American College of Physicians: Internal Medicine — Doctors for Adults ®

Monday, December 10, 2012

Error, expertise and the elephant in the room

In his TEDTalk, Dr. Brian Goldman provides an intimate portrait of medical error, recounting his own with deep emotion. My inclination is to look at the same issue from greater altitude, like that of a 747 in flight.

Dr. Goldman compares the performance of clinicians to baseball players, noting that even a "legendary" batting average in baseball would make for a dismal cardiothoracic surgeon. My inclination is to look at medicine as a team sport; teams get hits even when individual players do not.

In my view, one of the salient reasons for highly prevalent medical error and attendant iatrogenic harm is medical expertise. So much so, in fact, that I am inclined to coin a neologism: medical "ERRORudition." Error, born of erudition.

That may sound oxymoronic, give or take the "oxy," but it's true just the same. The problem pertains to that infamous tendency to miss the forest for the trees, and to overlook the elephant in the room.

In "The Blind Men and the Elephant," an Indian parable of antique vintage most indelibly rendered as a poem by John Godfrey Saxe in the mid-19th century, six blind men set out to satisfy their curiosity about the titular beast. Inevitably, each takes hold of some small patch of anatomy, from tail to tusk to ear, and each reaches a distinct conclusion about the nature of the animal. As Saxe notes in his conclusion, "each was partly in the right, and all were in the wrong."

Dr. Goldman's apparent empathy would seem the antidote, if not the antithesis, of errorudition, but I'm not so sure.

The two salient illustrations of his own fallibility Dr. Goldman shares involve sending patients home from the emergency room who went on to get worse rather than better, and in one case, to die. Dr. Goldman suggests we own up to such mistakes, and learn from them each time.

But is that really enough? Is that enough when lives are on the line? Is it enough when medical errors constitute a leading cause of death nationally? Would it be enough for the pilots of 747s?

I would argue that doctors can be fallible prognosticators, and still protect patients just by seeing them, past their body parts and pathologies.

When sending home a patient after treatment for congestive heart failure, the issue is not just the status of the heart failure but of the person. Do they live alone? If things get worse instead of better, can they get back safely before a true calamity? Do they have social support? Transportation?

We can all accept that any given doctor might make the wrong call about a condition -- predicting it will improve, only to have it worsen. Modern medical technology is impressive, but has yet to devise a working crystal ball. But we don't need one to note whether a patient has friends or family, or a car. The only way to make errors about such considerations is to ignore them altogether. And that's not acceptable ever.

What is left out of Dr. Goldman's talk, and medical education in general, is a standard set of criteria used to determine when it's safe for a patient to go home and when it's not, based not just on the condition, but on the person and their circumstances.

Despite the fact that doctors make decisions about admitting and discharging patients every day, I have never encountered standard criteria pertaining to both condition and context on which such decisions should be based. I devised my own, and in my years as a medical educator, shared them with my charges.

Applying such considerations, the very same condition might allow for one patient's discharge, but require hospitalization in another living alone, or without transportation, or too far from the hospital to get back in time if things got worse instead of better.

We doctors are fallible, irrefutably so. But so are the pilots of 747s, and we nonetheless expect those babies to make it back safely damn near every time. When lives are at stake, the way the system works must compensate for human fallibility.

In medicine, one of the best ways to prevent fallibility from turning fatal is for care to be more about people than pathology.

There was a time when medicine was all, and only, about the patient in the room. There was relatively little science to call on, little relevant erudition and thus generous doses of attentive compassion were de rigueur. Doctors knew the social circumstances of their patients well, if understanding the pathophysiology less so.

This history is far from ancient. My father is a cardiologist, and in the early days of his on-going career, the care of myocardial infarction constituted little more than token drugs for comfort, tincture of time, and hand-holding.

Now, of course, balloon-tipped catheters are threaded into the coronary arteries to restore flow and abort infarctions. Drug-eluting stents made of high-tech alloys are expanded into those arteries to maintain flow and prevent re-occlusion. It is at most a modest exaggeration to suggest that the care of MI has advanced as much in the past several decades as in all the centuries between them and our first recognition of it. To one degree or another, similarly dizzying progress characterizes medicine at large.

And that's good, but it's also bad. Dizzying progress makes for dizzy people. Profound insights inculcate their own particular brand of blindness. The greater the magnifying capacity of a microscope lens, the smaller the part that fits into the field of scrutiny. Patients, let alone families, may be too big to see.

And that, then, is where we find ourselves. Ever more right about the parts, ever more wrong about the whole.

There is a macabre joke about the blindness of modern medicine's reductionistic erudition, and you have likely heard it: "The operation was a great success. Unfortunately, the patient died." That would be a whole lot funnier if it weren't so close to a perilous truth.

It may well be that only a tiny part of any given elephant fits in a surgical field, or under a microscope. But if we are to care for our patients and not just body parts, if we are to eliminate the error from modern erudition, and if we are to pre-empt the fatal consequences of inescapable fallibility, we must, even in the 21st century, see past parts to the whole elephant.

Or, at least, see the patient in the room.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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