physician error and medical misjudgment and thomas gallagher

Ever since the Institute of Medicine released a report in 2000, entitled "To Err is Human," in which it reported that physician error accounted for between 44,000 and 98,000 hospital patient deaths a year in the US, there has been a strong debate in the medical field about when, if and under what conditions physicians ought to apologize to their patients when a mistake in care has been made. Now, added to the debate, is a report to appear later this week in the Archives of Internal Medicine that suggests that a major factor in preventing many physicians from disclosing that they made an error is not the factor most have supposed (malpractice litigation) but rather the inability of the doctor to know how to express his/her sentiments. Is an apology necessary? An expression of regret? Saying nothing unless you are forced into a corner? A generic description of the problem without assigning or taking blame? How do you actually frame the words to express these various options?

In the opinion of Dr. Thomas Gallagher, a medical historian and ethicist and Associate Professor of Medicine at U of Washington Medical School, physicians don't admit error primarily because of the "culture of medicine." That is, doctors are not trained in how to admit that they have made mistakes. When you combine this lack of training with a fear that if you admit mistakes someone, sometime will turn around and sue you for such an admission, you can have a situation where honest disclosure of error not only is not encouraged but might seem to be the enemy of the profession.

Thinking About Mistakes, Learning and the Professions

In my 54 years I have had occasion to observe many, many competent people at work and have had the chance to work on lots of projects. The irony about errors and learning I have discovered, however, is that I end up learning more when I make more mistakes. Or, to put it slightly differently, I end up learning more when others make mistakes, too. For example, if I am reading a well-written and researched account of something, an account that seems to "flow" and deal with all the questions that one might raise about something, I find myself somewhat entertained and instructed by the account but often I am lulled into a sort of soporific state because someone is "taking care" of me in the "knowledge" department. It is only when I think someone hasn't given a full-enough or tightly argued-enough account of something that I spring into action, dive into the primary sources, comb them for meaning and end up coming up with an alternative, and much more satisfying, explanation of the phenomenon I am studying. In other words, errors help me crystallize my method, refine my thoughts, and make knowledge my own. This realization makes me almost indifferent on which books to assign to students to read, because I feel that the bad can become the instrument of more learning than the good. But, to bring myself back from the precipice upon which I have just perched, I usually assign the "good" books, because I cannot assume that my students will have the same approach to knowledge as I. But, is that a sort of "wimping out" on my part?

With the reality just described, why is it that professionsals who are paid the most and are seemingly the most respected in our culture, medical doctors and lawyers, are loath to admit that mistakes are a part of what they do? I suppose they all would embrace the notion that uncertainty is characteristic of their trade (even though the general public would like to think that things are more certain in medicine and law than they are), but few distinguished doctors or law professors would admit that they make many mistakes in their daily work. Why? My thesis is that law (which I know better than medicine), as exemplified by law professors, is unwilling to admit its mistakes because lawyers catch very early in their training that they are paid, yes paid, to get it right and that there really is no excuse for being anything other than right. If you are wrong it is because you haven't done your homework, haven't read the cases properly, haven't written well and clearly, haven't argued your point eloquently enough. The stigma attached to making an error in law (and probably in medicine, too) is so great that in many years in law, I have rarely heard a colleague admit frankly that s/he made a mistake.

What Clients Want and Need

But sometimes what lawyers and doctors are trained not to give--an apology--is precisely what clients want and need to hear. Most people honor and even sometimes revere their health care and legal professionals but they know that they are human and that they err. Sometimes what a client needs to hear clearly stated to them is that the professional has erred or, if an error is not plainly in view, that the professional "guessed" wrong, that s/he didn't consider all the factors or things that could go wrong, that ambiguity and mistake and dripping uncertainty is a part not only of life but of their professional existence.

Gallagher's study may suggest that an increasing number of doctors are realizing that confession of error might not only be good for the soul (it really is good to admit to yourself and others sometimes how little you really know and how often you mess up) but it might also save some money. When disgruntled patients bring lawsuits, the possibility of an apology coupled with a payout will, I believe, yield a lower payout than a "no holds barred" attitude toward admitting the alleged error (i.e., fighting against an admission tooth and nail) and an attempt to wear down the other side by exhausting their resources rather than admitting misjudgment. Most people aren't vindictive toward professionals who truly are trying to help them; they want to know, most of all, that the person dealing with them is human and recognizes the frailty of his/her own life and ego, as well as the frailties of the person who might have suffered under the doctor's care.

Conclusion

When the studies first came out indicating the huge number of people who are killed by physician error in the US, we realized that physician error is the third leading cause of preventible death in the US. Don't you think that greater attention not simply to reducing this error but also getting physicians to develop a language and a culture of recognizing/admitting error is the first step toward reducing error yet further? We pay a very high price not only for health care in this country but also for the folly of those who are slow to admit that they made mistakes.

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