(GAWANDE, 2002)

Reactions to error and adverse outcomes in medicine are greatly magnified because so much can be at stake. Few other professions face the possibility of causing the death of another person with such regularity, although the likelihood of this obviously varies in different areas of healthcare. The preventable death of a child under one’s care is one of the worst clinical experiences for a doctor or nurse. The brave and thoughtful account reproduced here (Box 10.1) foreshadows many of the themes of this chapter. The doctor concerned acknowledges his personal contribution and responsibility in not appreciating the increasing frequency and severity of the seizures. Yet it is clear that he was failed by others and that organizational problems contributed to the delays and possibly to the final outcome. Although the personal impact on the doctor is not directly discussed it was probably profound, as the case is still vivid eight years later. Although a child died, and he was the clinician with immediate responsibility, he was never able to discuss the case in way that would have helped him personally or foster any clinical learning. The phrase ‘a spirit of openness’ exemplifies the cultural shift that he believes is needed.

The experience of error

Virtually every clinician knows the sickening feeling of making a bad mistake. You feel singled out and exposed – seized by the instinct to see if anyone has noticed. You agonize about what to do, whether to tell anyone, what to say. Later, the event replays itself in your mind. You question your competence but fear being discovered. You know you should confess, but dread the prospect of potential punishment and of the patient’s anger.
REPRODUCED FROM BRITISH MEDICAL JOURNAL, ALBERT W WU. “MEDICAL ERROR: THE SECOND VICTIM”. 320, NO. 7237, [726–727], 2000, WITH PERMISSION FROM BMJ PUBLISHING GROUP LTD.

For decades there was very little public debate or discussion of the impact of errors on clinicians. Those that tried to bring the subject into the open did not always fare well at the hands of their colleagues. For instance Hilfiker, (1984) argued that ‘We see the horror of our own mistakes, yet we are given no permission to deal with their enormous emotional impact… The medical profession simply has no place for its mistakes’ (Hilfiker, 1984: p. 118). This paper drew some supportive correspondence, but also some summary and dismissive comment such as ‘This neurotic piece has no place in the New England Journal of Medicine’ (Anderson, 1984: p. 1676). Hilfiker hoped that others would follow his example and write about their own errors, but was apparently disappointed that progress was slow thereafter (Ely, 1996).

For some young doctors mistakes are the most memorable events of their training. In interviews Mizrahi (1984) found that half of the young doctors he interviewed had made serious and even fatal mistakes in the first two months of their jobs. Jenny Firth Cozens found that British junior doctors singled out making mistakes, together with dealing with death and dying, relationships with senior doctors and overwork, as the most stressful events they had to deal with (Firth-Cozens, 1987); a missed diagnosis by one young doctor made him reject a career in subspecialties that involved ‘a lot of data collection and uncertainty’. This echoes the experience of Carlo Fonsecka (1996), who recounted the personal impact of mistakes in a remarkable personal paper that began ‘Error free patient care is the ideal standard but in reality unattainable. I am conscious of having made five fatal mistakes during the past 36 years’ (Fonsecka, 1996: p. 1640). Fonsecka wrote that, with hindsight, he believes that the impact of the first case was so great, that he no longer felt able to carry on with clinical work and turned eventually to a laboratory based career.

Medical students anticipate the mistakes they will make as doctors, even before entering medical school (Fischer et al., 2006):

I think one of the scariest things about becoming a doctor is realising how much responsibility you have and that human error happens all the time. I thought about it even before I decided that I definitely wanted to go to medical school.
(FISCHER ET AL., 2006)

Students and young trainees regarded errors as inevitable and part of the practice of medicine, though their responses to errors were influenced by a number of different factors. The nature of the error made, the attitude of their supervisor and the consequences of the error all played a part in their response. However, they were also influenced by what Fischer describes as the ‘hidden curriculum’, the subtle education in the mores, attitudes and values of one’s chosen profession which are powerful and pervasive, though seldom explicitly stated. The culture of medicine as exemplified and inculcated in the hidden curriculum could override personal ethics and beliefs (Box 10.2).

In a series of 11 in-depth interviews with senior doctors, Christensen et al. (1992) discussed a variety of serious mistakes, including four deaths. All the doctors were affected to some degree, but four clinicians described intense agony or anguish as the reality of the mistake had sunk in. The interviews identified a number of general themes: the ubiquity of mistakes in clinical practice; the infrequency of self-disclosure about mistakes to colleagues, friends and family; the emotional impact on the physician, such that some mistakes were remembered in great detail, even after several years; and the influence of beliefs about personal responsibility and medical practice. After the initial shock the clinicians had a variety of reactions that had lasted from several days to several months. Some of the feelings of fear, guilt, anger, embarrassment and humiliation were unresolved at the time of the interview, even a year after the mistake. A few reported symptoms of depression, including disturbances in appetite, sleep and concentration. Fears related to concerns for the patient’s welfare, litigation and colleagues discovery of their ‘incompetence’.

Although relatively few studies have focused on nurses or other professions, studies that do exist suggest that nurses also suffer similarly in the aftermath of errors. Not surprisingly they experience the same basic human responses of shame, guilt and anxiety about the consequences. In one study on medication error, nurses were more likely than doctors or pharmacists to report strong emotional responses to making an error and fear of disciplinary action or punishment (Wolf et al., 2000; White et al., 2008), which perhaps reflects the different disciplinary culture of nursing.

The wider impact on clinical staff

Surveys of clinical staff show that the reactions described above are common responses to making a serious error (Aasland and Forde, 2005; Schwappach and Boluarte, 2009). In an early study, Wu et al. (1991) sent questionnaires to 254 doctors in training in the United States asking the respondents to describe the most significant mistake in patient care they had made in the last year. Almost all the errors had serious outcomes and almost a third involved a death; feelings of remorse, anger, guilt and inadequacy were common and over a quarter of the doctors feared negative repercussions from the mistake. Accepting responsibility for the error was most likely to result in constructive changes in practice but was also associated with higher levels of distress. Studies have also begun to examine longer-term effects on physicians. Waterman and colleagues examined the effects of medical error experience on five work and life domains in a large survey of 3171 physicians in the United States and Canada (Waterman et al., 2007). Over 90% remembered a specific error or adverse event. Increased anxiety about future errors was reported most frequently (61%) as response to being involved in error, followed by loss of confidence (44%), sleeping difficulties (42%), reduced job satisfaction (42%), and harm to reputation (13%). Experience of one of these reactions was significantly more likely if responders were involved in a serious rather a minor medical error.

Once mood and well-being are affected, the likelihood of making an error can become greater in a cycle of poor clinical performance and deteriorating psychological state. West et al. (2006) carried out a remarkable study in which doctors completed self assessments of burn out, depression and capacity for empathy every three months. Doctors who reported a major error were more likely to feel emotionally exhausted and depressed, but also likely to become more depressed and emotionally exhausted in the subsequent three months. In other studies, doctors with high burn out scores were also more likely to report providing sub-optimal care such as ‘making treatment errors that were not due to lack of experience’ or discharging patient simply to make the service more manageable. These results suggest that personal distress and self-reported error involvement are related in a reciprocal cycle. Feeling responsible for a serious medical error can induce depression and exhaustion, which in turn increases the likelihood of sub-optimal patient care and future errors (Schwappach and Boluarte, 2009).

The suicide of a patient under one’s care is a particularly disturbing event. Alexander et al. (2000) studied the impact on psychiatrists who were asked to describe their most distressing suicide; 159 consultant psychiatrists provided information on suicides that had happened between 1 month and 20 years ago. While the study does not specifically concern mistakes, any suicide by a patient in one’s care raises the spectre of blame and personal responsibility, coupled with anxiety about the critical reactions of both the patient’s family and colleagues. The most common reactions were irritability at home, being less abletodeal with routine family problems, poor sleep, low mood, preoccupation with the suicide and decreased self confidence. Although none of the psychiatrists took time off work, the effectsofthe suicide were very persistent, with a number seriously considering early retirement. These salutary experiences, not surprisingly, also affected their clinical management of suicidal patients, generally moving them towards more structured management, more use of suicide observations, more detailed communication about records, a greater willingness to intervene and a more cautious approach to suicide risk.

What makes an error traumatic?

When a patient is harmed, the errors made are often only part of a chain of events inseparable from a web of organizational background causes. Seldom, after close analysis, is it possible to lay the blame for an adverse outcome solely at the door of one individual, however tempting this may be. Junior doctors for instance, may find themselves forced to deal with events that are well beyond their competence, inheriting problems that originate elsewhere in the organization. For them to then take responsibility and shoulder all the blame may be both unwarranted and personally damaging.

What then singles out a mistake as being particularly traumatic for a clinician? Errors, as we have seen, are frequent. Yet only a small proportion bring anguish, regret and shame in their wake. There is almost no research on this issue to my knowledge, but the nature of the error, personal characteristics and medical culture probably all play a part in determining the personal impact.

The error and the reactions of those involved

First, and most obviously, the outcome will be severe. Hindsight bias applies in this area, in that a bad outcome makes one more critical, and indeed more self critical, of the care given. If you ‘get away with it’, the feeling is likely to be more relief than guilt. Second, it will be a clear departure from the clinician’s usual practice, rather than a close call in a genuinely uncertain situation. The reaction of colleagues, whether supportive or defensive and critical, may be equally powerful. The reaction of the patient and their family may be especially hard to bear, especially when the outcome is severe and if there has been a close involvement over a long period. For instance, psychologists or psychiatrists may find the suicide of a patient very hard to face if there has previously been a long therapeutic relationship.

Personal standards and self criticism

Clinicians, like everyone else, vary in temperament, resilience and attitude to their own errors. Jenny Firth-Cozens (1997) has found that a tendency to self criticism is predictive of stress; this tendency may be rooted in earlier relationships, which in turn may find an echo in relationships with senior colleagues. For a highly self critical person, errors and mistakes will be particularly disturbing; in serious cases the clinician may enter a vicious downward spiral of anxiety, shame and deteriorating performance. There is a fine balance to be struck between personal high standards and undue self criticism. The high personal standards of excellent clinicians may in fact make them particularly vulnerable to the impact of mistakes.

Attitudes to error and the culture of medicine

In his landmark paper on error in medicine, Lucian Leape (1994) argued that one of the most important reasons that clinicians have difficulty dealing with error is because of the culture of medical practice. He argued that physicians are socialized from the very first days of medical school to believe that errors are simply not acceptable. While error-free practice is a worthy ambition it is, of course, completely unattainable, so an internal conflict is inevitable:

Physicians, not unlike test pilots, come to view an error as a failure of character – you weren’t careful, you didn’t try hard enough. This kind of thinking lies be hind a common reaction by clinicians: ‘How can there be an error without negligence.’
(LEAPE, 1994: P 1852)

All clinicians recognize the inevitability (though perhaps not the frequency) of error. However this seldom carries over into open recognition and discussion. There is therefore a curious, and in some ways paradoxical, clash of beliefs. On the one hand we have an enterprise fraught with uncertainty, where knowledge is inadequate and errors are bound to occur. On the other hand those working in this environment foster a culture of perfection, in which errors are not tolerated, in which a strong sense of personal responsibility both for errors and outcome is expected. With this background it is not surprising that mistakes are hard to deal with, particularly when so much else is at stake in terms of human suffering.

Beliefs about control and the power of medicine

Beliefs about the degree of control the clinician has, will strongly affect their sense of personal responsibility for adverse outcomes and attitudes to mistakes. A certain degree of realism about the likelihood of mistakes, especially with increasing constraints on practice, pressure of work and the need to take short cuts at times, tempers reactions to individual mistakes and makes it less likely that someone will generalize from a single, regrettable mistake to a more general belief that they are incompetent. For instance, in the study of the impact of suicide, discussed above, Alexander et al. (2000) comment that psychiatrists have to strike a balance in their attitude to the suicide of their patients. If they regard suicide as unavoidable, they protect themselves and their profession, but consequently end up in a position of therapeutic nihilism. If, on the other hand, they view every suicide as preventable, they lay themselves open to blame and guilt and would probably eventually be unable to continue their work.

The impact of litigation

The impact of errors and mistakes is compounded and deepened when followed by acomplaintor litigation. Even the investigation of a serious incident, if badly handled by senior staff, may be very disturbing for a young nurse or doctor. Patients now demand much more of the doctor or nurse, and may be less forgiving when their own expectations of outcome are not fulfilled, though are rightly angry when no apology or explanation is given. The considerable media attention given to medical catastrophes has also made the public much more aware of the potential for harm as well as benefit from medical treatment.

The experience of being sued in a prolonged and difficult case was dramatically documented in Charles and Kennedy’s (1985) book, Defendant: A Psychiatrist on Trial for Medical Malpractice. The psychiatrist in question described feeling utterly alone and isolated from colleagues, later finding that this was quite a common experience for those accused of malpractice. The case lasted five years, seemed to swallow up her life completely, demanded constant attention and made her anxious and insomniac. She felt she had lost her integrity as a person and as a doctor (Charles and Kennedy, 1985).

Charles and Kennedy’s book broke new ground in bringing the experience of litigation into the open. Later studies of the wider impact of litigation suggested that these experiences were by no means unique (Shapiro et al., 1989; Martin et al., 1991; Bark et al., 1997). Depression, anger and other nervous symptoms were common responses to litigation. Some doctors find their work less rewarding, at least for a time. In Martin et al.’s (1991) study of physicians who had been sued, anxiety, depression and traumatic responses were highest in the two years following litigation, but gradually reduced thereafter, though not to the level of physicians who had not been sued. In contrast, feelings of shame and doubt, though prominent at an early stage, did return to ordinary levels, particularly in those who had won their case. Older physicians however, seemed less affected and more able to put litigation into perspective, as a job hazard rather than an indictment of their ability.

Litigation can clearly be very unpleasant, and sometimes traumatic, but the impact oflitigation should not be overstated. We should remember though that in the last 20 years our understanding of the extent and causes of patient harm been transformed; a claim for compensation need not be seen as a shameful personal attack on the responsible doctor. Often, when the case is clear cut and the harm not severe, or at least not permanent, it may be little more than tedious. In most countries very few cases ever reach trial, almost all being settled by lawyers and risk managers, sometimes with little involvement of the clinical staff (whichissometimes welcome and sometimes not). Although some people will always complain, and a few unpleasant or deluded characters delight in litigation, very few injured patients sue; this is partly because, whatever the rights and wrongs of the case, it is a deeply wearing experience in which they constantly have to recall experiences they would much prefer to forget.

We should also just step back for a moment and reflect, from the perspective of both clinician and patient, why litigation hasto happen at all? When patients do sue it is for explanations, apologies, to bring about change in the system and, to a widely varying extent, for money (Vincent, Young and Phillips, 1994). For most of the deserving cases, all of these things could be provided by proactive healthcare organizations without litigation and in fact without the need for legislation or no fault compensation. This in turn would make life a great deal easier for the staff involved; when care had been sub-standard, they would know the patients and family were being looked after. When care had been satisfactory, and a case had to be defended, they would have the organization firmly on their side.

Strategies for coping with error, harm and their aftermath

Many of the doctors interviewed in these various studies had not discussed the mistakes or their emotional impact with colleagues. Shame, fears of humiliation, fear of punishment and all acted to deter open discussion and isolate people from their colleagues. When the case was discussed, it would be with close friends or colleagues whom they had come to trust overa long period. The doctors involved wanted the emotional support and professional reaffirmation, but their culture did not often permit such open discussions (Christensen, Levinson and Dunn, 1992; Newman, 1996).

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