Medical Mistakes
A NextGen Free Standing Perspective
Article
By Emory Hsu
Each day, the healthcare system makes thousands of costly mistakes, ranging from misread orders to operating on the wrong side, to incorrect diagnoses…each one jeopardizing individuals’ health. With greater emphasis on eliminating clerical errors —such as mixed-up prescriptions—the focus has now shifted to include to heart of medicine and diagnosis. Scrutiny now turns to reducing the errors in physicians’ decisions.
Misdiagnosis is common. Dr. Jerome Groopman, the author of the recent book, “How Doctors Think,” tells the anecdote of a woman who, having been diagnosed with anorexia-bulimia, follows the advice of her doctors to eat three thousand calories a day, an enormous amount. Despite her efforts, she continues to loose weight, which in the eyes of her physician, seemed to have only confirmed the diagnosis of anorexia-bulimia. Her physicians did not accept that she could weigh only eighty pounds while following such a diet, and concluded that she had not been following the dietary guidelines, dismissing her cramps and nausea as psychological. It was fifteen years after her first diagnosis that a physician correctly recognized her disorder as celiac disease, a disorder in which the body cannot absorb nutrients such as gluten. Not only was this physician discerning, but he had to challenge fifteen years worth of incorrect diagnosis from other physicians.
The mistakes mostly do not reflect of poor knowledge or acumen of physicians. It partially mirrors the gap between learning and application. While medical students have encyclopedic knowledge of the human body and its illnesses and can go through a laundry list of symptoms and causes, once out of medical school, most physicians make real life decisions rapidly using pattern recognitions, a non-linear clumping of cues and instincts, rather than a binary, yes-no algorithm that is often instilled in teaching. Physicians such as Groopman advocate that the current system inculcates a Bayesian analysis of algorithms, evidence, and statistics, at the expense of emphasizing that patients aren’t averages—they are unique. Each person presents a distinct background, environment, and symptoms. And to ignore the possibilities of less-common ailments would be a grave mistake. Hence, some physicians have resisted efforts to standardize protocols, believing they would ignore any individual differences. However, others have advocated standardized procedures as an effective means of increasing consistency of care and reduce the chance of overlooking of possible symptoms by physicians. [1]
While modern medicine is aided by a dazzling array of technologies, like high-resolution MRI scans and pin-point DNA analysis, language is still the bedrock of clinical practice. … few of us realize how strongly a physician’s mood and temperament influence his medical judgment.” [2] Even the most advanced diagnostic techniques require someone to interpret the results; hence despite technological breakthroughs, we still depend on human judgment and all its whims and errors. The clutch is to reduce those errors.
Physicians could lessen the chance in misdiagnosis is in improving communications with the patients. The body language and tone, whether a warm greeting or hurried “where does it hurt”, the choice of open versus closed-ended questions, the amount of interruptions – these all impact the patient’s responses, compliance, and level of confidence in revealing information that may help in diagnosis. Empathizing with the patient and making him or her feel more comfortable seems to allay fears in the patient, since oftentimes the patient does not want to waste time or may be timid in the company of such an authority figure. “Communication” may seem simple, but Groopman tells the experience of an elderly African-American woman who was repeatedly chastised for being non-compliant with doctors ignoring her complaints. Until a physician took the time to talk with her, no one had realized that she was illiterate and could not understand some of the instructions prescribed.
Beyond anecdotal evidence, in a recent study that recorded conversations between 270 cancer patients and their oncologists, patients broached the topic of emotional concerns only about one-third of the time, with the sampled doctors often failing to encourage discussions. Since in cancer care, a physician’s show of empathy often elicits patients to express emotions, and consequently reduce anxiety levels, this study suggests that cancer specialists need more training in how to respond to patients’ emotional needs, and in identifying “empathic opportunity.” [3] Encouraging the patient by asking questions or merely taking time to express understanding or empathy only occurred about a fifth of the time, while terse ends, such as “give us time,” frequently terminate the conversation. Thus, better emotional and physical health outcomes can come from increased communications rather than ignoring or closing around a patient’s questions.
Yet, even when physicians communicate with patients, misdiagnosis can still arise from mental biases. A physician often has a psychological commitment to a certain diagnosis, and the few small disparities or abnormalities that do not match can be easily attributed to random errors or as rare symptoms. The prevalence of one condition, like a virus, may lead a physician to overlook other common problems, such as aspirin toxicity, when faced with a patient who presents symptoms that are common to both. There is always this problem of cherry-picking the symptoms that match the desired diagnosis – confirmation bias--and the opposite, excessively ordering unwarranted tests trying to find rare diseases. The competition to prove one’s one diagnosis over another doctor’s, or to find a rare disease that can be studied producing a research publication, or over the lack of time, all challenge physicians’ abilities to make accurate judgments.
Other differences in judgment may be attributed to characteristics such as the gender of the physician or even the appearance of the patients. The striking contrasts, for example, between a patient who seems healthy and athletic and one who is unshaven and unkempt may alter the way physicians approach the case. A recent study found that a statistically significant higher proportion of women received radiation following breast conservation surgery for breast cancer if her surgeon was a woman, even when adjusting for age, race, co-morbidities, tumor type, and socioeconomic factors. [4] As one of only a few studies to try to correlate surgeon characteristics with method or quality of care, the results, while not fully conclusive, hint at differences in physician behavior based on characteristics previously ignored. Even routine tasks are affected by psychology – physicians may be unwilling to perform unpleasant tests on people who they take affinity to – for example, a physician skips over examining the genital region, only to miss a soiled abscess that leads to infection.
How has the medical field responded to this increased focus on preventing misdiagnosis? Previous attempts, such as the ones cited by “To Err is Human,” a report published the Institute of Medicine [5], have addressed the issue through clerical safeguards, while giving less emphasis on the critical piece of using the system to promote individual conscientiousness. [6]
Efforts to increase hand-washing, for example, have long been known to reduce infections in hospitals and institutions. In the mid 19th century, a physician named Semmelweis observed that puerperal fever was correlated with physicians moving from patient to patient without washing hands. Yet when he instituted his hand washing regimen, physicians and nurses were routinely scolded and reprimanded instead of encouraged, and ultimately, the system was undermined and ignored. Thus, not only must the system be implemented, but the emotional persuasion must be effective to garner the support of the hospital staff. In modern times, where hand washing is recognized as one of the primary ways to prevent spread of infection, systematic changes such as training and placing sinks and sanitizers in high traffic locations are partially responsible for increased compliance. Yet apart from the infrastructural changes, but equally as important, is the awareness of infection control staff in hospitals reminding personnel to wash hands, and of systems to motivate staff to remind each other and report violators in a way that does not create a sense of fear but yet reinforces the importance of personal responsibility. [7]
Since individual conscientiousness is recognized to be the best defense against errors, physicians have been encouraged to remind each other of the proper practices and measures. In one area where much progress has been made, team members working in operating rooms have been encouraged to catch one another’s mistakes—ideally, even an assistant can point out the mistake of the chief surgeon8. The environment must one of mutual respect – contamination by a physician is no better than contamination by an orderly.
Although preventative measures have been implemented, given millions of patients each day, inevitably a few mistakes will still be made in the healthcare system. Despite the guilt that physicians may feel when they make mistakes, a study [9] claims that family members feel guiltier than physicians when mistakes happen - in not watching closely or researching enough or choosing the wrong procedure in the choices that the physician offered. Indeed, families prefer genuine apologies and plans for future actions rather than avoidance, as silence breeds distrust and evasion mainly leads to worse outcomes than communication.
Finally, recognizing suboptimal decisions or blatant blunders also prevent the next instance of error. To encourage this honesty, several states have passed laws reforming malpractice laws to ease physicians’ fear of the lawsuits that may follow frank disclosures. This partnership of physician, patient, and family is as much a mental and personal connection as it is a financial and medical one.
Human beings are each uniquely different and cannot be commoditized – nature and biology present ever changing mysteries. Things are never completely identical, as even the same person can have different responses at different times, and because of that, the value of a physician’s thinking stays imperative. The contrast of the joys of recovery with the pain of mistakes gives mandate for physicians to constantly evaluate their thought processes to ensure provision of optimal treatment. It is this essence of the adaptability and spontaneity of life that reaffirms our need to not lose the intellectual, social, and spiritual courage that forms the idealistic foundations for medicine.
References
- Tinetti M., Bogardus S., and Agostini J. Potential Pitfalls of Disease-Specific Guidelines for Patients with Multiple Conditions. New England Journal of Medicine. 2004; 351:27 2870-2874
- Groopman, J. How Doctors Think. Houghton Mifflin. 2007
- Pollak K., Arnold R., Jeffreys A., Alexander S., Olsen M., Abernethy A., Skinner C., Rodriguez K., and Tulsky J. Oncologist Communication About Emotion During Visits with Patients with Advanced Cancer. Journal of Clinical Oncology. 2007; 25: 36 5748-5752
- Hershman DL., Buono D., McBride RB., Tsai WY., Joseph KA., Grann VR., and Jacobson JS. Surgeon Characteristics and Receipt of Adjuvant Radiotherapy in Women With Breast Cancer. Journal of the National Cancer Institute. 2008; 100(3) 196-206
- Kohn L., Corrigan J., and Donaldson M. To Err is Human: Building a Safe Health System. National Academy Press. 2000
- Leape L., Berwick D. Five Years After To Err Is Human. Journal of the American Medical Association. 2005; 293:2384-2390
- Goldmann D. System Failure versus Personal Accountability- The Case for Clean Hands. New England Journal of Medicine. 2006; 355: 121-123
- Nuland S. Mistakes in the Operating Room – Error and Responsibility. New England Journal of Medicine. 2004; 351:13 1281-1283
- Delbanco T., Bell S. Guilty, Afraid, and Alone- Struggling with Medical Error. New England Journal of Medicine. 2007; 357:17 1682-168
Emory Hsu is an Editor for the Next Generation and a member of the Harvard class of 2008.