By KENT BOTTLES, MD
St. Augustine: “Fallor ergo sum”
When I was in charge of the medical residency programs in Grand Rapids, Michigan, David Leach introduced me to the expanded Dreyfus Model of how physicians can progress from beginners to masters. I was always struck by how master physicians freely admitted their mistakes and used them as a teaching tool. As a young surgical and cytopathologist, my sanity was saved more than once by University of California San Francisco’s Dr. Theodore R. Miller, a true master of cytology, being willing to share with me some of his mistakes. I do not honestly think I could have survived in diagnostic pathology without his guidance and wisdom. Years later, I still remember Dr. Miller showing me a breast fine needle aspiration biopsy slide of fat necrosis that mimicked ductal carcinoma and a case of wrongly diagnosed pancreatic cancer that turned out to be inflammatory atypia.
Mistakes and errors are on my mind because I just finished reading some extraordinary works.
Kathryn Schulz’s Being Wrong: Adventures in the Margin of Error (New York: Ecco, 2010) has convinced me that we should replace our usual pessimistic model of error with an optimistic model of error. All physicians make mistakes and are familiar with the former model and the accompanying feelings of worthlessness, shame, and depression. Recalling cases where I got the diagnosis wrong still make me want to throw up years later. Schulz is right when she writes, “being wrong runs a narrow, unhappy gamut from nauseating to worse than death.”
Some of my own errors formed the basis for my chapter “Pitfalls in Cytology of the Breast” in Errors and Pitfalls in Diagnostic Cytology (Baltimore: Williams & Wilkins, 1997), and I still remember being uncomfortable giving the lecture to the International Academy of Pathology in Washington, DC in 1997. Admitting to mistakes might mean I was a bad pathologist; being a bad pathologist felt a lot like being a bad person. That day at the Hilton Hotel on the podium I did not feel like a master pathologist.
Schulz contrasts this pessimistic reaction to error with an optimistic reaction where one can be baffled, fascinated, amused, excited and delighted by owning up to a mistake. She quotes both William James and Henri Bergson to great affect.
“Our errors are surely not such awfully solemn things. In a world where we are so certain to incur them in spite of all our caution, a certain lightness of heart seems healthier than this excessive nervousness on their behalf.” James
“Look upon life as a disinterested spectator. Many a drama will turn into comedy.” Bergson
Henry Petroski’s Success Through Failure: The Paradox of Design (Princeton: Princeton University Press, 2006) argues for the optimistic view of mistakes in examples such as bridge design, tall building architecture, bicycle lock design, and NASA’s Challenger tragedy. Over and over again, Petroski shows how success teaches us very little and failure teaches us a lot. The creed at IDEO, the famous design company, is “’Fail early, fail often.’” Professor Jack Matson believes so strongly in the role of failure in design that he expects students in his Innovative Engineering Design course at Penn State University to fail in order to pass. “Innovation requires that you go beyond the known into the unknown, where there might be trap doors and blind alleys. You’ve got to map the unknown. You map it by making mistakes.”
What really got me thinking about error in a new way was Schulz’s treatment of illusions. I was already familiar with the two faces/vase and old woman/young woman visual illusions, but I was blown away by Scottish explorer John Ross discovering the illusory Croker Mountains in Lancaster Sound and American Robert Peary who saw a mirage of an entire continent in northern Canada. Although Ross’ illusion ruined his career, our usual response to illusions is amusement and wonder. Illusions really do upend our conventional reaction to being wrong.
This amazing book by Schulz made me think about life in a new way. Her thoughts on St. Augustine, Dadaism, zealotry, groupthink, Ben Franklin, and the Talmud convince me that to be human is to make mistakes. Just one example: according to the Talmud, “if there is an unanimous guilty verdict in a death penalty case, the defendant must be allowed to go free – a provision intended to ensure that, in matters so serious that someone’s life is on the line, at least one person has prevented groupthink by providing a dissenting opinion.”
In The Invisible Gorilla: And Other Ways Our Intuitions Deceive Us (New York: Crown, 2010) Christopher Chabris and Daniel Simons expanded my appreciation for humans making mistakes by explaining the brain’s illusion of knowledge. Examples include the world’s leading geneticists predicting that humans have between 25,747 to 153,478 genes when the right answer is 20,500. Leon Rozenblit and Frank Keil did dozens of experiments which all showed that we are “blissfully unaware of the shortcomings in our own knowledge.” For example, The Big Dig in Boston cost 250% more than originally planned because the civil engineers thought they knew more than they really did about putting streets underground. The authors also remark that our illusions all tend to cast an overly favorable light on human mental capacities. “There are no illusions of blindness, amnesia, idiocy, and cluelessness.” Later in this blog, we will see they may be wrong here. It is also sobering to note that people with depression are said to have a more accurate view of their relationship to reality than others who are not depressed.
I zeroed in on Jonah Lehrer’s treatment of mistakes in How We Decide (Boston: Mariner Books, 2010), and I think Schulz would be happy with his effort. Bill Robertie, a world-class expert at chess, poker, and backgammon, claims that the way to improve is to focus on mistakes. The famed physicist Niels Bohr defines an expert as “a person who has made all the mistakes that can be made in a very narrow field.” I was impressed by Carol Dweck’s studies at Stanford that showed that praising students for their intelligence resulted in worse performances than praising students for their effort. However, I was most impressed by the story of Michael Riley of the Royal Navy and how he used his intuition to correctly differentiate a silkworm missile from a friendly airplane by listening to his intuition and his dopamine receptor.
Since mistakes are such a central part of human life, one would think we would get really good at apologizing. Think again. Lisa Belkin nicely summarizes how difficult it is for us to say sorry sincerely (http://nyti.ms/dnZ230). Although apologies are “the most profound of human interactions” that can heal and resolve guilt and anger, some now see many non-apology apologies that do not satisfy either the sinner or the victim. Think recent apologies by Tiger Woods or BP’s Tony Hayward. Or maybe an even better example of non-apology apologies is GOP Congressman Joe Barton apologizing to BP and then apologizing for apologizing to BP.
According to Belkin, some states have passed laws making a doctor’s apology inadmissible as evidence in a lawsuit, in the belief that patients find solace when a doctor admits a mistake, and that doctors are more likely to do so if they are taking part in a conversation and not a confession. “These laws might well free doctors to speak more honestly with patients and families and allow for a chance to truly repair their relationship. Or they might have the opposite effect entirely. With less at stake for the doctors, could apologies become pro forma and, as a result, less powerful?”
My friends, family, and co-workers were getting tired of me raving about the above four books, when I stumbled upon something even more mind boggling: Errol Morris’ The Anosognosic’s Dilemma: Something’s Wrong but You’ll Never Know What It Is (Parts 1-5) (http://ow.ly/26IeJ).
This article ricochets from Donald Rumsfeld to McArthur Wheeler (a hapless bank robber who thought lemon juice would make him invisible) to the famed neurologist Joseph Babinski to President Woodrow Wilson to Marcel Proust to surrealism. The starting point is the Dunning-Kruger Effect which was described in a landmark article titled “Unskilled and Unaware of It: How Difficulties of Recognizing One’s Own Incompetence Lead to Inflated Self-assessment.”
Anosognosia (from the title of the Morris article) is a condition in which a person who suffers from a disability seems unaware of or denies the existence of his or her disability; it was first described by Babinski in patients who were paralyzed but refused to acknowledge their problem.
Morris thinks deeply and creatively about “known unknowns,” “unknown unknowns,” and “unknowable unknowns.” In interviewing David Dunning, he discusses how the mediocre doctor is not aware of diagnostic possibilities and treatments that he never considers. More disturbing is a study of medical students which shows that those at the bottom of the class cannot learn by being shown what the smart students are doing to progress along the Dreyfus model of competence. They are like McArthur Wheeler who was too stupid to know that he was too stupid to successfully rob banks.
Morris’ epilogue states:
I have to admit my fondness for the Dunning-Kruger Effect. But is it a metaphor for existence? For the human condition? That we’re all dumb and delusional? So dumb and delusional that we can never grasp that fact? It’s so profoundly depressing and disturbing. Even sad. Dunning gives us no hope. The McArthur Wheelers of this world will never understand their limitations. But aren’t we all McArthur Wheelers? (http://ow.ly/26IPb)
I think we are all McArthur Wheelers, but I am comforted by V. S. Ramachandra’s observation that “It may well be our brains are wired up to be slightly more optimistic than they should be.” (http://ow.ly/26N9k) For any physician to be a master diagnostician he or she must learn from mistakes and also be acutely aware of what they know they don’t know. They must also admit that some things about people and their ailments are just unknowable. Making mistakes does not make you a bad doctor or a bad person. Making mistakes makes you a human being. Get used to it. And learn how to apologize sincerely. You might want to read On Apology by Aaron Lazare, MD (Oxford: Oxford University Press, 2005). I just did, and I have a lot of work to do.
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I enjoyed this so much I printed it off to read again. Helps us think about the definition on insanity- doing the same thing over and over again and expecting different results. As someone who wants to learn what goes on on the hospital units, I do safety rounds and talk to the frontline staff- what they have to say brings a reality that we often shy from. THey are key to helping us keep our patients safe
Nicola Heslip
Certified Professional in Healthcare Quality
PolicyMedical
Online: http://www.patientsafetypeople.com or http://www.policymedical.com
Beautiful post. I really appreciate you sharing it.
However, what is one to make of the persistent failure to act on lessons learned from mistakes? For example, it is common knowledge that hand-washing is essential to preventing the spread of disease between patients. Yet, we face ever-troubling statistics on the number of clinicians who simply neglect to do it. There are best practices that can reduce certain infections (like of central lines) down to practically zero. However, even in the face of knowledge of how to prevent these infections, the practices that enable a higher rate of infections to continue are not changed. Medical science also has clear evidence on how to reduce birth trauma rates down to as close to zero as one may reasonably see(1-2 per 10,000 births). Again, the methods to attain this goal are not a mystery, yet birth trauma rates ten-fold higher are tolerated at facilities around the nation.
That is the part of this discussion that seems to merit a closer look: why don’t we learn from errors and adopt new behaviors that minimize the potential for mistakes? The airline industry did so via the oft-noted pre-flight checklists. What will it take for health care to become an industry that learns how to avoid repeating the same mistakes over and over again?
No need to worry. Mistakes and errors will be facilitated by CPOE and unusable EMRs. The human traits of error making will become commonplace, and reult in deaths.
I’m afraid the deep revelation here eludes me for some reason. We all understand that physicians are human and therefore fallible. However, I doubt that “one can be baffled, fascinated, amused, excited and delighted by owning up to a mistake” when it comes to medicine. Amused??? Like in “Oops, another one bites the dust… LOL”? “’Fail early, fail often.’” doesn’t work very well either, does it?
Physicians would have us believe that theirs is an exalted profession reserved for the unique and the very best. I understand the, equally human, need for absolution and I understand that “being wrong runs a narrow, unhappy gamut from nauseating to worse than death”, particularly when it involves death, but joy is in no way a prerequisite for learning from those mistakes.
Perhaps a less consequential occupation, like design, would afford happiness to be derived from failure.
It is a great post. Mistakes happen by every human being. But we have to learn from the mistakes to improve. There was a great quote “Failure is the pillar of success” and I agree with it fully. Thanks for sharing this post.
We presented results of how poorly we performed some diagnositic testing at the International AARC Congress a few years back and were applauded for our willingness to share our failures. Many came up to us and said they took the same flawed approach and never thought to investigate their quality. It simply never crossed their minds that something in their technique would cause less than ideal results. They just assumed the quality was there because they’d done it that way for so long.
Learning from your own mistakes tell us you’re normal, learning from other’s mistakes tell us you have wisdom. That’s why I like to read journals so much. I’m always learning from someone’s success and failure.
There is a female patient safety advocate (was it Lisa Lindell) who frequently posts comments here. A while ago, she wrote something like: “Isn’t every medical mistake (or misdiagnosis) malpractice?” Most people do not understand that medicine is inexact, a judgment call … when is a physical sign (e.g. a heart murmur) present, and in what context do I have to interpret this possible finding that could be just nothing? Medicine is different then flying commercial planes, which is very complex, but standardizable and almost entirely predictable (yes, some things in medicine are standardizable, too, and that should be used to our advantage – see checklist manifesto etc).
WOW! I don’t think I have ever read a post that speaks to me so directly. I will think about this for a while (and download a few books to my Kindle tonight!!
Thanks –
Excellent post. I too have thoroughly enjoyed Kathryn Schulz’s “Being Wrong.” I now work in health care QI. I cut my professional teeth in a forensic-level environmental radiation lab in Oak Ridge, where fools were not suffered gladly. (Much of our work was for litigation support, providing analytical evidence in contamination/exposure/dose cases.)
“Being Wrong” is an utter delight. Rather exhaustively researched, and written in a style at once erudite and witty. Highly recommended.
Thank you for a diverting read that didn’t make me forcus on political moral dilemas, crises in health care, or the potential dangers of technology. I’ve had quite enough of that lately. 🙂
To quote Alexander Pope in his An Essay on Criticism (1709):
“Now they who reach Parnassus’ lofty crown,
Employ their pains to spurn some others down;
And, while self-love each jealous writer rules,
Contending wits become the sport of fools:
But still the worst with most regret commend,
For each ill author is as bad a friend
To what base ends, and by what abject ways,
Are mortals urged, through sacred lust of praise!
Ah, ne’er so dire a thirst of glory boast,
Nor in the critic let the man be lost
Good-nature and good sense must ever join;
To err is human, to forgive, divine.”
“The Big Dig in Boston cost 250% more than originally planned because the civil engineers thought they knew more than they really did about putting streets underground.”
I would postulate they knew enough about the cost of buidling streets underground but that they did not know enough about cronyism, corruption, and nest feathering.