To err is human, they say. We all make mistakes at work, and hopefully many of us resolve these mistakes by acknowledging the oversight, learning whatever lessons can be gleaned, and moving on. But for physicians and physicians-in-training, the consequences of a serious mistake could be life-ending or life-altering for the patient, and possibly career-ending for the doctor.
The question is, how do we, as a medical community, always strive to avoid mistakes while simultaneously fostering a culture that makes it OK to admit fault and learn from mistakes, rather than being devastated by them?
It’s true that some health systems have employed “error-relief” measures to promote honesty and transparency among physicians, but these are mostly in place to help mitigate the financial and legal ramifications, and don’t account for the emotional fallout from errors. The effect of a medical error on one’s reputation can be a far more daunting barrier to transparency. Decades of medical training and career-building efforts can be leveled by some bad online reviews from patients, even if they reflect personality clashes, not medical errors. Psychological factors of shame, guilt and denial add further complexity and pose hurdles in the path to “doing the right thing.” The patient is the primary victim of a medical error, but the physician will also experience emotional fallout even if the mistake never becomes public.
It’s not easy to explain to a patient not only what went wrong, but also the actual and potential consequences for his or her health. Offering patients and their loved ones both a sincere apology along with the relevant facts, all in a calm and clear manner during an emotionally charged time, is a tall order for even the most seasoned physician, let alone a young trainee. We need to make changes in our current medical training to better prepare our future doctors for these incredibly stressful scenarios.
We can take a look to the airline industry — another field where risks and the pressure to be infallible are extremely high — to help create a model for medicine and inspire a critical shift in culture. This is especially so for medical students and residents, who are both the most vulnerable and the most impressionable members of our workforce.
Recently, many schools have incorporated "standardized patients," trained actors who play the role of patients in order to provide trainees experiential learning with real-time feedback. Standardized patient encounters are typically based on difficult clinical scenarios (such as breaking bad news) to test and reinforce the trainee’s knowledge base and interpersonal skills — what I call “grace under pressure” — without the potential to harm real patients. As one of my fourth-year medical students, Jason Han, has shared, these simulations can enhance the learning experience and help students feel better prepared for difficult real-life conversations.
Yet this approach can simulate only conversations, not emotions. Trainees get to practice delivering apologies, but without the inevitable psychosocial elements – such as profound guilt, embarrassment, feelings of ineptitude, fear of repercussions – which come along with disclosing error. This is where some controlled doses of reality may help to enhance the standardized patient model. A "virtual reality” video library of simulated interactive clinical encounters could help bring to life a variety of difficult error disclosure scenarios, based on real-world examples. These cases could be presented not only from the standpoint of the physician, but also from the patient's perspective.
Ultimately we must gradually but measurably transform the culture of perfectionism into one that is also restorative and supportive. Medical students routinely face pressures to excel in many areas at once. Written examinations assess their mastery of an unearthly amount of material. In clinics and in class, they must impress their fellow students and attending physicians with their knowledge and insights. All of this is critical to excelling in medical school, and medical students live to excel. This perfection-demanding environment also is a product of society’s expectations that physicians must always be sharp, meticulous, and correct. Rightly so: We are responsible for others’ lives.
Still, no one is immune to error, and it is crucial to learn from mistakes rather than deny them.
I often share my own story about the time when, as an intern on a tough overnight shift, I gave an actively psychotic and violent patient a dose of antipsychotic medication at 3 a.m. without waiting for the on-call psychiatrist to call me back. I didn’t realize that dose of medication could have been dangerous— even fatal — until the next morning. Fortunately, the patient was not harmed. But I quickly learned that the situation could have easily gone in another, more traumatic direction and I would have been responsible.
Using this and other examples, I have counseled many of my students through their struggles with admitting and accepting their own errors in judgment and action. I have seen my students tormented when they observe senior physician mentors, whom they consider heroes, make mistakes and then openly explore what happened, using appropriate root-cause analyses. And I have tried to teach them the importance of self-forgiveness and maintaining perspective so that a mistake, however small, becomes a learning point to avoid future errors rather than a counterproductive source of shame.
We must reconcile the seemingly conflicting hallmarks of the medical profession: our dedication to first do no harm and our lifelong commitment to learn, improve, and evolve. Perhaps for this reason, physicians will always “practice” medicine, regardless of title or status. So, too, when it comes to disclosure of error, deliberate practice buttressed with lessons from social psychology can be the harbinger of success. As with any endeavor in medicine, the progress will not be solely for our profession to reap. Increased transparency and honest communication can preserve and even restore trust between doctor and patient, ultimately improving outcomes for all.
Neha Vapiwala, M.D., is a vice chair of education, radiation oncology, and the advisory dean at the Perelman School of Medicine at the University of Pennsylvania.