When you have made an error of judgement

There is much room for human error in the practice of Medicine. The figures suggest that it is not uncommon, yet when you personally make that error it feels terrible and as though you are the only one who could have done so.

I recently watched a TED talk by Brian Goldman⁽¹⁾ who stressed the importance of talking about making errors, saying as humans we are fallible and making errors of judgement is almost inevitable, however well trained and conscientious we are. Mark Graber, an expert in quality and safety from North Carolina, says that there are breakdowns in the process of diagnosis everywhere.^{( 2)} It has been estimated that 9% of in-hospital deaths are due to wrong or inappropriately delayed diagnoses. Makes you nervous, does it not!

There are now approximately 10,000 identified diseases, multiply that by the fact that each one may present in different ways and at different stages in different populations and that gives an idea of the breadth of knowledge a doctor requires. Then each disease has its own individual management recommendations. There are many reasons for these errors of judgement; inexperience may be one but even experienced doctors are at risk. Time pressure in community medicine means that much as clinicians would prefer otherwise, there is sometimes inadequate time to take a thorough history, a full examination and undertake fool proof clinical reasoning – as well as dealing with the multiple other issues the patient wants to deal with. The sheer volume of medical knowledge means it is almost impossible for one person to upskill or maintain their skills in all areas.

So how does it feel when you know you have made an error of judgement and in particular if that has caused the patient harm?

As doctors we are very vulnerable in these moments. It may be a time for self-recrimination, shame, grief and self-doubt. It is a time when doctors are susceptible to developing depressive symptoms and even suicidal ideation. We are all good at looking after other people but not always so good when it comes to ourselves, and this is definitely a time when a deep level of self-care and self-compassion is vital.

How can we care for ourselves in these moments?

• Seek the support of a trusted colleague or friend and debrief

It is important to seek support. Choose a trusted colleague or friend with whom you can speak honestly, without fearing judgement. These incidents can be very isolating and it is easy to ruminate on them, to catastrophise or to become very anxious or depressed. As doctors, our role is to take care of others and often we care deeply for our patients, especially those we know well. To hurt or harm them is the last thing in the world we would choose to do. It is important to review the situation, taking responsibility for what is ours and accepting that there may have been other factors at play. I recall a time I disclosed to a colleague about a delayed diagnosis I felt had harmed my patient. He and his wife visited me later with a bunch of flowers. In that generous gesture there was an acknowledgement that none of us is infallible.

• Talk with the patient and or their family

It used to be the case that we were discouraged from talking to patients when an error had been made. This felt completely unnatural, often worsening the situation. Difficult as it may be, an expression of sorrow at what has occurred and an attempt to explain why it may have occurred are at times really healing for both parties. Make space and time to do this, both for your patient and for yourself. One of the most humbling experiences in my career was when I shared my dismay about a delayed diagnosis with my patient’s husband. Instead of being angry and blaming he asked if he could pray for me.

• Seek professional help

If you feel your psychological wellbeing is in any way compromised, do not hesitate to seek professional help. Sometimes this is difficult, but having your own GP or a trusted psychologist can support you, if necessary, to manage your own emotional reaction to the situation. It is a good time to explore your relationship with Medicine, the pressures you are under and to look honestly at how this error of judgement was made.

• Contact your Medical Defence organisation

Reporting errors of judgement to your medical indemnity organisation gives you access to legal advice should this be needed. Often their trained staff will help you put the situation into perspective and offer advice on how to proceed.

• Practise self-compassion and self-care

It is always important to bring balance into your life. We all tend to remember the “things that have gone wrong” forgetting the many more “things that have gone right”. Remember the many people who have trusted you and valued your care. Remember that you were not the cause of the patient’s original illness. Remember that you are not alone in making errors of judgement; it is unusual for a doctor practising over a long period to have no incidents they have been concerned about.

• Share your experience: it is not an error unless you fail to learn from it
  

When life is back on an even keel, if you choose, be brave enough to share your experience and what you have learned. As Emeritus Professor John Murtagh in his wisdom quotes:

“A mistake is not a mistake unless you fail to learn from it.”

By sharing, we learn from one another and perhaps help to prevent future problems and reduce the awful feeling of shame and isolation that we all feel when an error occurs. It is necessary for us all to work together in whatever way we can to reduce the number of medical errors and our honesty and willingness to learn helps us to do this.

References:

1. Goldman, Brian: Doctors make mistakes

https://www.ted.com/talks/brian_goldman_doctors_make_mistakes_

2. Graber, M: The incidence of diagnostic error in medicine

http://qualitysafety.bmj.com/content/22/Suppl_2/ii21