Another big mistake

August 15, 2007

Peter J. McDonnell, MD, addresses the fact that working as hard as humanly possible will seldom prevent all mistakes. He points out that at one time or another we have to live with the fact that a mistake was made and decide how to address it. It is sometimes especially hard for physicians and surgeons to do this because perfection is expected from them.

Key Points

"Hard work pays off in the future, laziness pays off now." -Steven Wright American actor, writer, and comedian (1955- )

"I attribute my success to this: I never gave or took an excuse." -Florence Nightingale Founder of the nursing profession (1820-1910)

A lot of people (firefighters, clergy, lawyers, stock-brokers, businessmen, Supreme Court justices, and even physicians-but, fortunately, not department chairmen) make mistakes. In many professions, mistakes can be made and the worst-case scenario is that someone loses a bit of money or time.

Although Steven Wright may be correct that hard work pays off in the future, my belief is that even working as hard as humanly possible will seldom prevent all mistakes. We must, at one time or another, live with the fact that a mistake was made and decide how to address it.

That is where excuses come in so handy.

Is your clinic running 2 hours late because of a) a long lunch, b) sleeping too late, or c) because you have been out of the office for a meeting or vacation and told your staff to double-book? In these instances, tell your patients that their long wait is the fault of the technicians who are too slow. Or there's the classic excuse I've seen used many times: "There was an emergency surgery." That excuse makes a patient feel bad that he or she is complaining about a long wait when another (albeit mythical) patient supposedly had a terrible eye problem requiring emergency surgery-and the ophthalmologist is thereby transformed from the uncaring physician, who allowed his or her patients to wait excessively, to the victim.

The number of possible excuses is as enormous as is the range of their potential validity: "The scrub technician didn't tune the phaco correctly," "The patient never mentioned he took Flomax," "The zonules were weak," or "The sun was in my eyes."

Because physicians are expected to be perfect diagnosticians and surgeons-and not to make mistakes-excuses are indeed helpful. My belief has always been that the purpose of excuses is to say: "Yes, this bad thing happened, but it's not really my fault."

A friend tells me that in the field of moral theology, excuses are viewed as invitations to pretend that the mistake never occurred. If I make a mistake, offer an excuse, and you accept the excuse, then we are agreeing that the mistake never really happened. I'm allowed to hold on to my myth of being an infallible physician.

It seems that surgeons, in particular, can have difficulty admitting mistakes. A recent paper in The New England Journal of Medicine tends to reinforce this belief.1 Surgeons-in-training at 17 U.S. medical centers were asked confidentially about needlesticks. By their final year of training, 99% had at least one needlestick injury; more than half involved a "high-risk" patient (history of infection with HIV, hepatitis B or C, or intravenous drug use). Although testing and prophylaxis against HIV are almost 100% effective at preventing transmission, amazingly, less than half of the needlesticks were reported and managed appropriately.

According to the paper's lead author "Doctors don't talk about it. There's some degree of humiliation involved" [when you have to acknowledge that you made a mistake].

The aversion to admitting we are not perfect runs so deep, it seems, the majority of surgeons will forego the opportunity to avert a potentially life-threatening infection!