Friday’s reflections: A courageous doctor.

The best part of doctoring is its humanness. Machines cannot 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.

Today, 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% 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’ wellbeing 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 are not 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 4000 word case report in the New England Journal 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, 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.

Today, Dr Ring’s humanness is no exception.

Wow.

JMM

6 comments

  1. Actually, Apple products come close but I catch your drift. Nice post. This stuff needs more visibility.

  2. I just cannot agree with you. Admitting a mistake is not courageous or breathtaking; although in medicine it may be unprecedented. It’s simply the done thing. The doctor in question failed to execute the most rudimentary process in a hospital, which is to validate the patient’s identity and what you’re supposed to do to them. I was a phlebotomist in college, the hospital’s position was that if you did not correctly identify a patient, and you stuck the wrong person, you were fired on the spot. The phlebots had much less opportunity to do harm, but that was the rule. Those of us who really needed the job were very careful with confirming identity and what blood was to be drawn. Is your admiration because he wrote the event up as a journal article? This was a never event, and it’s different than a bad outcome of a procedure because it is preventable. Surgery carries an inherent risk of failure, but this was a process violation of the first degree.

  3. AM,

    Thanks for those extremely thoughtful words.

    I hear you. Loud and clear. Point taken.

    However…

    I don't think it is just medicine, that likes to cover, forget, abolish-the-thought of mistakes. It's human nature.

    Paradoxically though, learning from our mistakes is what makes us better.

    I bet Dr Ring will be a better surgeon now. Slower, more careful perhaps. His hospital will improve too.

    But if he didn't admit to it publicly only he and his hospital would have benefited. Now, so many more will. It will be talked of (his "never" error).

    I know that I have learned tons from my mistakes.

    Would this be experience? Wisdom? Is it why I am a better doctor at age 47 than 33?

    JMM

Comments are closed.