Autumn 2017
Doctors Make Mistakes. Can We Talk About That?

The health-care system isn’t foolproof, and it’s time to open up about it, says U of T alumnus Dr. Brian Goldman


Illustration of a circle of chairs, one occupied by a doctor, and the rest empty. A patient sits on a bench in the centre, facing the doctor.

Illustration: Pete Ryan.

I’ll never forget the first time I heard the three words that emergency physicians dread: Do you remember? “Do you remember that patient you sent home?” a nurse asked me matter-of-factly one late afternoon, early in my career. “Well she’s back.” Mrs. Drucker, a patient I’d treated earlier that day – had returned to the hospital and was near death. About an hour after I’d sent her home, thinking that I’d solved her problem, she had collapsed. Her family had called 911 and the paramedics had brought her back to the emergency department in severe shock. She was barely breathing. The emergency staff were able to stabilize her, but over the next two or three days, it became clear that she wasn’t going to wake up. The family gathered. And at about the nine-day mark, they agreed to stop all life support – Mrs. Drucker, a wife, a mother and a grandmother.

They say you never forget the names of those who die.

Over the next few weeks, I beat myself up and experienced for the first time the unhealthy shame that exists in our culture of medicine – where I felt alone, isolated, sick inside. The unhealthy shame says not that what you did was bad, but that you are bad. Why did I make such a stupid mistake? Why did I go into medicine? I made myself a bargain: if I redoubled my efforts to be perfect and never make another mistake, the accusing voices would stop. I went back to work.

And then it happened again. Two years later, I saw a 25-year-old man with a sore throat. I was busy, in a bit of a hurry. I gave him a prescription for penicillin and sent him on his way. Two days later, I heard the same three words: “Do you remember that patient with the sore throat?” It turns out he had a potentially life-threatening condition called epiglottitis that can cause the airway to close. Fortunately he didn’t die. He was placed on intravenous antibiotics and he recovered after a few days. But I experienced the same feelings of shame and recrimination. 

Hospital-related harms in Canada are estimated to result in patients occupying an additional 1,600 hospital beds each day,
costing roughly $685 million a year.

 
I’d like to be able to say that my worst mistakes happened in my first five years of practice – as I’m sure many of my colleagues would say about their own errors. But this would be false. Some have been in the last five years. Here’s the problem: If I can’t come clean and talk about my mistakes, if I can’t find the still-small voice that tells me what really happened, how can I share them with my colleagues? How can I teach them about what I did so that they don’t do the same thing? If I told a room full of my fellow physicians these stories, they would probably get uncomfortable, somebody would change the subject and we would move on. That’s the kind of system we have. It’s a system in which the perception is that there are two kinds of physicians – those who make mistakes and those who don’t. And we have this idea that if we drive the people who make mistakes out of medicine, we’ll be left with a safe health-care system. But there are problems with that idea.

In my 20 years of medical practice, I’ve learned that we work in a system where errors happen every day. It’s estimated that between 9,000 and 24,000 Canadians each year die in hospital of preventable medical errors – and this is probably a gross underestimate, because we really aren’t ferreting out the problem as we should.

One in 18 Canadian hospital patients experience harm from preventable errors. Among the most common are: falling, pressure ulcers, intravenous line infections, surgical site infections, medication errors (such as the wrong dose or wrong medication), and C. difficile infections.

 
I’m not a robot; I don’t do things the same way each time. And my patients don’t tell me their symptoms in the same way each time. Given this, mistakes are inevitable. If you weeded out all the health professionals who make errors, there wouldn’t be anybody left.

In my other career as the host of a show about health care on CBC Radio One, I’ve found that medical profes­sionals want to tell their stories. We want to be able to say, “Don’t make the same mistake I did.” What we need is an environment in which we can do this. What we need is a redefined medical culture. This starts with one physician at a time.

The redefined physician is human, knows it and accepts it. He or she isn’t proud of making mistakes, but strives to learn one thing from what happened in order to teach somebody else. The redefined physician points out other people’s mistakes, not in a gotcha way, but in a loving, supportive way so that everybody can benefit. He or she works in a culture of medicine that acknowledges that human beings run the system, and that they will make mistakes from time to time.

I can’t compel my colleagues to admit their mistakes. All I can do is say that I’m human, I make mistakes. I’m deeply sorry when they happen, but I always strive to learn one thing that I can pass on to other people.

And I do remember.

Adapted from a TEDx Talk by Brian Goldman (MD 1980), an emergency room physician, author and broadcaster.


Reader Comments

# 1
Posted by Harry Schonert B.A.Sc%201985 on September 25th, 2017 @ 10:32 am

This article caught me off guard, in that I thought the health-care system, including doctors, would foster a culture of free and open reporting and voluntary acknowledgement of errors and omissions. Perhaps a look at the Royal Canadian Air Force Flight Safety Program would be helpful:

http://www.rcaf-arc.forces.gc.ca/en/flight-safety/index.page

I believe there are parallels in other safety programs as well.

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