The Myth of the Godlike Physician Harms Both Practitioners and Patients
Dr. Steve Small of Massachusetts General Hospital likes to see his fellow physicians make mistakes.
That’s how he gets them talking.
The mistakes he sees occur in critical events staged in his high-tech medical simulation lab for Boston-area doctors--a sort of Top Gun flight school for physicians.
The project is part of a growing national movement to abandon the myth of perfection in medicine, to try to stop mistakes before they occur and to deal with the consequences of mistakes.
Doctor errors include everything from failure to request a follow-up culture to wrong-site surgery. Most are relatively minor and do not affect the patient. But some result in permanent harm and death.
Researchers at Harvard University released a study in 1993 that estimated 1 million potentially preventable medical errors lead to 120,000 deaths each year.
The result is a wrenching story of human loss, sometimes splashed over front pages, such as the death of Betsy Lehman, a Boston Globe health columnist who died four years ago after she was given too much of a chemotherapy drug.
What is not as often discussed is how all mistakes, including minor ones that harm nobody, are potentially devastating to the doctors involved, according to Small and his colleagues.
Doctors are scarred by “eidetic imagery” from such events, that is, moments that are vividly recalled and readily reproducible in one’s memory long after they have occurred.
Doctors can carry these events with them for their entire careers, feeling a mixture of embarrassment, humiliation, guilt and shock that extends long past the incident.
One doctor, then a resident in pediatrics, was performing a routine blood transfusion for a baby. He mistakenly infused the baby with packed red blood cells, thinking he was using fully constituted blood. He failed to notice a bag of plasma, hanging just behind the red blood cell bag, that should have been added.
He only realized his mistake when the baby began to turn gray. Fortunately, a senior doctor arrived and promptly remedied the situation.
Mistakes are inevitable in the practice of medicine, doctors say, but the consequences of even small mistakes are often severe.
“The energy of the organization is spent on perpetual witch-hunting,” says Dr. Don Berwick, who heads the Institute for Healthcare Improvement, a nonprofit group in Boston.
The result is a culture of fear that makes it difficult for hospitals to see past the individual and address more deeply rooted causes of errors.
“The culture is, ‘Let’s keep this to ourselves,’ ” says Dr. Harry Greene, vice president of the Massachusetts Medical Society. “If you’re going to turn it [a mistake] into anything positive, you need to share.”
Dr. Lucian Leape, a Harvard researcher who is one of the world’s foremost experts on medical errors, says the focus on individuals in error evaluation leaves medicine far behind other industries, such as aviation and nuclear power, that understand the key to prevention of errors lies at the system level.
The solution is not to berate doctors to try harder but to put in place systems that will catch errors before they can harm a patient, Leape says.
The myth of perfection has also set up doctors for an inevitable fallout with patients.
Malpractice suits abound, often against doctors who have given impeccable care to their patients.
“It’s easy to take it personally,” says Small, an anesthesiologist. “You’re standing in a white coat and in your place of work, and you’re handed a subpoena by a sheriff.”
Small’s simulator program, which began in 1994, is his way of chipping away at a culture from the inside. Since 1994, all Harvard anesthesiology residents--about 250 per year--have gone through his program. He wants to expand it to include surgical and emergency medicine residents.
Dr. Josh Bloomstone, an anesthesiologist at MGH, went through the simulator when it began.
Four years later, he can still outline the details of each crisis scenario he went through, a tribute, he says, to the realism of the simulator.
More important, he says, he remembers the debriefing that followed.
“There was no specific fingerpointing. No one was told they did a horrible job. They focused in a really positive way,” he says.
According to Small, the goal is not only to heighten doctors’ ability to handle crises but to make them more vigilant in observing system-level problems that might need changing.
“It’s easy to blame the person who made the last mistake,” Small says. It’s much more difficult, and painstaking, to review the event step-by-step, as they do in the simulator, to see where the system broke down.
There are signs that others in medicine are beginning to come around.
The National Patient Safety Foundation, dedicated to addressing medical errors, was established a year ago. It is one of several organizations sponsoring a national conference in Rancho Mirage in November on medical mistakes.
In Massachusetts, a group of 20 medical organizations with a similar mission has joined to create the Massachusetts Coalition for the Prevention of Medical Errors.
Such programs can only help doctors who know, Small says, that “someday, we’ll all be patients.”
