A Fresh Perspective On Medical Errors
How I Nearly Killed A Guy!
A few weeks after graduating med school, I was the junior doctor on call when a middle-aged man arrived in the ER in obvious discomfort. The patient, whom I’ll call John, was complaining of a severe pain that ripped down the right side of his abdomen and stabbed into his groin.
I examined John and, using a simple bedside test, found blood in his urine. This finding, coupled with the severity, location and radiation of John’s pain, instantly suggested an obvious cause—a kidney stone on the move towards his bladder. Easy diagnosis, next patient please…
For confirmation, I requested an I.V.P. This is a medical test performed by an x-ray doctor. At least it would have been had the patient not collapsed in the radiology department.
The radiologist, with years of experience for every one of my days, realized that I’d made a classic mistake.
I’d overlooked the fact that bleeding from the artery that supplies the lower half of the body (abdominal aorta) can also cause severe flank pain that stabs into the groin. In this case the blood had also tracked into John’s right kidney which explained the blood in his urine.
Unlike a kidney stone, bleeding from the aorta is a life-threatening emergency. Here’s the bone-chilling bottom line: I’d misdiagnosed a severe internal hemorrhage. Fortunately the vascular surgeons arrived in time to fix up the patient so that he could return home. Even so, what if the patient had died? How could I have explained that outcome to his family?
A Horrifying Statistic!
I revisited my medical error in the light of a horrifying statistic that was published recently in the BMJ. Namely that medical errors may now be the third leading cause of death in the US. To be clear, the term “medical error” is extremely broad and covers everything from a patient administered the wrong drug and post-surgical infections to misdiagnoses.
After a decade spent showing other doctors how to avoid medical misdiagnoses, here are some suggestions on how we can raise our game…
You Won’t Find The Solution In A Medical Textbook
It’s not what you know that determines your skill as a diagnostician but, rather, what you can bring to mind in the moment. This conclusion is supported by academic studies which underscore the high frequency of well-recognized thinking errors, rather than inadequate clinical knowledge, in diagnostic mistakes. This means that the keys to reducing the number of medical misdiagnoses lie within psychology textbooks, not medical tomes.
Most Doctors View Psychology As A Soft Option
And it’s easy to understand why. In general, there’s a mandatory psych 101 course during a medical student’s first pre-clinical year and then (s)he gets distracted by far more emotionally engaging fare—bullet wounds in the ER, watching brain surgery, running with the crash team. This, the stuff of life and death, feels so much more “real” than learning about experimental participants tackling puzzles in the contrived surroundings of a psych lab.
Striking Interactive Demonstrations
In my experience, using striking interactive demonstrations is the best way to introduce the role of cognitive errors in misdiagnosis. It’s important to select exercises that expose mission-critical perceptual and cognitive errors from the front of the room, in real time.
Make It Relevant!
After demonstrating that all of us have a much more limited outlook than we realize, it’s essential to immediately apply this notion to clinical settings. This is best done using case studies.
Summarize With A Metaphor
It’s vital that your clinical staff not only leave with actionable steps, but that they also remember to apply these tactics in the moment. I’ve found that linking everything back to a metaphor makes it much easier for clinicians to remember and apply my tactics. I use the notion of a mental version of a picture frame, a “Brain Frame.”
These are the steps I use to present psychological tactics to medical staff in a non-judgmental, easily accessible and immediately implementable way. You can find a more detailed description of my Brain Frame metaphor with related case studies HERE