Year : 2018 | Volume
: 6 | Issue : 2 | Page : 195--204
“Primum non nocere,” harmful medical mistakes, hubris syndrome, and human fallibility; Getting to the heart of the matter
Bhaskara P Shelley
Professor and Head, Department of Neurology, Yenepoya Medical College, Yenepoya (Deemed to Be) University, Mangalore, Karnataka, India
Prof. Dr. Bhaskara P Shelley
Department of Neurology, Yenepoya Medical College, Yenepoya (Deemed To Be) University, Mangalore - 575 018, Karnataka
|How to cite this article:|
Shelley BP. “Primum non nocere,” harmful medical mistakes, hubris syndrome, and human fallibility; Getting to the heart of the matter.Arch Med Health Sci 2018;6:195-204
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Shelley BP. “Primum non nocere,” harmful medical mistakes, hubris syndrome, and human fallibility; Getting to the heart of the matter. Arch Med Health Sci [serial online] 2018 [cited 2019 Aug 21 ];6:195-204
Available from: http://www.amhsjournal.org/text.asp?2018/6/2/195/248660
“A believer is a bird in a cage; a freethinker is an eagle parting the clouds with tireless wing”
–Robert Green Ingersoll
“Freethinkers are those who are willing to use their minds without prejudice and without fearing to understand things that clash with their own customs, privileges, or beliefs. This state of mind is not common, but it is essential for right thinking”
My father, my hero and role-model, lost his life on Children's Day in 1995. He was the victim of a major surgical error at a premier institute in India. The negative surgical encounter was even made ‘intolerable’ to bear since I discovered an additional ‘serious pathological error’ in his pre operative liver biopsy reports. I was then a Holmesian neurology resident and had managed to send his HPE slides to a Professor of Hepatopathology, Regional Liver Transplant Unit, Newcastle Upon Tyne through my lifelong friend Prof GP. The Professor of Hepatopathology did admit the slides to be quite interesting from a diagnostic perspective, took the liberty to retain 2 unstained slides, yet unequivocally with irrevocable evidence stamped the process to be benign and not hepatocellular carcinoma. It is this one thing in my life that I could not put behind me, my despair, which gave me the insight to write on “harmful medical mistakes” as an editorialist.
Am I being cynical? No, I am a medical idealist who is frustrated and disappointed as “the spirit of the law of medicine” of “primum non nocere” was violated here by grave diagnostic pathological and surgical errors. I lost my father and had to witness the grief and pain in my siblings and my mother. I still ask this question even today –Before “God's law”, and not the “Laws of Medicine” - Is there a defense for the pathological error and surgical misadventure as in my father's illness episode? The PDF of my father's biopsy report is still on my laptop. This serves me as a constant reminder of the immense duty and terrible responsibility of “primum non nocere” I have not only towards patient-centered humanistic care, instead supremely, to promote patient safety culture in our modern ‘hi-tech, no-touch’ healthcare system. What made it worse was that when my father was dying, I was not with him. I am who I am because of my father; I am my father's son. I wanted “the truth.” Both grave errors were not disclosed to us by the doctors of this premier institution. Can we afford such harmful medical mistakes, surgical errors, and negligence? Who takes the responsibility? Does the doctor honor the life that departed because of his/her harmful medical mistakes or do doctors merely turn away from their mistakes? Do we remember the lives of patients who we could not save? Do we, as doctors, with the many degrees as ‘the jewel in the crown’ along with a long impressive curriculum vitae actually posses a certain degree of ‘hubristic personality’ that we can million medical errors, and ‘scientific evidence based knowledge’? Does the ‘blood of the lives lost’ create a self reflection into the ‘conscience’ of our practice? Isn't this moral virtue I pose here i.e. “ To pay tribute to a doctor's invaluable teacher:A dead patient' a crucible for appreciative learning? So, I end this opening section with a reflective quote that all surgeons, I feel, need to abide by.
“Every surgeon carries about him a little cemetery, in which from time to time he goes to pray, a cemetery of bitterness and regret, of which he seeks the reason for certain of his failures.”
– René Leriche (1951)
The so-called Hippocratic injunction “primum non nocere” in Latin has been an axiom central to the ethical practice of medicine. The Hippocratic Oath reiterates the commandment “to abstain from doing harm” in our “soulful” profession. The origin of this phrase is perhaps uncertain as Hippocrates was a Greek. How is this quoted in Latin? From my understanding, it appears to me that the phrase “do no harm” is not from the Oath but from the Hippocratic Corpus, “Of the Epidemics,” Book I, Section 11, 5 which stated, “Practice two things in your dealings with disease: Either help or do not harm the patient.”
“If liberty means anything at all, it means the right to tell people what they do not want to hear.”
“In a time of universal deceit telling the truth is a revolutionary act.”
Do we not need Hippocrates, Sir William Osler, and Dr. Francis Peabody in the theatrics of 21st-century medical schools and medical practice today? Why did I pose this question? Undoubtedly, I do see what is beautiful, what is wonderful and certainly feel so deeply appreciative of the leaps of modern medicine that has contributed to humankind. Nevertheless, as a critical insider, more as a freethinker, an optimistic pessimist, a controversialist, and a realist, I do not see a “soulful” enterprise today; instead, I have witnessed a phenomenal climatic change in the milieu of academic medicine and the practice of medicine. Now, the cultural and moral fabric of our medical enterprise has become increasingly technocratic where the “art, science, heart, and soul” of medicine has shifted away from the concept of “whole medical systems” and “whole person” health and “wellness.” Medical scientism has thus ignored, neglected, and disengaged the patient (or patient individuality) from the “biopsychosocial–spiritual” equation of a disease model rendering the patient–doctor relationship as something less than a fiduciary relationship. I would reiterate that the “individuality” equation for healing is crucially missing from our philosophical epistemology and medical scientism of modern medicine despite Sir William Osler's wisdom: “The good physician treats the disease; the great physician treats the patient who has the disease.”
Has this change in academic milieu led to de-professionalization and dehumanization of our profession? The answer in the affirmative has led to tremendous attrition of an “emotionally-inclusive care” devoid of “relationship- and patient-centered.” This transformation in academic medicine is also echoed by Kenneth M. Ludmerer, a medical historian and educator, who reiterated that “Medicine is, at its center, a moral enterprise grounded in a covenant of trust. Today, this covenant is significantly threatened.” Today, at the core of the heart of medical practice and its moral contract with society, I sadly acknowledge the “soulless encounter” and reiterate that genuine medical professionalism is indeed in peril. Having witnessed the “limitations and laws of medicine as an uncertain science” throughout my doctor-hood journey, I regret to state unequivocally that the whole thrust of our “determinism-based” philosophy of medical scientism on the “disease pathogenesis model” is certainly flawed. Therefore, I do dare to ask the question “Are we in our scientism of modern medicine barking up at the wrong tree?” Doctors no longer see a patient as a distinctive human being, instead as a set of deranged organ systems based on reductionist approach. I would reiterate that medicine at its heart must have a “human touch” and cannot be governed by “cold science” alone. Our “scientism” cannot see the “forest for the trees” and suffers from simultagnosia, a scientific world that is unglued to holism, wellness, and healing outcomes. Instead, our scientism is promulgated by the empiricists and rationalists with an ideology of the reductionist concept of disease and hi-tech as its surrogate remedy, thus ignoring the “individuality” factors. As a result, the distressed patient as a “whole” is absent in this equation of healing. Unfortunately, commercialism, commoditization of medicine, and consumerism have changed the patient–doctor relationship as something less than a fiduciary relationship. My ideology of a healing scientism is that of an eclecticism philosophy, one that integrates “pluralistic theories” of medical knowledge with its healing whole-person practice.
Furthermore, medicine is no more at its center, a moral enterprise due to powerful influences of commercialization of health care, health insurance companies, powerful influence of pharmaceutical companies, growing privatization and monetarization of medicine, cost-effectiveness, transformation of health care to a “profit-maximization model,” all of which transforms the moral soulful enterprise of medicine to a “healthcare industry.” Disease has become the focus of the technologic and market-driven medical system, patients as “cases” while illness and the socio-cultural and humanistic aspects of medicine and patient/relationship-centered care have been undervalued and blurred into the background. I have now realized that our philosophy of western medicine has got us up “barking up at the wrong tree” of “elephanomics” akin to the “The Blind Men and the Elephant.” There is “Dark Side of Medicine” that stems from flaws in the epistemological foundations of our medical scientism, our excessive reliance on the conventional scientific orthodoxy of the “disease pathogenesis model,” absence of an alternative holistic biopsychosocial–spiritual model of health promotion and well-being, “disease awareness campaigns,” “disease mongering,” pseudo-disease promotion, creating a “fear of epidemics,” the “follies and fallacies” in medicine, soulless scientism of false research with drug and pharmaceutical companies (scandal of poor medical research), and unnecessary medical interventions. This editorial deals with “medical errors” as one of the surrogate topics of “The Dark Side of Medicine.”
“Modern Medicine is a negation of health. It isn't organized to serve human health, but only itself, as an institution. It makes more people sick than it heals”
In this milieu of climatic change of our profession I dare to ask “Is primum non nocere a lie?”… since every weapon in the physician's armamentarium is double-edged; every cure has a potential harm … so could we debate that primum non nocere is indeed a lie that is outdated and a commandment that we need to abandon in today's ever-changing enterprise of the modern 21st-century medicine. Well, in my collective wisdom, it is certainly not a lie and should not be “misunderstood” or “misapplied”. Instead, we, as doctors, to the best of our current and updated knowledge and evidence, must try to help our patients to the best we can, and when we cannot, at least we must try not to make things worse for them.
With this backdrop, my next question is centered on the axiom “to err is human.” Is this applicable to the practice of medicine? Do doctors make “harmful medical mistakes” (medical errors)? What is their prevalence worldwide? Is there a role for forgiveness when a doctor commits harmful medical mistakes? What is responsible for medical errors? Are doctors, like humans in any other profession, succumbing to the “necessary human fallibility factor?” Can doctors talk of their harmful medical mistakes? Do harmful medical mistakes occur as a result of the “hubris syndrome?” At the outset, I do not wish to get into the limitations of definitions, semantics, legalities, and criminalization of medical errors and ethics or the “Swiss cheese” model of error causation, namely medical errors (diagnostic, treatment, preventive domains), adverse events, serious adverse events (medication errors), errors of judgment, medical negligence, medical malpractice, negligent adverse events, nursing errors, and/or surgical errors. In general, medical error is an umbrella term for all errors including mishandled surgery, diagnostic errors, equipment failures, and medication errors. However, my endeavor here is to dwell on “Slips, Lapses, Fumbles by Doctors and Medical Mistakes” that sadly leads to iatrogenic injuries, death, or loss of precious human life that I call it a “preventable human tragedy.” Can we explicate the drivers of these “medical mistakes,” can we resolve these “harmful medical mistakes,” and “is there a role of forgiveness?” Is the religion of medicine an “unforgiving” one for those who have chosen to become doctors?
Considering the mammoth scientific data that emerge at a rapid pace, it is conceivable that doctors will find it difficult to be abreast with all current medical information. Dr. Charles Sidney Burwell, a cardiologist and Dean of the Faculty of Medicine, Harvard Medical School, in an address to students at the Medical School in 1944, said, “Half of what we are going to teach you is wrong, and half of it is right. Our problem is that we don't know which half is which.” Similarly, the Father of Evidence-Based Medicine, Dr. Dave Sackett also did reiterate “Half of what you'll learn in medical school will be shown to be either dead wrong or out of date within 5 years of your graduation; the trouble is that nobody can tell you which half – so the most important thing to learn is how to learn on your own.” In this context, I really wonder how a doctor or medical student can keep up with knowledge explosion in the 21st-century scientific publication overload, information overload in medicine, and the explosion of journals and publishers. Here lies my word on the value of recognizing “the evidence-burdened medicine,” and the absolute need for lifelong learning, the need to have continuing education, and mandatory re-certification to practice safe, high-quality healthcare. Nevertheless, doctors are liable to forget. All these factors make doctors fallible; since doctors are humans, and to err is human, medical errors do occur; especially so if they are coupled with the problem of medical hubris. Medical errors are now viewed as “omnipresent” in medicine, and the image of medical care today conspicuously encompasses fallibility.
Perils of “Cognitive” Hubris Syndrome
Not only are they wrong but physicians are “walking … in a fog of misplaced optimism” with regard to their confidence.
Leaders in the study of human cognition have taught us so much about the “limits of reason” in any scientism. Medical training should devout time not only to give understanding of this human fallibility but also to give training that will explicate why reason sometimes fails, and how. There will be a subjective emotional nature of human cognition for rational thinking, and hence, I would reiterate the need to develop “cognitive humility” that ameliorates “cognitive hubris” since knowing the limits of our minds can help us to make better cognitive thinkers and reasoners. Reason itself is fallible, and this fallibility must find a place in our medical logicism. Perhaps, we need to inculcate the “enlightenment attitude” about the limits of what the human brain can accomplish This is elegantly summarized in what Descartes had to say “If you would be a real seeker after truth, it is necessary that at least once in your life you doubt, as far as possible, all things including how smart you think you are, and how objectively rational you think you and people in general can ever be.”
Allow me to illuminate to “Hubris syndrome.” This originates from Homer's Iliad in the context of Ajax the Lesser, who fought valiantly in the Trojan War. When the war ended, he celebrated victory by dragging Cassandra, the daughter of King Priam of Troy, away from the temple of the Goddess Athena and assaulting her. This act evoked Athena's fury, and she saw to it that Ajax and his fleet were shipwrecked during their voyage back home. Ajax had the immense good luck to be rescued by Poseidon, the sea God. However, instead of thanking Poseidon, he gloated in his invincibility. Supremely arrogant, he pronounced himself victorious against the will of a goddess. That was undisguised hubris. Poseidon reacted by drowning him. For ancient Greeks, hubris was unforgivable. Another tale is that of Icarus. Icarus in his ambition flew too high near the sun defying the caution of his father. The heat melted his wax wings, and he fell into the sea. In Greek mythology, these stories do illustrate that hubris was a dangerous trait responsible for the downfall of many a God.
In a similar vein, I would reiterate that modern medicine has succumbed to the threat of hubris. Perhaps, I should acknowledge that the term “Hubris” is not as yet an accepted medical term. Nevertheless, as doctors climb in their career, their knowledge and hi-tech armamentarium are used to “fight and fix” disorders, and they develop the excessive pride and confidence in their medical armamentarium and progressively lose insight to “The Laws of Medicine.” Due to the error of hubris, doctors start believing in their own invincibility. The antidote to hubris is humility, in particular, “cognitive humility.” I would reiterate that “intellectual/cognitive humility” is absolutely essential today than ever. It is sad that young doctors resort to the surrogacy of technological advances in medicine are potentially liable to lead to excessive self-confidence and feeling of being all-powerful, losing insight to the “medical powerlessness” and the “uncertainty principle” in human fractal physiology and chaotic systems biology.
“Our medicine and its scientism are indeed a science of uncertainties and an art of probabilities lesson” as expounded by Sir William Osler (medical fallibility). This is more in tune with Heisenberg's uncertainty principle in contradistinction to Newtonian deterministic predictability laws. We are not taught the “imperfection” and the “fallibility” of our knowledge of medicine, its limitations, the “known unknowns,” and the “terra incognita” of our system of modern medicine. In no uncertain terms, I would vehemently assert that the “egotism and hubris” of medical professionals who think they can “treat” every human affliction and its complications have to end! We must train our students, interns, and residents that hubris is the enemy and teach “the necessary human fallibility” and “the uncertainty principle” in our medical scientism.
Medical/Human Fallibility: Why Doctors Could and Can Fail
Medicine as a practice is more opaque and blurred than we normally perceive it to be. We approach medical problems and disorders with well-formed algorithms with a preconception of infallibility. Humans are fallible, and this ‘fallibilism’ is the hardest thing for us, as medical professionals and educators, to grasp. We do have limited knowledge, and the limits of our knowledge routinely prevent us from realizing just how much we do not know. I will refer to 3 subtypes of fallibilism as (i) Epistemological fallibility, (ii) Psychological fallibility, and (iii) Ethical fallibility. Unavoidable medical errors that are inherent in the nature of medical practice occur not merely because of the limitations of human knowledge or even the limits of human intellect but, rather, because of the fundamental epistemological foundations of our medical scientism. This may be understood if we view the human body as a scarily intricate machinery with “innate human intelligence,” many a times, unfathomable, hard to be certain, with the bits of puzzles and imperfect information we get to learn in medicine. The total length of the human genome is over three billion base pairs, with estimated 19,000–20,000 human protein-coding genes. It is widely believed that the human body has 78 organs, with 13 different organ systems, 3.7 × 1013 human cells; and an estimated 60,000 different diagnoses, 60,000 different ways by which the human body can fail. Added to this marvelous human system is the fact that human dynamic system is governed by the rules of chaos unlike the linear model of deterministic predictability of Newtonian science. The “necessary fallibility” in decision-making certainly occurs when dealing with unpredictability of events in a nonlinear, nondeterministic human system that works on fractal physiology. Acknowledging the powerlessness of medicine in several nightmarish clinical situations, accepting the limitations of medicine, and that medical scientism is not an exact science; we need to better understand the “necessary fallibility” in medical practice. Because of the complexity of the human organism, we will never escape a degree of necessary fallibility. This is explained as a “theory of medical fallibility” proposed by Gorovitz and MacIntyre in 1975, so as to distinguish unavoidable “necessary error” from other medical errors that seems culpable. I would state that the origins for these errors (failures) are due to (i) ignorance – the knowledge needed to reach the desired outcome does not exist, (ii) ineptitude – the knowledge needed to reach the desired outcome exists but is not correctly applied, and (iii) necessary fallibility – science is unable to deliver the knowledge needed to reach the desired outcome. It is certainly uncomfortable looking inside our fallibility. There is a sense that there is some shame or guilt attached to the fact that we do not get it right all the time. However, it is imperative to expose this narrative to understand medical errors and explore methods to mitigate them since by not having an “open discussion” puts lives at stake in the future.
The “Laws of Medicine” that we should indoctrinate is not solely upon the things we do know, instead to understand “what we do not know” about this wonderful and incredible human machine that works on non-Euclidean fractal theory, chaos theory, and quantum physics. We as doctors must possess a “sixth sense of a reverence” of how we must deal with the incompleteness of our medical knowledge (that I refer to as medical powerlessness or “epistemological fallibility”) and the necessary imperfection of our clinical skills. We must not be fearful of introspecting and reflecting on our fallibility and accept that we cannot “repair” all disorders and we cannot “quick-fix” and in this process attain the wisdom how to avoid making “harmful medical mistakes.” Our reductionist science, the essence of medical school teaching underscoring the need “to make a diagnosis” and “fix it” attitude is not truly logical in a dynamic “systems biology” and we are treading far away from harnessing “the healing art” and “philosophy of wholism” in medicine.
Epidemiology of Medical Errors; “The Silent Killer”
Injuries secondary to adverse events from unsafe care present significant challenges to health systems across the globe. The Joint Commission on Accreditation of Healthcare Organizations and the World Health Organization have estimated that medical errors happen in one out of 10 patients every year globally. According to a 2013 study (Global Burden of Unsafe Medical Care) by Dr. Ashish Jha of Harvard School of Public Health, of the 421 million hospitalizations in the world annually, about 42.7 million adverse events of medical injury take place, two-thirds of which are from low-income and middle-income countries (LMICs). The figure from this study that has been extrapolated to the Indian scenario is 5.2 million medical errors, and adverse events (medication and hospital-acquired infection errors) to occur annually.
Various benchmark studies in the United States and Australia have enlightened the epidemiology of medical errors, its prevalence, and consequences. In the United States (Harvard Study), the magnitude of medical error has been projected to be 44,000–98,000 unnecessary deaths each year and 1,000,000 excess injuries., If doctors were compared to pilots in the aviation industry, translating these numbers to a plane crash analogy, these figures would translate to a Boeing 747 crashing each month. An Australian study that looked into 28 in New South Wales and South Australia in 1995 reported adverse events to occur in 16.6% of admissions, resulting in permanent disability in 13.7% of patients and death in 4.9% of patients; 51% of adverse events were considered to have been preventable. A more recent study found that medical errors may claim as many as 251,000 lives each year in the U.S. Medical errors now account for 9.5% of all deaths in the U.S., making errors the third leading cause of death after heart disease and cancer. A Commonwealth Fund Survey documented that the error rates are significantly higher in the U.S. than in other developed countries such as Canada, Australia, New Zealand, Germany, and the United Kingdom. Thirty-five percent of U.S. patients reported medical, medication, and/or laboratory mistakes. Medical mistakes, medication errors, or laboratory errors are now reported to have increased in the U.S. from 22% to 48%. Unfortunately, in 75% of these patients, there was no disclosure of errors by their doctor.
Notwithstanding the pivotal policies of ‘Universal Health Coverage’ (UHC) and Sustainable Development Goals' (SDGs), we should not lose sight to strategize measures to maintain high standards for safety and quality for world's citizens within the healthcare systems. From the various global, LMICs, and Indian reports, medical errors undoubtedly do represent an important public health problem and pose a serious threat to patient safety. The growing awareness of the frequency, causes, and consequences of error in medicine reinforces an imperative to improve our understanding of the problem and to devise workable solutions and prevention strategies. To my mind, the magnitude of the data from these studies is alarming and should prompt policymakers across the globe to invest further into systematic data collection on medical errors, as well as programs to measure, audit, and improve the safety of the healthcare systems by strategic plans to mitigate medical errors.
Defining Medical Error
Medical errors represent a serious public health problem and pose a threat to patient safety. Unfortunately, there are limitations and a lack of a harmonious and standardized nomenclature with the resultant prevalence of multiple and overlapping definitions of medical error. Perhaps, the notion of “primum non nocere” has given credence to an “outcome-dependent” definition of medical error. However, I would state that a “process-dependent” definition would be more ideal to construct strategies and measures to mitigate medical errors. In this regard, Reason's “Swiss cheese” model of error causation defined medical error as the failure of a planned action to be completed as intended (an error of execution) or the use of a wrong plan to achieve an aim (an error of planning), whereas Leape expounded the “process-dependent” definition differently as an unintended act (either of omission or commission) or one that does not achieve its intended outcome. Both definitions have its inherent limitations. Thus, Bohnen and Grober resorted to an outcome- and process-dependent definition of medical error that states medical error to be an act of omission or commission in planning or execution that does contribute or could contribute to an unintended result. Why does the definition of medical error mean so much? Here, it is important to realize that the definition used in various studies would reflect the accurate measurements of its incidence and prevalence which in turn are essential prerequisites for effective action.
Medical error has been defined as an unintended act (either of omission or commission) or one that does not achieve its intended outcome, the failure of a planned action to be completed as intended (an error of execution), the use of a wrong plan to achieve an aim (an error of planning), or a deviation from the process of care that may or may not cause harm to the patient. Patient harm from medical error can occur at the individual or system level. The taxonomy of errors is expanding to better categorize preventable factors and events. We need to address the preventable lethal events to highlight the scale of potential for improvement. From a psychological perspective, the two basic medical errors can be “unintended action” (slips from attentional failures, and lapses from memory failures) and “intended action” (rule-based and knowledge-based mistakes). Another way of distinguishing these two basic errors is as “planning failures” (mistakes) and “execution failures” (slips and lapses).
It is mind-boggling to note that the data from several large-scale, retrospective, chart-review studies of adverse events have shown a high percentage of diagnostic errors ranging from 8% to as high as 18%. In many cases, autopsy studies not only document diagnostic errors but at the same time provide an opportunity to learn from one's errors (errando discimus) if one takes advantage of the information.
The potential sources of most medical errors have been found to originate from diagnostic decision-making errors, physician overconfidence (error of hubris), rather than technical errors. The cognitive errors may be attributed to the three “A”s, i.e., (i) “anchoring,” where a person overvalues the first data he/she encounters and so is skewed in his/her thinking; (ii) “availability,” where recent or dramatic cases quickly come to mind and color the judgment about the situation at hand; and (iii) “attribution,” where stereotypes can prejudice thinking; therefore, conclusions arise not from data but from such preconceptions. If all these factors are coupled with the “problem of hubris,” along with “our ineptitude” to apply knowledge correctly, it will set the milieu for the genesis of harmful medical mistakes, negligence, and malpractice.
Most of the cognitive errors in diagnostic reasoning are ascribed to breakdown in clinical reasoning skills, including the use faulty heuristics and cognitive biases, attitudinal physician over-confidence with neglected knowledge-seeking behavior coupled failure of meta-cognition (the willingness and ability to reflect on one's own thinking processes and to critically examine one's own logico-deductive assumptions and conclusions).
I do visualize that Medical Science is sometimes the exploration of ignorance, and the information we as medical educators teach may be misinformation, since the voluminous writing on a disease does reflect that there is much “known unknowns” and “unknown unknowns” on the subject. This has been reflected by Sir William Osler's quote on Huntington's disease “In the history of medicine, there are few instances in which a disease has been more accurately, more graphically, or more briefly described.” Many a times, the various diseases we learn from medical textbooks start with the statement “Although the exact cause of the disease is unknown, it is widely thought to be due to….” This “terra incognita” is the epistemology of ignorance in modern medicine. This meta-ignorance (ignorance of the ignorance, not having the insight to the limitations of medicine) must be made visible and “taught” to students in medical schools so as not to get “caught” by the uncertainty and unpredictability of human chaotic fractal systems) and succumb to our “medical fallibility.” This lesson will teach medical students and doctor how to deal with the incompleteness of our medical knowledge and not succumb to the illusion of human infallibility within the corridors of medicine. It will equip us with a mind-set to “learn from our failures” that is quintessential to the successful and safe culture of practice of medicine.
“Putting on the spectacles of science in expectation of finding the answers to everything looked at signifies inner blindness”
–J. Frank Dobie
“Science becomes dangerous only when it imagines that it has reached its goal”
–George Bernard Shaw
Medical science, unfortunately, in its reductionist concept, cannot be the whole truth; it may only be a part of the truth. Many a times in my doctorhood, I have accepted the laws of medicine as ‘uncertainty is the only certainty there is’ and yet we need to make sound clinical reasoning for decision making in vexing clinical scenarios. It is quite obvious to me that there are a lot of areas in medicine that we do not have unequivocal, irrefutable, and definitive answer to.
Do we as medical educators teach these “Laws of Medicine” that their chosen profession does involve an “uncertain science?” Nevertheless, we as doctors need to learn to make “perfect decisions” with the imperfect, uncertain information with such certainty when facing several episodes of our daily clinical dilemmas. This should be a core competency for a developing physician. We must also be responsible for “harmful medical mistakes” and take cognizance of its consequences.
“It is reasonable to expect the doctor to recognize that science may not have all the answers to problems of health and healing.”
“Doctors are men who prescribe medicines of which they know little, to cure diseases of which they know less, in human beings of whom they know nothing.”
–François-Marie Arouet Voltaire
The marvelous human body is intricately complex systems biology, a dynamic system that is governed by the rules of chaos with its inherent “innate human intelligence.” Therefore, can we “predict the unpredictable uncertainty” in medicine using the linear model of deterministic predictability of Newtonian science when the systems biology of Homo sapiens are a complex dynamic, nonlinear chaotic system that plays by the rules of fractal physiology? Instead, perhaps, this century's greatest scientific discovery is the discovery of human's ignorance, the necessary human fallibility, the meretricious effects of medicine, its incompleteness of knowledge, the limitations of medicine, and our inability for “quick fixes” for diseases we encounter.
Medical education must therefore accept the truth that we doctors, are humans, and therefore are liable to make “medical errors,” and this “human inevitable fallibility” must be communicated and discussed with the patient, relatives, and caregivers due to the fiduciary responsibility we have in the patient-centered relationship. It is totally wrong to believe that doctors do not and cannot commit mistakes. We doctors are human beings, are fallible, and are liable to make mistakes and that has to be made known to our patients so that they don't get the idea that doctors are Gods. We, in the practice of modern medicine, should not give an impression of hubris, and remain unperturbed by the “terra incognita” of “known unknowns,” and “unknown unknowns” in medical knowledge (medical fallibility) and that we have the “power of treatment” and “quick fix” solutions well within the scientism of modern medicine. I feel we should not create a medical delusion and pave the way for a “soulless scientism” with our “arrogance and medical ignorance” that we can solve medical disorders without bothering to recognize the “uncertainty principle” in medicine and our inevitable human fallibility. For the relatives and patients to unequivocally understand and condone any genuine mistake done during the therapeutic encounter, we must develop humility to accept our mistakes honestly, be more humane and authentic, learn to communicate, and discuss these setbacks with the patients and caregivers which will go a long way to avoid medical consumerism and medical litigation.
To Err Is Human
Errare humanum est: “to err is human” is a well-known saying that captures the fallibility of human beings. The 1999 Institute of Medicine Report, “To Err is Human: Building a Safer Health System,” bears witness to the fact that medical errors are not uncommon. Medical errors will therefore continue to be an unfortunate unavoidable aspect of medical practice, but I would reiterate that it must be researched, and strategies are identified to mitigate and prevent these iatrogenic tragedies. While many doctors under the guise of concern for patient welfare do not disclose medical error, such behavior is not ethically justified. I would remind our fraternity that the fiduciary nature of the doctor–patient is such that the doctor is ethically obligated to disclose medical errors to patients. I would emphatically put in another word, i.e., “To err is human, to cover up is unforgivable; to fail to learn is inexcusable.” Medical errors must be viewed in a culture of patient safety as instructive and that lessons learned from various life-threatening and negative medical experiences would prove to be of great worth in our profession.
In no uncertain terms, I would reiterate that if we choose to become a doctor, take allegiance in the “white-coat ceremony,” don an attire that symbolizes the honor the tradition of “doctoring” and professionalism, knowing that white color represents a symbol of purity, a dedication to “do no harm” and an emblem of trust, belief, and hope for the patients placed in your trust and care; and if we have chosen this terrible obligation to hold the power of life and death in your hands, then we must be responsible to abide by ‘primum non nocere’ and create a safe and high-quality healthcare environment. We should strive to make errors less common and less harmful when they do occur.
The book titled “Death by Medicine” by Gray Null et al., 2005 and various studies have indeed opened medicine's Pandora's Box (limitations of medicine, doctor's potential fallibility, and problem of hubris) that is in tandem with what George Bernard Shaw (1856–1950) said “Science becomes dangerous only when it imagines that it has reached its goal” and “Science is always wrong. It never solves a problem without creating ten more.” The publication by Dr. Lucien L. Leape of Harvard Medical School titled, “Error in Medicine” in the 1994 Journal of the American Medical Association, further corroborated Starfield in the same prestigious journal in 2000, revealed the sad story of a “health scare system” in the United States. It is estimated that about 225,000 people have died due to iatrogenic diseases in the United States in 1 year. Of these, adverse drug reactions (ADRs) amounted to 140,000 patients. Seventy-nine million had serious ADR that needed treated on an outpatient basis. There have been three million medical errors due to medical interventions with an annual death rate estimated at around 44,000–98,000. Nosocomial infections were reported to have caused 80,000 deaths in a year in hospitals. Screening healthy people and unnecessary interventions bare the true picture of this sad story.
“All men make mistakes, but a good man yields when he knows his course is wrong, and repair the evil. The only crime is pride.”
– “Antigone,” Sophocles
Medicine, being an unforgiving religion, I would assert that it should not be like other fields: thinking styles, cognitive psychology, cognitive strategies, emotions, decisions, actions, and consequences are too critical, and do certainly affect patient safety and quality of healthcare in the medical profession. Physicians deal with life, and life is too precious to permit harmful medical mistakes. Despite doctors' medical proficiency and competency, no matters how well trained, no matter how careful, are fallible. In the human condition, error is the risk we take. And such errors, even more regrettably tragic, may also be irretrievable: The patient may die. This fallibility, inherent in medicine as it is in any other human activity, is the price of action in any field. It is only that in medicine, the stakes are so high. However, no matter how high the stakes, no matter how dreadful the consequences, mortal human is bound to err. We can only strive to make an “indeterminate situation more determinate.” Although medical errors will likely continue as long as clinicians remain fallible humans, it does not mean that it should be accepted as a matter of fact. Once they occur though, what should be the attitude of the medical profession? Medical errors will likely continue as long as clinicians remain fallible humans. Many of the medical errors may originate from cognitive errors coupled by personality attributes of negative emotions, lack of empathy and compassion in problem-solving, and ineptitude in understanding the vast emotional vocabulary of medicine in the therapeutic encounter.
What appropriate measures must be taken to redress and prevent medical errors in the future? One must learn to reflect from one's mistake and take absolute care not to repeat the same mistakes twice or sweep in under the carpet. We need to sublime and transcend above these medical mistakes, the necessary fallibility, to be a better doctor through self-realization, humanism, and professionalism. When, however, physicians fail to acknowledge error even to themselves, self-delusion blocks even self-learning, and errors are prone to be repeated We need to use this “inevitable human fallibility” as an instrument for growth and learning rather than as a cause for condemnation or blameworthiness.
Hence, what should physicians do in the aftermath of medical harm, with respect to forgiveness? The physician can work toward self-forgiveness, by taking responsibility for his or her past, by working to understand his or her role in an incident that slipped beyond the envelope of safety, and by responding to the needs that have been created as the result of harm. Valuing forgiveness as a desirable and authentically human response to human error in medicine requires physicians and their colleagues to create the conditions that will help those who have been harmed to offer forgiveness and that will also help those whose actions have caused harm to be restored, as healers.
Should “harmful medical mistakes” be withheld from patients since “what they don't know can't hurt them” or should such information be honestly disclosed to patients? The cultural change in “acceptable medical behavior” from a paternalistic stand of not wanting to upset the patient to that of “open discussion” makes it imperative that doctors tell their patients the truth since deception in medical practice is no longer acceptable. This change is supported by the fact that the codes of ethics of most medical associations address disclosure of errors and incompetence. The doctor–patient relationship, unlike an arms-length transaction, is a fiduciary relationship. A fiduciary is “one who owes to another the duties of good faith, trust, confidence, and candor.” As a fiduciary relationship, it must rely on principles of autonomy, nonmaleficence, beneficence, justice, and fidelity at all times. Will we admit to making a culpable medical mistake that could have caused serious iatrogenic injury or death? If we admit, do we feel ashamed and incompetent? Afraid from being blamed and judged, will we hide this from others to preserve our veneer of perfection and cover up our potential or inevitable human fallibility? Will this decision leave us feeling “worse” inside or will we continue as “detached doctors” with “hardening of the heart?”
Accepting blameworthiness in medicine and having the courage to learn from the tragic consequences of our hubris with humility can be a stimulus to learning, growth, and moral development to achieve safe and quality medical practice. However, we need to set a platform for doctors to learn from harmful medical mistakes by fostering a “no-blame” culture, yet medical mistakes are still viewed as shameful, embarrassing, and demoralizing events. The negative effect of harmful medical mistakes (medical errors) do set a cascade of emotional events. This is referred to as the “second victim.” Reportedly, they experience initial numbness, detachment, depersonalization; confusion, anxiety, grief, depression, withdrawal, shame, guilt, anger, and self-doubt have all been documented as reactions to making mistakes.
Barriers to discussing mistakes include shame, embarrassment, fear of judgment, and unapproachable seniors must be tackled. Alongside reporting such incident to clinical governance, there must be a supportive cultural milieu to enable doctors to share learning experiences and discussing errors as a group enacting strategies to avoid repetition of mistakes.
Are there any studies designed to have a qualitative exploration of the nature and impact of grief in physicians resulting from loss of patient lives? Beyond curricular reforms, I would reiterate the need to establish an environment within medical schools for learning to “mind the heart,” to learn to perceive and attend to the emotions of patients and self during medical training, acknowledging both the generative aspects and the limitations of emotions, yet to skillfully disengage from professional alexithymia and other maladaptive strategies. In my experience, the art of doctoring unequivocally has a vast emotional vocabulary. This would involve the teaching (through psychodrama and narrative medicine) the panoply of negative, positive emotions, giving credence to personality characteristics with a training for emotional awareness, emotional intelligence, and emotional regulation. As educators, we need to educate the “emotions” in medical education in the hidden curriculum and sculpt “feeling physicians” which in the long run do minimize medical errors and maximize the quality of medical care.
From Hubris to “Cognitive” Humility
Thus, I reiterate the need to convert our crucibles of hubris into cradles of professionalism enriched with pro-social qualities such as compassion, altruism, and empathy with special emphasis on medical humanism. Doctors should not be captured by a certain character trait of hubris, learn to accept the limitations and powerlessness of our modern science, to say “I don't know” in all intellectual honesty and personal integrity. We need to be a rare alloy that blended ambition and confidence with conscientiousness and compassion, humanitarian; we can fail, we have power, but we do recognize the limitations of medicine, medicine is not an exact science, and medicine has its powerlessness; believing that you possess both the power of Atlas and are as insignificance as an Ant is a difficult paradox for the human ego to navigate, but it is the key to being extraordinary. In general, it is a prevalent notion that having a long list of publications in the “curriculum vitae” to be an indicator of a “good researcher” and perhaps taken as a “surrogate marker” to be a good doctor or clinician. Even with the years of medical experience, academic medicine, research experience with such a “curriculum vitae,” I would still urge that we as doctors should not be hubris-filled heroes. Instead, we should have the intellectual maturity and integrity to realize that humans are indeed fallible. We should be trained in ethical mindfulness to expose the “hubris in knowing all” and avoid the dangers of being too entrenched with our factual empiricism laden evidence without being cognizant of the “uncertainties” we do have in medical scientism and medical logicism. We need to balance how the limits of knowledge can be a weakness, and at the same time, how accepting our ignorance can be a strength, which I call it as “intellectual humility” and “intellectual maturity.” With the explosion of scientific data and evidence, we need to have this “intellectual humility” to recognize that most of what we know will in the years to come, become wrong or redundant.
Learning from and Mitigating Harmful Medical Mistakes
“Mistakes are a fact of life. It's the response to the error that counts”
–Nikki Giovanni (American Poet, 1943)
Human beings, in all lines of work, make errors. In the healthcare industry, where even the smallest mistake can have catastrophic implications, should not have any place or scope for errors. Notwithstanding our human fallibility, medical errors should be prevented by designing systems that make it hard for people to do the wrong thing and easy for people to do the right thing. However, a balance must be maintained not to exaggerate the magnitude of error in the public's mind – we should not scare the public and sensationalize the issue. The work of error reduction is too important to let these reactions prevail over improvement.
Despite the Institute of Medicine Report, “To err is human,” as humans, we sometimes find it difficult to admit mistakes. Nonetheless, it is important to be honest about errors and have an organizational cultural change for patient safety that would be conducive for an “open discussion” without ascribing to blameworthiness (“no blame culture”). Institutions need to move forward from an entrenched system of shame and blame to a balanced system of personal and systems accountability, reporting system for medical errors, regular audit, feedback information to clinical governance, promote a healthy learning environment, and help physicians cope positively after a medical error. Admitting an error in medicine is not easy, but the importance of admitting error cannot be understated. It is quintessential to orchestrate in hospital surveys of doctors with a view to understand better the culture surrounding mistakes and the types of mistakes that were being made. Once a culture of patient safety by reporting and open discussion of medical errors supervised by medical supervisor is in place, it would be less futile to enact strategies for mitigating medical errors in tandem with the clinical governance department. The first essential step is the need to disclose the error during “mortality and morbidity” meetings; provide empathy and emotional support for the “second victim” learn from it; and establish a dialogue with the clinical governance department for transparency and self-improvement. Effecting such a cultural change within the fabric of an organization will certainly move the way forward to establish patient safety systems and a safe healthcare system coupled with a CQI approach. In this perspective, India has paved the way forward for a “patient-centric” safe medical care within the context of UHC. The NPSIF 2018–2015 Framework under the aegis of Ministry of Health and Family Welfare, Government of India, is a national initiative is to improve patient safety at all levels of health care across all modalities of healthcare provision, including prevention, diagnosis, treatment, and follow-up within overall context of improving quality of care and progressing toward UHC in coming decade. This is in accordance with the “Regional Strategy for Patient Safety in the WHO South-East Asia Region (2016–2025)” that aims to support the development of national quality of care and patient safety strategies, policies, and plans into actionable strategies.
Here, I would acknowledge my “cerebral musings” of how I navigated my potential fallibility in the “science of uncertainty and the art of probabilities” during my journey through medicine. I learned painstakingly to utter three important words, i.e., “I don't know.” By accepting “the way of ignorance,” I obviated the problem of hubris as “my ignorance” and the ideology of the “Socratic paradox” (I know that I know nothing) showed the “beginning of all my learning” in medicine, even to this day. I will reiterate that these three words are the most important words in medical education. A good effective clinician–doctor should commit to a life time of motivated learning by displaying our ignorance and potential fallibility, not by hiding our ignorance. I urge the young medical students and developing physicians to ingrain a certain degree of scientific temperament, a questioning mind-set, “to read in between the lines” in medical textbooks and medical journals, use the principles of heutagogy and lifelong learning to differentiate from the widely taught “conventional truth” to discover the “hidden, ultimate truth” of the intricately complex dynamic “human body's intelligence.”
With over three decades of my doctor-hood experience, these are the “Laws of Medicine; the inherent uncertainty in the nature of medical evidence” that needs to be “made known” for the greater ethos of “societal wisdom.” We should not create the myth of “certainty;” instead, we acknowledge the “inherent uncertainty” in our medical scientism. Not being a “medical routinist practitioner,” still a “student of medicine” with a “questioning mindset,” I believe that the “art, science, heart, and soul” of medicine should indeed be a moral enterprise with a fiduciary responsibility (through medical professionalism, ethics, and humanism) to its patients. This, to my mind, this will restore the physician's tarnished title to a “Friend of Mankind,” and as a cognitive behavior specialist, I am certain it will enhance “the placebo effect” and the new physiology of doctor–patient relationship.
In conclusion, I reiterate that medicine is all about the art of preserving life, providing succor, and is an unforgiving religion. Reduction of errors has become an important marker of the quality of care and is included in the clinical performance indicators. We should practice “primum non nocere.” How many of us realize the enormous responsibility the patients' has entrusted us with? As physicians, we should be taught and not get caught by certain inevitable truths about “Risks, Benefits, and Uncertainty in Medicine and Healthcare,” “Uncertainty and Medical decision-making;” “The Hubris of Medicine;” “The Epidemiology and Mitigation of Medical errors,” and “The Safe Culture of Healthcare” Finally, I would reaffirm that “physicians must strive to be better judges of science” and not succumb to a medical nemesis and a health scare system. Data on physician diagnostic errors, autopsy data, why these diagnostic errors occur should be taken into consideration in implementing strategies for their prevention, and how the harm that results can be reduced. Errors cannot be ignored. They must be recognized, their causes analyzed, and preventive measures necessarily be taken.
To my mind, Medical Hubris and the lack of insight to the powerlessness of our medicine are indeed the obstacles to preventing medical errors. Acquiring “cognitive humility” and avoiding the “hubristic behavior,” respecting “Primum non nocere,” harnessing clinical wisdom to be able to see “uncertainty with such certainty” in the indeterminacy of our modern science is quintessential. By my reckoning, passionate lifelong learning, re-education through enhancing meta-cognitive skills, computer-based training of cognitive heuristics in diagnostic reasoning skills, increased autopsy rates, clinical governance, auditing and feedback, rapid incident follow-up will undoubtedly pave the way forward to mitigate “harmful medical mistakes” and build a safe healthcare system integrated to a CQI program.
“Think not of the amount to be accomplished, the difficulties to be overcome, or the end to be attained, but set earnestly, at the little task at your elbow, letting that be sufficient for the day.”
–Sir William Osler
“Two sorts of writers possess genius; those who think, and those who cause others to think”
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