The Dirty Secret About Medical Errors

no syringesby Riva Greenberg
Huffington Post

In my last post, “Can We Let Doctors Be Human?” I interviewed Dr. Danielle Ofri, an attending physician at Bellevue Hospital and author of four books.

Her latest book, What Doctors Feel is an insightful look at what medical professionals experience emotionally — how under-recognized and unaddressed these feelings are, and how they affect health care providers’ sense of self-worth, performance, and patient care.

In this, part two of my talk with Dr. Ofri, we delve into medical errors and shame.

Riva Greenberg: Why did you want to write about the emotions health professionals experience?

Danielle Ofri: As physicians we see medicine as a science. We think of ourselves, and present ourselves to the public, as rational, evidence-based practitioners. But in truth, most of what we do is based on experience, what we’ve learned from mentors, what we’ve seen, what we feel in our gut, what seems to work.

I think we are far less rational than we tell our patients and ourselves that we are. My experience, and others I’ve witnessed, has taught me that emotions play a large role in how we practice medicine and work with our patients.

RG: Can you give me an example?

DO: Medical errors, unfortunately. There’ve been pushes on many fronts to attack medical error, which of course we must. But how we’ve been going about it addresses only the tip of the iceberg — creating new systems approaches, relabeling medications and enacting legislation changes.

Yet medical errors will keep happening until we bring them out in the open and talk about them. But because making an error is so shameful for a doctor all we want to do is hide it.

In What Doctors Feel I write about one of my most egregious errors. An error that so shamed me it took me 20 years to write about. I was a second-year resident and I didn’t give a patient who was coming out of Diabetic ketoacidosis (DKA) a shot of long-acting insulin. That’s the very thing you’re supposed to do in this situation. Otherwise the patient goes right back into DKA, which is exactly what the patient did.

I called a medical consult in a panic. The senior resident asked me, “Didn’t you give the patient long-acting insulin before you turned off the drip?” I realized I had made a horrible mistake. I couldn’t get a word out of my mouth. “What were you thinking?” she yelled, right there in the middle of the emergency room. My intern was by my side, gunshot wounds were rushing past us, and I was so humiliated and ashamed that all I wanted to do was dive into a hole and die.

The person I thought I was no longer there. Until that moment I thought I was a pretty good doctor. I was studying hard, doing the right thing, but in one moment that whole persona was shot to bits.

As doctors, if we fail, it’s not something outside of us; it is us. We are the error. The shame is so powerful that most doctors will never come forward about an error.

So we can make all the laws we want and change the color of syringes, but until we address the shame, we’ll never get past this problem. We won’t know about the enormous number of hidden medical errors until someone dies from them.

RG: Why is the shame so intense that doctors would risk more errors occurring?

DO: I think the socialization of doctors makes it extremely hard for us to admit a mistake. We tend to pick perfectionists as medical students, knowing that the medical system is not for the faint of heart. Then they’re trained to be perfectionist doctors. There’s no place for a “good enough” doctor. You’re either excellent or terrible.

When I was a medical student, the review of medical errors (the “M&M,” which stands for morbidity and mortality) was combative. At one review, the chief of surgery standing at the lectern yelled out, “Who put that IV in?” Then he made the resident who’d done it stand up in front of 150 people. He made her the “error maker” who kills her patients. After witnessing this humiliation, who would then come forward about a mistake that no one has noticed?

RG: Are reviews still conducted this way?

DO: Now they are more about what lessons we can learn. Also I’ve seen responsibility shift from the individual who made a mistake to the leader of the team so that the whole team bears the error together.

But there’s still room for improvement. I’d like to see the chairman say at a review, “Here’s the error that I made, here’s how I dealt with it, here’s how I handle the shame. It was difficult, but it didn’t destroy me. I’m still here. I am not the error, but I can learn from the error to be a better doctor.” What a difference that would make.

When we are patients, we may feel our doctors don’t see us, yet do we see them? As What Doctors Feel captures so well, the stresses of medical life — from hours of paperwork to fear of lawsuits, shame about mistakes and grieving the death of a patient — the health care system is in need of repair, not just in caring for patients but also caring for providers.

As Ofri said in “Can We Let Doctors Be Human?” when medical professionals and their patients are supported to go on a journey together, we will all be more successful.

And as I read the final page of What Doctors Feel, a last thought from Ofri resonated. Beyond curing, doctors must also be taught, and supported, to help patients heal. As more and more Americans are, and will be, living with chronic illnesses, medical technologies can only take us so far. It is in truly “caring for” patients — with compassion, empathy and connection — that patients begin to heal.  (from the Huffington Post)