When Doctors Make Mistakes: About Humanness And Perfection
The best part of doctoring is its humanness. Machines can’t do it — not even Apple products.
But that’s the worst part, too. Since humans practice medicine, there will be “medical errors.” And when doctors err, people — not spreadsheets or profits — are hurt. That’s the rub. Like any endeavor, the greater the reward the greater the risk. Those cards were put on the table in medical school.
“Don’t want mistakes? Don’t do anything. Don’t make any decisions. Don’t do any procedures. Then, there will be no errors,” the grey-haired, Swiss-born cardiac surgeon counseled me many years ago after an imperfect ablation.
The headline was about a doctor’s error. It was a doozy. But for me, the story belies the headline. A Boston Globe reporter called a surgeon’s public admission of performing a wrong operation ”an unusual display of openness.” I would call it something else: Breathtaking. Unprecedented. Courageous.
Doctors may be labeled in many ways, but a common thread in 99 percent of us is that we take great pride in our work. We strive for that which is impossible to reach: Perfection. We know that others’ well-being is at stake.
But perfection is like an asymptote. We can get close — with checklists, time outs, protocols, and the like — but in the end, doctors will be just like you: They will be human.
Sponges don’t get left behind out of malice. Pacemakers aren’t hooked up backwards on purpose. Perforations of the heart during catheter procedures happen despite our best efforts to navigate gently.
Dr. Ring performed the wrong operation. The 4,000-word case report in the New England Journal of Medicine explains the problem from every conceivable angle. Medicare even denotes events like this as “never events.” Sesame street had the game: Which things “don’t belong together.” How about “never” and “humanness.”
In reporting his error and examining the processes in detail, Dr. Ring helps the medical community improve. The asymptote will get closer to perfection. This is good. However, the safety article could be 400,000 words and the protocols and checklists infinite, but as long as your doctor is your neighbor, there will be mistakes.
(Do not misunderstand: I am not against processes, checklists, and systems’ analysis. Undoubtedly, innovation can help us limit our imperfections, but like in AF therapy we must avoid making the treatment worse than the disease.)
The benevolence of medicine inspires me always. Dr. Ring’s humanness is no exception. Wow.
JMM
*This blog post was originally published at Dr John M*
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