Posted: August 21, 2014
Dr. Brian Goldman answers your questions on medicine, making mistakes, and how the entire medical system can benefit and learn from being wrong.
Brian Goldman is an emergency room physician who has worked at Mount Sinai Hospital in downtown Toronto for more than 20 years. He's also a prominent medical journalist and the host of CBC Radio's White Coat, Black Art. He says every doctor makes mistakes but medicine's culture of denial keeps doctors from talking about and learning from those mistakes. His new book, The Secret Language Of Doctors, examines the code of hospital slang.
Dr. Goldman was featured on the TED Radio Hour episode Making Mistakes.
Was there ever a time when making a mistake in the medical profession wasn't so taboo?
It wasn't all that long ago when making mistakes was neither unexpected nor taboo within the medical profession. If you want to see what I mean, check out The Knick, a new television drama series on Cinemax in the U.S. and on HBO Canada. The show stars Clive Owen who plays a surgeon at New York's Knickerbocker Hospital and is set during the early twentieth century. From practically the opening scene, doctors kill patients practically left and right. Back then, there were no antibiotics or blood pressure pills, and certainly no clot-busting drugs. Surgery was crude and often did more harm than good. But it didn't matter, because back then, society accepted that death was part of life and that illness was almost always followed by death. In those days, doctors were all bedside manner and little cure. You could make as many mistakes as you liked - provided you evinced the manner and bearing of a doctor. Medicine itself was simpler in those days. The pharmacopaeia was just a handful of medications. There were no CT scans that could emit cancer-causing radiation.
Fast forward more than 100 years. Doctors can unblock coronary arteries and replace worn out joints. Deep brain stimulation can make people with advance Parkinson's disease walk. Medicine has become much more dense and complex to practice. It is impossible to know every drug in the pharmacy. Side effects and interactions alone demand that extra staff be hired to navigate them.
Corporate medicine has brought expectations of McDonald's-like consistency to medicine, while reducing the amount of meaningful contact time between doctor and patient to a paltry 5-10 minutes. With great success has come rising expectations by patients and by the public. Mass media and social media run on biblical and other archetypal stories like "David and Goliath," the God-like doctor being cut down to size, the virtuous doctor with the sterling reputation revealed as a serial incompetent.
All of those factors and others have magnified the unhealthy shame that doctors feel when they make mistakes and the shame that is projected on them by colleagues and the public alike.
How can medical schools begin to address the culture of not talking about mistakes?
In my opinion, medical schools can and must play a constructive role in changing the culture of medicine as it pertains to errors. Instead of expecting perfection, educators must teach medical students that mistakes are inevitable in a high pressure field with increasing complexity and productivity pressure. Instead of being appalled when mistakes happen, educators should teach young doctors to become curious about how, when and why mistakes happen. I find that shame inhibits the exploration of medical error; curiosity induces a state of calm and even pleasure that facilitates such exploration.
Instead of asking, "oh how COULD you?" We would be far better off asking, how and why do well-trained and well-meaning professionals make mistakes? What roadblocks does the system put in place that make it harder for health professionals to make fewer mistakes?
I showed your talk to a physician who replied, "this will never catch on." With increasing legal liabilities, openly confessing to medical mistakes is not going to get easier. Would you support anonymized discussion of medical mistakes? If not, why not?
To a large extent, your comments are bang on! If I were a malpractice lawyer, I'd be looking to find a way to lurk in chat rooms and listservs to look for confessions of malpractice. The airline industry has gone much further with anonymized discussions of aviation mishaps. It's pretty clear that the current culture's lack of open discussion of mistakes inhibits us from discovering errors and dealing with them. I believe we have little option but to try and increase discussion before, during and after procedures in which errors occur. To do that, we need to change the culture so that everyone involved in patient care — from the person who cleans the patient's room and the OR to the hospital CEO — feels free and safe to point things out that don't look right.
To do that, we have to extricate the shame loaded into such discussions.
I would certainly be in favor of special legislation that protects reflective debriefs about errors from being used in a court of law.
Can medical whistleblowers play a larger role in changing the culture of medicine? If so, how would that work?
Medical whistleblowers can play a big role in reporting medical errors and substandard medical care. Look no further than the role whistleblowers have played in uncovering the recent Veterans Administration scandal. In the U.K., medical whistleblowers were instrumental in uncovering the scandal at Stafford Hospital, where between 400 and 1200 patients died needlessly as a result of poor care. That scandal and another involving poor outcomes in pediatric heart surgery led the British government to introduce a new hospital inspection regime and legislating for a duty of candor in National Health Service organizations so they have to be open with families and patients when things go wrong.
Unfortunately, health care whistleblowers are almost non-existent in Canada. In the U.S. and the U.K., whistleblowers continue to be subjected to harassment. The latter is a strong indication that the fundamental problem is within the culture of medicine. Whistleblowers call attention to fear and inertia within medical culture. Like an immune system, the culture sends antibodies to destroy whistleblowers. Whistleblowers won't change the culture, but they could destroy it if the public is roused to anger over the failure of medical leaders to address impediments to discovering and dealing with error.
Is it possible – or even a good idea – to make the general public more comfortable with the idea that doctors make mistakes?
It is imperative that patients and the public accept that in a complex system, doctors will make mistakes. I blame the public in part for forcing doctors into the false goal of perfection. Far better for the public to accept that mistakes happen and to play a constructive role in prompting doctors to consider alternative diagnoses, to overcome cognitive biases, and — like other members of the health care team — to point out things in the course of medical care that "just don't look right."
Extras: TED Radio Hour
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