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?”

The quest for medical error transparency suffers setbacks

Two recent articles in American Medical News highlight the difficulties in moving toward a blameless culture in medicine.

First we have the results of an Agency for Healthcare Research and Quality survey of 600,000 staff from over 1100 hospitals. Half of them “believe their mistakes are held against them, and 54% said that when an adverse event is reported, ‘it feels like the person is being written up, not the problem.’" And two-thirds are concerned that records of errors are maintained in their personnel files. Despite lip service by medical thought leaders, the reported responses have not changed since the last AHRQ survey in 2007.

Much more alarming is the second amednews.com piece, which involves a family secretly recording a conversation with the chief medical officer [CMO] of an Ohio hospital.

Two days after knee surgery, a man died of cardiac arrest apparently secondary to an overlooked high serum potassium level. Before he died, the patient’s children met with the CMO, who had not personally been caring for the patient. Unaware that the conversation was being recorded, the CMO “made sympathetic and apologetic comments and admitted fault on the part of the hospital for Smith's condition, according to court records.”

The Ohio appellate court ruled that the secret recording was admissible and not protected by peer review privilege, as had been argued by the CMO’s lawyers. They had claimed that the CMO had learned of the error via the peer review process. Ohio law states that as long as one party consents, conversations can be recorded.

Thus we are left with pie-in-the-sky appeals for greater transparency and candor regarding medical errors [the so-called “Just Culture”] vs. a litigious society with stealth technical capabilites and a workplace atmosphere of fear and distrust.

Somehow I do not foresee a major change in the way doctors and hospital staffs approach this issue.