Facing our mistakes

Nowadays, the popular press focuses on medical errors from the perspective of the patient.  Pick up any current patient-focused periodical and you’re apt to find a Doctor So-and-so did me wrong article.  Many times the patient has a valid gripe.

In his recent TED talk Doctors make mistakes: Can we talk about that?, Canadian physician Brian Goldman offers a viewpoint from the opposite camp: How do clinicians react when confronted with the oft-times detrimental effects of errors in clinical judgement?

We know that Sir William Osler made at least one attempt to address this issue head on when he called his residents to the morgue to witness his error in diagnosis.

“Once in a ward class there was a big colored man whom he demonstrated as showing all the classical symptoms of croupous pneumonia. The man came to autopsy later. He had no pneumonia, but a chest full of fluid. Dr. Osler seemed delighted, sent especially for all those in his ward class, showed them what a mistake he had made, how it might have been avoided and how careful they should be not to repeat it. In 30 years of practice since then…I remember that case.”

Over the course of my career I’ve tried to get at such issues by writing about them. I recall one of my early pieces published in the premier issue of Dermanities, Abdominal Pain. Although revisiting it still leaves me feeling a bit queasy, it offers a lesson that I shall never forget.  Or in Doctor Goldman’s words, “Yes, I remember…”

Facing our mistakes is one of the most effective tools that we clinicians have to improve our clinical diagnostic acumen. What a pity that more of us don’t take advantage of it.

Decisions, Decisions

These days the subject of medical error has become a hot topic. Morbidity and mortality secondary to medical error is staggering.  Groopman has delineated some of the foibles in medical decision making.  Gawande has proposed a standard check list to curb the number of surgical errors.  Leading experts opine that widespread implementation of the electronic medical record might serve to drastically reduce the number of errors made by practicing clinicians.

Now New York Times science columnist John Tierney delves into the subject of decision making by examining not how decisions are made, but rather the state of mind of the decision maker.  Citing recent extensive psychological research, Tierney proposes that the attentiveness and care that we muster when making a decision seems to be directly dependent upon the supply of glucose to our brains.

In the Times article (which is adapted from a book Tierney authored with Roy F. Baumeister, Willpower: Rediscovering the Greatest Human Strength), Tierney expounds on the concept of decision fatigue, the idea that the more decisions we are forced to make during the course of the day, the more likely we are to opt for the path of least resistance.  Either we act impulsively or refuse to commit to making a choice.

Obviously, in medical practice either tack has the very real potential of resulting in suboptimal care for the patient.

“‘Good decision making is not a trait of the person, in the sense that it’s always there,’ Baumeister says. ‘It’s a state that fluctuates.’ His studies show that people with the best self-control are the ones who structure their lives so as to conserve willpower.”

“The restored willpower improved people’s self-control as well as the quality of their decisions: they resisted irrational bias when making choices…they were more likely to choose the better long-term strategy instead of going for a quick payoff.”

Nearly all practicing clinicians do not enjoy the luxury of structured 4-hour workdays.  We are thrown into the daily fray, forced to evaluate those patients that find their way to us in whatever area of clinical medicine we work.

So what can we do to avoid decision fatigue?

As it turns out, “glucose is a vital part of willpower….Your brain does not stop working when glucose is low. It stops doing some things and starts doing others. It responds more strongly to immediate rewards and pays less attention to long-term prospects.”

If these data are to be believed, in order to keep our minds sharp one simple solution might be a mid-afternoon snack consisting of a load of glucose: perhaps a sugary soft drink coupled with a cookie.

The Cognitive Dimension

In his recently published New Yorker (January 29, 2007) article, “What’s the Trouble?”, Dr. Jerome Groopman explores the issue of how doctors think.

Groopman quotes Dr. Pat Croskerry, a emergency medicine physician at Dartmouth General Hospital, Halifax, Nova Scotia, stating that, as a medical student, Croskerry was surprised at “how little attention was paid to the ‘cognitive dimension’ of clinical decision-making—the process by which doctors interpret their patients’ symptoms and weigh test results in order to arrive at a diagnosis and a plan of treatment.”

Croskerry opines that many medical misdiagnoses result from identifiable—and often preventable—errors in thinking.

In making diagnoses, most doctors rely on “shortcuts or rules of thumb,” known as “heuristics.”

Although heuristic principles help doctors diagnose patients, they can sometimes lead to serious errors.

One type of mistake physicians often make is called a “representativeness” error. According to Groopman, this happens when doctors base their judgments on what is “typically true,”—failing to consider other diagnostic possibilities—and attribute symptoms to the wrong cause.

Doctors also make mistakes when they allow their judgments about a patient’s condition to be influenced by the symptoms of other patients they have just seen, as is often the case during disease epidemics.

Another type of error, dubbed “availability,” refers to the tendency to consider a patient’s symptom complex to be relevant as similar examples—“templates of disease”— come to mind.

Sometimes a doctor’s impulse to protect a patient he admires can adversely affect his judgment. Croskerry terms this tendency an “affective” error.

When physicians are confronted with diagnostic uncertainty, they are susceptible to underlying emotions and personal biases that can cloud their ability to make sound decisions.

Croskerry believes that the first step toward developing an awareness of these issues in medical practice is to recognize that “how doctors think can affect their success as much as how much they know, or how much experience they have.”

As clinicians, it behooves us to approach the patient with an attitude of humility and respect. Both Groopman and Croskerry should remember that, at core, the diagnostician’s ego plays a large role in errors of medical judgment as well.