Tessa Davis: Making mistakes

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.