Friday, May 11, 2012

Are you afraid to be wrong?

Richard Smith, a former editor of the British Medical Journal, wrote a thoughtful essay offering guidance for new medical students. Full text here. Although it was published in 2003, someone just brought it to my attention via Twitter.

Dr. Smith lists many pearls of wisdom in a scholarly and lightly humorous way. I disagree with only one of his statements:

“Do not be afraid to be wrong.”

It is not that this is bad advice. To me, a timid doctor is prone to failure. Sometimes you have to take your best shot based on the information at hand. The problem is that in today’s medical world, we are expected to be perfect. If you make a wrong diagnosis and the patient suffers a poor outcome, you have a good chance of being sued and a better chance of experiencing an inquisition by emissaries from the quality improvement and/or risk management departments, AKA the “thought police.”

I once did some expert witness work for a malpractice insurance company. There is rarely a case that does not have many opportunities for second-guessing. When you know the outcome, you can always find something in the medical record that could have been done differently.

The current medicolegal and patient safety climate creates a feeling among physicians that any error is going to be extensively scrutinized. This results in a situation analogous to an athlete trying not to lose a game instead of trying to win. For those of you not familiar with sports, that strategy usually fails. Fear of being wrong can lead to excessive testing too.

Many say that medicine should have a blame-free or “just culture” like the airline industry, where reporting of near-miss and other events does not result in sanctions to pilots or air traffic controllers. It would be nice, but I know of no hospital that has achieved that state of nirvana in this country. For more on the pitfalls of just culture, see a recent blog I wrote.

This reminds me of the comic strip where the pointy haired boss says to Dilbert: “According to the anonymous online survey, you don’t trust management. What’s up with that?”

6 comments:

Anonymous said...

Your link to the original article isn't working for me. Try removing the /%20 from the end of the URL. Love your blog!

Skeptical Scalpel said...

Thanks for the kind comment and alerting me that the link was bad. I fixed it. It should work now.

Anonymous said...

Medical student here.

Interesting comments on timidity and its adverse effects on patient care. I often hear from my superiors that, at least during our medical training, it's better to be "strong and wrong" than quiet, contemplative, or reserved. Would you agree with this sentiment based on your experience as a surgeon & educator?

Skeptical Scalpel said...

There are times for contemplation and observation and times for rapid decision-making and action. The art of medicine is knowing how to choose. Neither is right all the time.

SkeptVet said...

I think the balanced perspective in your followup comment is right on target. Being paralyzed by indecision is clearly not the path to being a good doctor. On the other hand, being entirely too confident in one's own judgement is a far more serious and ubiquitous problem, in my opinion.

It is accepted in science generally that most hypotheses will turn out to be wrong, and mistakes generally teach us more than successes. Understanding that we are wrong far more often, and for more subtle and conplex reasons, than we usually realize is key to making effective efforts to prevent and correct our mistakes.

The checklist project Atul Gawanda has promoted is a great example of a kind of error that is easy to correct except when doctors perceive they are too smart to make it and so don't need the preventative intervention. Being timid may be just as dangerous as being overconfident, but I'd be willing to bet it's a lot less common among doctors.

Skeptical Scalpel said...

SkeptVet, Thanks for the comments. Great points.

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