Theobald C, Huang RL, Scheurer D, Hunt S, Jacobson TA, Rask KJ, Vaccarino V, Gandhi TK, Bates DW, Williams MV, Schnipper JL, & for the PILL-CVD (Pharmacist Intervention for Low Literacy in Cardiovascular Disease) Study Group (2012). Effect of a Pharmacist Intervention on Clinically Important Medication Errors After Hospital Discharge: A Randomized Trial. Annals of internal medicine, 157 (1), 1-10 PMID: 22751755
Baker RG, Norton PG, Flintoft V, Blais R, Brown A, Cox J, Etchells E, Ghali WA, Hébert P, Majumdar SR, O’Beirne M, Palacios-Derflingher L, Reid RJ, Sheps S, & Tamblyn R (2004). The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. Canadian Medical Association Journal, 170 (11) DOI: 10.1503/cmaj.1040498
West CP, Huschka MM, Novotny PJ, Sloan JA, Kolars JC, Habermann TM, & Shanafelt TD (2006). Association of Perceived Medical Errors With Resident Distress and Empathy: A Prospective Longitudinal Study Journal of the American Medical Association, 296 (9) DOI: 10.1001/jama.296.9.1071