A physician's mistakes
12/09/19 05:29
Medical training in the United States is a rigorous undertaking. The highly competitive process of gaining admission to a medical college often eliminates well-qualified candidates. Over the years I’ve known several brilliant young people who aspired to become doctors but who could not gain admission to a medical college. Then, once in a medical school, candidates are subjected to a highly structured and very intense process that includes sleep deprivation, intense pressure and more competition. The result is that the highly trained and highly skilled physicians who work in the medical system in our country are an exceptional group of individuals.
There are, however, a lot of qualities, essential to the delivery of health care, that are not taught in medical school. One of those qualities is humility. Those who survive the process of medical education usually have a very high opinion of themselves. They believe that they are exceptional and that they know more than others. They have been taught that what they do is something that the average person cannot do. And they believe what they have learned.
I’ve written in my journal before about how those trained in scientific method and evidence-based medicine frequently fail to apply science and evidence-based techniques to certain aspects of their practices. While doctors and hospitals tend to follow the latest scientific discoveries and trends in administering drugs, they rarely achieve state-of-the art business practices. Hospital and medical practice billing departments often are overly costly and inefficient. Doctors are among the largest barriers to reform simply because they find it so difficult to admit failure.
A recent experience by a friend illustrates how an inflated ego can be a barrier to effective medical treatment. My friend had been referred by a doctor to a routine radiological screening. A couple of spots were discovered that could be signs of malignancy. The radiologist delivered the news to the patient with clinical coldness and then explained than a biopsy would be needed in order to confirm the initial diagnosis. The patient asked, “So it might be benign?” The doctor responded, “Unlikely.” “How do you know?” asked the patient. “I’ve seen a million of these” was the doctor’s curt response. He failed to hear the cry for hope in the voice of the person he was treating.
Of course “a million of these” is just an expression. The doctor was literally too young to have reviewed a million diagnostic tests. But it is a common type of exaggeration. The doctor was trying to establish his credentials and inspire confidence in his abilities. But what if we assumed he was delivering factual information in his response. There has been a fair amount of research on the error rate among radiologists. A simple second opinion of radiologists’ readings finds that the second look produces a 30% disagreement rate. Radiologists produce different diagnoses in about 25% of the cases where they are giving a second opinion of their own readings without knowing who did the original diagnosis. It is estimated that the error rate in radiology is between 10 and 15%. That means that if the doctor had really read a million of the tests, he would have mis-diagnosed between 100,000 and 150,000 cases. That’s a whole lot of human lives affected by simple human error. A 2001 review of American radiologists found that the rate of clinically significant errors in radiology was between 2 and 20%. If we move towards the low end of that finding, say 4% that would mean 40,000 cases where the quality of life of the patient was seriously affected by the radiologist’s mistakes.
The answer given by the doctor was misplaced. It did nothing to advance medical treatment or patient care. Quite frankly boosting the ego of the doctor is not among the responsibilities of the patient. Furthermore, the patient’s question was the right question. What the patient wanted to know was “is there a chance that the initial diagnosis could be wrong?” The answer is, most certainly, “yes.” That is why the next step after the radiology is a biopsy - a different type of medical test that involves analysis of actual tissue from the patient.
It was a single exchange between a physician and a patient. It has little clinical significance in this particular case. The patient will go on to deal with a surgeon and an oncologist and will not have to deal with the radiologist for much more than occasional diagnostic tests ordered by other doctors.
The practice of medicine is an art as well as a science. Of course scientific process and precision is important to effective medical treatment and advances in science have contributed a great deal to patient outcomes and quality of life. But science is only part of the practice of medicine. The results of tests need to be interpreted by trained human eyes, though in the case of initial reading of radiological tests, evidence is mounting that robots are more accurate than humans. Beyond interpretation, the results have to be communicated to patients in ways that enhance understanding and engage patients in the process of treatment and recovery. That is where this radiologist made the biggest mistake. Telling a patient “I’m smarter than you” does nothing to promote healing. The physician might have desired to establish credibility or even enhance trust, but the display of an over-inflated ego to a patient who has just received shocking and life-altering news is not the way to inspire trust.
It is possible to become a medical doctor in today’s university environment without ever taking a single course in the humanities. Science, technology, engineering and mathematics are important fields of study for physicians. But to provide that education without philosophy, ethics, literature and art is to fail to produce a well-rounded doctor.
As the experience of my friend illustrates, every physician eventually comes to the point of having a dramatic effect on the real lives of real people. Improper diagnoses and mistaken diagnoses can permanently affect the lives of real people who are loved and treasured.
The doctor with the over-inflated ego will one day encounter the limits of his own health. He will one day experience illness and disability. I hope and pray that when that happens he encounters a physician with more compassion than he displayed.
There are, however, a lot of qualities, essential to the delivery of health care, that are not taught in medical school. One of those qualities is humility. Those who survive the process of medical education usually have a very high opinion of themselves. They believe that they are exceptional and that they know more than others. They have been taught that what they do is something that the average person cannot do. And they believe what they have learned.
I’ve written in my journal before about how those trained in scientific method and evidence-based medicine frequently fail to apply science and evidence-based techniques to certain aspects of their practices. While doctors and hospitals tend to follow the latest scientific discoveries and trends in administering drugs, they rarely achieve state-of-the art business practices. Hospital and medical practice billing departments often are overly costly and inefficient. Doctors are among the largest barriers to reform simply because they find it so difficult to admit failure.
A recent experience by a friend illustrates how an inflated ego can be a barrier to effective medical treatment. My friend had been referred by a doctor to a routine radiological screening. A couple of spots were discovered that could be signs of malignancy. The radiologist delivered the news to the patient with clinical coldness and then explained than a biopsy would be needed in order to confirm the initial diagnosis. The patient asked, “So it might be benign?” The doctor responded, “Unlikely.” “How do you know?” asked the patient. “I’ve seen a million of these” was the doctor’s curt response. He failed to hear the cry for hope in the voice of the person he was treating.
Of course “a million of these” is just an expression. The doctor was literally too young to have reviewed a million diagnostic tests. But it is a common type of exaggeration. The doctor was trying to establish his credentials and inspire confidence in his abilities. But what if we assumed he was delivering factual information in his response. There has been a fair amount of research on the error rate among radiologists. A simple second opinion of radiologists’ readings finds that the second look produces a 30% disagreement rate. Radiologists produce different diagnoses in about 25% of the cases where they are giving a second opinion of their own readings without knowing who did the original diagnosis. It is estimated that the error rate in radiology is between 10 and 15%. That means that if the doctor had really read a million of the tests, he would have mis-diagnosed between 100,000 and 150,000 cases. That’s a whole lot of human lives affected by simple human error. A 2001 review of American radiologists found that the rate of clinically significant errors in radiology was between 2 and 20%. If we move towards the low end of that finding, say 4% that would mean 40,000 cases where the quality of life of the patient was seriously affected by the radiologist’s mistakes.
The answer given by the doctor was misplaced. It did nothing to advance medical treatment or patient care. Quite frankly boosting the ego of the doctor is not among the responsibilities of the patient. Furthermore, the patient’s question was the right question. What the patient wanted to know was “is there a chance that the initial diagnosis could be wrong?” The answer is, most certainly, “yes.” That is why the next step after the radiology is a biopsy - a different type of medical test that involves analysis of actual tissue from the patient.
It was a single exchange between a physician and a patient. It has little clinical significance in this particular case. The patient will go on to deal with a surgeon and an oncologist and will not have to deal with the radiologist for much more than occasional diagnostic tests ordered by other doctors.
The practice of medicine is an art as well as a science. Of course scientific process and precision is important to effective medical treatment and advances in science have contributed a great deal to patient outcomes and quality of life. But science is only part of the practice of medicine. The results of tests need to be interpreted by trained human eyes, though in the case of initial reading of radiological tests, evidence is mounting that robots are more accurate than humans. Beyond interpretation, the results have to be communicated to patients in ways that enhance understanding and engage patients in the process of treatment and recovery. That is where this radiologist made the biggest mistake. Telling a patient “I’m smarter than you” does nothing to promote healing. The physician might have desired to establish credibility or even enhance trust, but the display of an over-inflated ego to a patient who has just received shocking and life-altering news is not the way to inspire trust.
It is possible to become a medical doctor in today’s university environment without ever taking a single course in the humanities. Science, technology, engineering and mathematics are important fields of study for physicians. But to provide that education without philosophy, ethics, literature and art is to fail to produce a well-rounded doctor.
As the experience of my friend illustrates, every physician eventually comes to the point of having a dramatic effect on the real lives of real people. Improper diagnoses and mistaken diagnoses can permanently affect the lives of real people who are loved and treasured.
The doctor with the over-inflated ego will one day encounter the limits of his own health. He will one day experience illness and disability. I hope and pray that when that happens he encounters a physician with more compassion than he displayed.