The Simple Math of Medical Errors
Medicine’s a tough gig. For one thing, there are so many diseases out there it’s almost impossible to learn them all. Although we physicians spend the majority of our time treating a core group of relatively common disorders, we still encounter the bizarre and unexpected often enough to keep us on our toes.
Next, some diseases are protean. It’s not uncommon for two people with the same ailment to have entirely different presentations. The converse is also true – unrelated diseases can sometimes generate remarkably similar signs and symptoms.
Another stumbling block is the fact that some patients are poor historians. A portion bury vital clues beneath mountains of irrelevant trivia. When that happens, we have to dig like archaeologists to excavate the information we need. Others have a frustrating tendency to withhold critical details when relating their histories. And then there are always those who just can’t seem to remember exactly what it was they came in to see us for. That never portends well.
On the other side of the coin, there are certainly times when we doctors impede the diagnostic process. Sometimes things like being hungry, tired, stressed or swamped reduce our effectiveness. Sometimes we’re lazy. Occasionally we develop tunnel vision and fail to consider other potential diagnoses. And sometimes we just plain screw up. How could we not? We’re made of the same flesh and blood as everyone else.
In my office I see about 40 patients a day. By the end of most of these encounters I have to make several management decisions. Is this person sick, or not? Is their illness primarily physical or psychological? Do they need investigations? If so, which ones? In what sequence? Within what time frame? Should their medications be adjusted? Do they need to be started on something new? Would they benefit from a visit to an allied health professional or a specialist? What type? How soon? I have approximately 15 minutes to extract an accurate history, perform a relevant examination and come up with a game plan. Does that sound like a tall order? Well, it isn’t. It’s just business as usual.
In addition to the continuous flow of patients, dozens of reports cross my desk every day. Blood tests, urinalyses, cultures, stool studies, EKGs, x-rays, ultrasounds, CT and MRI scans, bone scans, bone density studies, mammograms, Pap smears, pathology reports, pulmonary function tests, ambulatory blood pressure readings, cardiac monitor reports… . The list is endless. As I review each report I have to try to recall why the test was ordered. If the result is normal it can usually be filed away. Significantly abnormal results are flagged and dealt with promptly. Mildly abnormal results are tricky, because they require an answer to the question: Can this be safely filed, or are further investigations required? Not every abnormal test result needs to be acted upon. Part of the art of medicine is knowing when it’s appropriate to ignore a result that falls slightly outside the normal range. “Incidentalomas” abound in clinical medicine, and they don’t all require a million-dollar workup.
For as long as history has been recorded, most societies have held their healers in high esteem. This respect has usually been accompanied by a certain degree of tolerance vis-à-vis medical errors. We physicians have always been extremely grateful for this unspoken buffer zone of forgiveness. Doctors are human beings, and all human beings make mistakes. If the guy at Domino’s makes a mistake, someone could end up getting anchovies instead of mushrooms on their pizza. If I make a mistake, someone could end up dead. It’s a terrifying responsibility.
Over the past 30 years there has been a seismic shift in our collective attitude towards mistakes in North America. All of a sudden errors are no longer permissible. Now if something goes wrong, someone has to be held accountable. Our current zeitgeist fosters the belief that if you look hard enough, eventually you’ll find someone to blame. Someone to blame equals someone to sue. Successful lawsuit equals big money.
Given the prevailing cultural mindset, it’s no surprise the public’s tolerance for medical errors has all but evaporated. Nowadays if a physician makes a mistake, there’s a fair chance their patient may be more angry than forgiving. Even sympathetic patients are often tempted to initiate litigation when family, friends or the media inundate them with stories of lucrative malpractice settlements. I’ve seen sweet little old grandmothers morph into near-psychotic greedheads after having been advised what their injury might be “worth.” It’s not a pretty sight.
Between patient encounters and interpretation of test results, I estimate I make at least 50 significant decisions a day. Even if I’m right 98 percent of the time (a near-impossibility in clinical medicine), that still means I make one mistake per day. That’s a minimum of five a week, or roughly 250 per year.
All of these mistakes are incubating in an increasingly hostile milieu in which highly-informed patients are demanding perfection. Practicing medicine in North America in the 21st century is like juggling hand grenades – no matter how good you are, eventually one of them is going to go off in your face.
Humble Pie
Buried within the classifieds of our local biweekly newspaper is a small “Thank You” column. In it community members thank one another for various acts of kindness. I receive a handful of these notes every year. Jan and I have a running gag – whenever the latest paper arrives, if there are no messages in it for me she jokes that the “Dr. Gray Thank-You Supplement” must have fallen out again. Pretty droll, but it always makes me laugh.
On those occasions when she mentions there’s a note for me, I like to try to guess who sent it before I read it. Over the years I’ve learned there is surprisingly little correlation between the acuity of the illnesses I treat patients for and subsequent thank-you notes (or lack thereof). Most times it is not patients I literally snatched from the jaws of death who send a note to the newspaper, it’s people I assisted in more mundane ways. I never expect to receive thank-you notes, so it brightens my day whenever one comes along. They serve as a reminder that I really am making a difference out here in the trenches.
Mr. Anderson was an 80-year-old patient of mine. He had an acerbic wit and a flawless memory. Although he tended to be fairly cranky with most other health care providers, he always had a good yarn and a devilish wink for me. Unfortunately his body wasn’t quite as resilient as his mind, and over time his internal organs began to fail. Despite our best attempts to quell the escalating mutiny, he eventually succumbed to multi-system failure. His death saddened me.
A few days after Mr. Anderson’s funeral I was scanning the paper when I came across a thank-you note submitted by his family. It was a long one. In it they thanked several friends of the family, some hospital and Home Care nurses, a couple of ambulance attendants, their minister, the funeral home and the florist. In short, everyone but me.
I’d like to pull a John Wayne and say that the apparent oversight didn’t bother me, but it did. I kept thinking: “All those years I worked so hard at trying to keep him healthy and the florist gets thanked? Now there’s gratitude for you.” I grumbled about it all evening. I was still muttering to myself that night as I fell asleep.
When I got to my office the next morning there was a beautiful gift basket waiting for me on my desk. The card attached to it read: “Thank you for your wonderful care of Dad over the years. From the Anderson family.”
I felt like a jerk.
Every Breath You Take
Molly was a slightly anxious 40-year-old woman whom I had seen in my office a few times for minor health issues. One morning she presented to the ER intensely short of breath. Her oxygen saturation was only 70 percent and her chest was full of crackles. It took a high-flow oxygen delivery mask to bring her sats back up into the normal range. A chest x-ray was done to help rule out congestive heart failure and pneumonia. To my surprise, it showed extensive scar tissue consistent with a diagnosis of severe pulmonary fibrosis. I admitted her for further investigation.