EP170: The Human Side of Medicine: Confronting Error and Discordance

Embracing Imperfection: Navigating Error and Diagnostic Discordance in Medicine

In this episode of The Girl Doc Survival Guide, Christine reflects on key insights from various experts across multiple episodes that discuss the inevitability of errors and diagnostic discordance in medical practice. Featuring quotes from Dr. Philip McKee, Dr. Ale Gru, Dr. Rose Elenitsas, Dr. Gauri Agarwal, and others, the transcript emphasizes the human aspect of medicine where perfection is impossible yet striving to mitigate errors and understanding diagnostic differences is crucial. The discussion extends to emotional intelligence, self-compassion, and the importance of creating a supportive environment where physicians can safely process and confront their mistakes, ensuring continuous improvement and better patient care.

00:00 Introduction and Purpose

00:10 Understanding Diagnostic Error

00:40 Expert Opinions on Error

02:12 The Concept of 'Good Enough'

03:49 Diagnostic Discordance

05:14 Facing Failure and Self-Compassion

06:07 Changing Behavior and Resilience

07:31 Emotional Intelligence in Medicine

12:43 Confronting and Processing Error

15:24 Conclusion and Call to Action

Transcript

Christine Ko: [00:00:00] Welcome back to the Girl Doc Survival Guide. It's been a while since I've done a compilation of thoughts from different episodes, and I wanted to do so again to reflect on ideas that are helpful to me. One of the major things that concerns me in daily practice is error. My own errors as well as diagnostic discordance, the concept that I didn't truly make an error, but someone else's opinion may differ from mine in a given diagnosis. And, that difference in opinion, that diagnostic discordance, can actually affect what happens to the patient. Not always, but sometimes. We've been talking about diagnostic error and diagnostic discordance on this podcast, and here are some key points.

First off, Dr. Philip McKee exhorts in episode 124:

Phillip McKee: A bit of advice to people: if you're going to do something, give 100 percent of yourself. Don't give anything less.

Christine Ko: Definitely when I give 100% to something, it does not by any [00:01:00] means preclude error and certainly not diagnostic discordance. Instead, the more I do something like dermpath, the possibility of an error actually increases. Dr. Ale Gru says in episode 125:

Ale Gru: Error is unavoidable in what we do. No matter what we do, you have to face and accept the fact that you're gonna make errors no matter how careful, conscientious, or good you are. I think it's important to accept the fact first that you're going to make mistakes. You have to accept that no matter how best you think you're trying, there's still mistakes going to be made.

Christine Ko: Similarly, Dr. Rose Elenitsas says in episode 127:

Rose Elenitsas: Everybody makes errors, right? We're human. We shouldn't think that physicians are infallible, even though sometimes I think society expects that. But the truth is we [00:02:00] can make mistakes.

Christine Ko: And Dr. Gauri Agarwal says in episode 126:

Gauri Agarwal: Perfection is not the reality, right? We make mistakes. We say things wrong. We do things wrong. We're not always perfect.

Christine Ko: And Dr. Caroline Elton says in episode 139:

Caroline Elton: Doctors are human. Humans are deeply relational animals. We need to feel safe. We need to feel that we're held in mind by somebody who can look after us. There's a very famous psychoanalyst of the forties and fifties. He was a pediatrician and psychoanalyst, Donald Winnicott, British, who talked about mothers being good enough rather than perfect. And he talked about that actually in terms of not only the mother trying to be perfect, but also in terms of the child needing to learn over time. We're not talking about in early infancy, but gradually over development, the child developing a more [00:03:00] realistic idea of their parents and also learning to manage those disappointments because as they go from the sanctuary of the home, when they go out to nursery, where they're going to be one of many, and into a classroom later on, it's important for both partners to be good enough, not perfect. Since Winnicott talked about the good enough mother, there is, if you look in the medical education literature, there are papers about the good enough doctor. And I think it needs to be talked about more. That's not saying doctors should be sloppy. Just as there are things that mothers can do that are neglect. It's not an excuse for dangerous parenting or dangerous medicine. But it is an excuse for an understanding. Perfection is humanly impossible.

Christine Ko: And again, slightly different than true error, there is diagnostic discordance where two opinions differ. Dr. Greg Hosler has addressed this and says in episode [00:04:00] 129.

Greg Hosler: The premise was to shine a new light on the concept of diagnostic discordance. There was about 24 percent of cases where there was some level of discordance. About 7 percent of these cases fell into this category where there was a significant impact on the path those patients would have gone down management wise, had these been real cases and real follow up. It's a little scary, right? So of that 7%, roughly half of those would be over treated, and the other half of that, the other three and a half percent significantly undertreated.

Christine Ko: Dr. Prieto summarizes diagnostic discordance nicely by saying in episode 145:

Victor Prieto: If we weren't infallible, there wouldn't be any second opinions. One thing that we tend to forget is that there is nothing that is absolutely 100 percent correct or wrong.

Christine Ko: And Dr. Fung emphasizes that lifelong learning is necessary in episode 154:

Maxwell Fung: Errors and things you [00:05:00] wished you had known earlier are just individual examples that speak to the general principle that you can never know everything. You're going to have to continue that lifelong learning, but some junctures are more painful than others.

Christine Ko: All of this error as well as discordance, particularly discordance with someone more senior or a mentor, or a well-known expert nationally or internationally, can make me feel that I have failed. Dr. Yemi Sokumbi says in episode 123:

Yemi Sokumbi: What most of us can relate to is the fact that failure is not a friend to most folks in medicine. We are uncomfortable with failure. We have a significant fear of failure. So that burden does not give you permission to recover. You feel it's the end, and that the failure will define you. Self compassion is key. It requires that you have grace for yourself, that you don't shame.

Christine Ko: Dr. Kathy Stepien agrees and in episode 156, she suggests a key is

Kathy Stepien: just [00:06:00] allowing ourselves to be human and have human needs and developing skills to make sure that those needs are met.

Christine Ko: A major barrier, is that it is difficult to change behavior. Dr. Vini Arora says in episode 152: 

Vineet Arora: When you're changing human behavior, it can be hard. And, you know, when we're talking about doctors, right? These are people who have gone through pretty rigorous training to get to where they are. They've sort of adapted with these really incredible survival skills. That's why I think the word resilience sometimes falls flat. These are resilient people.

Christine Ko: And I agree. I think physicians as a group are very resilient, and yet we have not necessarily been taught how to deal with error. I like how Dr. Rose Elenitsas emphasizes what an initial reaction to an error generally is in episode 127:

Rose Elenitsas: The first time you see you have an error, you panic, right? We're physicians. We don't want to make errors. We want to help patients.

Christine Ko: The problem with that initial feeling of panic, [00:07:00] or really maybe any feeling, is what Dr. Jessi Gold says in episode 135.

Jessi Gold: There's also an ethos of doctors don't have their own feelings. Doctors shouldn't be affected by their work. Doctors should be stoic. It matters what everyone else might think about you, and the culture tells us, be perfect. Don't make mistakes. Our environment tells us, compete and win and don't have a weakness. Our environment tells us, doctors don't have emotions; even if you do, probably don't talk about it. And so we don't talk about it.

Christine Ko: So it's important to remember the work of emotions researchers and psychologists like Dr. Dennis Proffitt who says in episode 130:

Dennis Proffitt: Affect and emotions are interpretations of what's going on the inside and what's going on the outside. Emotions are stories we tell ourselves about how we feel and why we feel the way we feel. They're not isolated atoms of [00:08:00] experience that occur because our internal state and our interoception is of a particular sort.

Christine Ko: And Jesse Gold puts it simply as, in episode 1 35, that

Jessi Gold: my new perspective is it's not my fault if all of the stuff I'm doing affects me; it's logical that all of the stuff I'm doing affects me. I need to not blame myself for that when I'm approaching stuff. I've worked on just that perspective change and in doing so some self compassion.

Christine Ko: I believe that emotions are useful, that I and other physicians definitely do have emotions, and it is helpful to talk about our emotions, error, and how to confront error. And in episode 141, Dr. Tamara Beckford suggests that fear is an emotion that tends to limit us.

Tamara Beckford: Fear definitely keeps us back as physicians. I really think we at times limit ourselves, but we have a lot more skills [00:09:00] than we give ourselves credit for in medicine.

Christine Ko: And Dr. Artur Zembowicz says in episode 142:

Artur Zembowicz: Learn when you get burnt on your emotions or something hurts. A lot of stuff is preparation.

Christine Ko: Important to using our full set of skills, is feeling safe in being vulnerable as Dr. Dara Kass says in episode 137:

Dara Kass: We're from a culture of not just service, but the system is bigger than us. Our voices don't entirely matter. And again, it isn't to say that you need to put demands on your employer to meet your needs at the expense of clinical coverage or the environment that you're working in, but it has to be a partnership so that people have a survivable life.

I personally feel like being comfortably vulnerable is important for my survival. When you're going through something hard, if you hold that all in, you wind up often resenting the fact that the world is not being kind to you when you need help. And it's not because you are trying to be [00:10:00] resentful. It's just that people can't read your mind. Now, I am not a huge fan always of everyone being forced to share their trauma and their stories all the time. But if you're the kind of person that knows that you're going to need a little more space, because you're going to have feelings, it's okay to be open early and let everybody be there for you. You'd be surprised how many people would be there for you if you gave them a chance. It's okay to be open at the beginning of a journey. And then if, and when there's a hard moment, you'll find more people will be there for you organically.

I don't need to be a hero. I don't act like I don't need help. I try to check myself regularly to say, do you need help now? Is there something that you need? Is there something you should be doing differently? Are you actually happy with what's happening in your life? And if not, do you need somebody to help you with it? Is there something that you need?

Christine Ko: Part of being vulnerable is being okay with ambiguity as Dr. Danielle Ofri says in episode 140.

Danielle Ofri: When we find ourselves falling short, we are traumatized and so ashamed of what we've [00:11:00] done. People who go into medicine, into health care, by and large are going because they care about their patients. People genuinely want to help their patients. And so when we recognize that we have harmed them or done poor duty to them, we are crushed about that.

I think there's an important distinction between guilt and shame. Guilt is about the action that happened and shame is about ourselves. Guilt prods us to make amends, but shame makes you want to hide. And those are two very different things. I think doctors in particular have difficulty distinguishing between guilt and shame. You know, being aware of that distinction requires someone to model that for you. And so when your senior resident or you're attending or someone higher than you talks about how they experienced an error, what it felt like, it's really important to see that. It's really an important thing to recognize that you can make an error, but you are not the error. Those are two different things. 99 percent of the people who make an error, it's either a slip of judgment, being [00:12:00] overworked, or genuine lack of knowledge. It's something that wasn't a deliberate thing. Not malicious.

When you care, that is when you have a capacity to feel shame. And of course, why do doctors have the highest rates of suicide and drug use and substance use compared to other common professions? I think part of it is because we take our charge so seriously. We genuinely care. We take an oath, and it defines who you are. It's who you are, not just what you do. And ,so when you fall short, it's cataclysmic, it's like the mirror just shatters and the person you thought you were is not the case any longer. Or so we think.

Being honest about our emotions, it's not so easy. We talk about, Oh, just be open, be honest, but it's really not that easy. We have a lot of pride in our work, and reputation means a lot.

Christine Ko: And ultimately, I think all of this mental work that we do in processing error and discordance will help us create a different story in our heads of how to handle error and discordance so that we can be better physicians and humans. As Dr. Rose Elenitsas says in [00:13:00] episode 127: 

Rose Elenitsas: After the panic sets in, I think, first, you try to correct it. If you can, try to correct it. The next thing you have to do after you overcome this feeling of, I screwed up. You have to analyze it. Like, why did it happen? You definitely need the analytical part. And then once you do that, it's good to put processes in place to maybe help prevent errors. Not always possible but moving forward, you want to try to put processes in place to reduce the risk of error.

Christine Ko: Key to properly processing and confronting error is feeling safe, as Dr. Tessa Davis says in episode 168: 

Tessa Davis: You need to feel safe. When something goes wrong or when you're feeling stressed about something. Maybe you've done something wrong, maybe someone else has. You have someone who's got your back and your team. That honestly is the thing that makes it great. Otherwise you're floundering on your own. Having someone there who [00:14:00] understands what's going on in the team that you can talk to makes a massive difference. When I was a trainee and made mistakes, it was horrible. It's a horrible feeling, and you feel so vulnerable.

Christine Ko: Robin Stern brings the conversation back to emotional intelligence in episode 158 saying,

Robin Stern: Being emotionally intelligent very simply means being smart about your emotions. Knowing how to use your feelings to inform your thinking and knowing how to use your thinking to inform your feelings.

Christine Ko: Emotional intelligence is important because the culture of medicine generally teaches physicians to suppress emotion rather than use emotions. Dr. Robert Smith says in episode 165.

Robert Smith: Most of us are taught to suppress emotions in the professions.

Christine Ko: Emotional intelligence will help us individually, but also in our relationships. As Dr. Wendy Stead says in episode 169,

Wendy Stead: Being able to understand and relate to and support your colleagues is one of the most important parts of the job. The [00:15:00] healing you get from your colleagues is one of those things that really, I think on the days that are terrible, and it feels you haven't figured out the diagnosis or haven't been able to help your patient, or you've made a mistake. They're the people that are able to keep you going.

Christine Ko: Feeling and thinking are complimentary and synergistic, and we should use both to deal with error, diagnostic discordance, and continuous improvement. Thanks for listening in. Please follow rate and share if you want to support this podcast! Thank you!