TED Radio Hour
8:49 am
Fri May 10, 2013

What Can Doctors Learn By Admitting Their Mistakes?

Originally published on Fri August 23, 2013 8:36 am

Part 1 of TED Radio Hour episode Making Mistakes.

About Brian Goldman's TEDTalk

Every doctor makes mistakes. But, says physician Brian Goldman, medicine's culture of denial keeps doctors from talking about and learning from those mistakes. Goldman calls on doctors to start talking about being wrong.

About Brian Goldman

Brian Goldman is an emergency room physician who has worked at Mount Sinai Hospital in downtown Toronto for more than 20 years. He's also a prominent medical journalist and the host of CBC Radio's White Coat, Black Art. In Dr. Goldman's first book, The Night Shift, published in 2010, he shares his experiences of working through the witching hours at Mount Sinai, as well as at the other hospitals where he has spent his long career.

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Transcript

GUY RAZ, HOST:

It's the TED Radio Hour from NPR. I'm Guy Raz. Back in the late 1960s, when Brian Goldman went to medical school ...

BRIAN GOLDMAN: Yeah.

RAZ: ... he was a perfect student, perfect.

GOLDMAN: The slang term they used back then was a browner.

RAZ: That's Brian.

GOLDMAN: I'm a staff emergency physician at Mount Sinai Hospital in Toronto, Canada.

RAZ: That's Toronto.

GOLDMAN: You know, about 30 years ago it was "Tranna" (ph). 'Cause I used to say Toronto and Canadians would correct me.

RAZ: Then say "Tranna" (ph).

GOLDMAN: I know, Toronto. There's no 'T'...

RAZ: Anyway, Brian went to medical school in that city and he described it in his TED Talk...

(SOUNDBITE OF BRIAN GOLDMAN TED TALK)

GOLDMAN: I was an obsessive compulsive student. In high school, a classmate once said that Brian Goldman would study for a blood test.

(LAUGHTER)

GOLDMAN: And so I did, and I memorized everything. I memorized, in my anatomy class, the origins and insertions of every muscle, every branch of every artery that came off the aorta, and all the while, I was amassing more and more knowledge and I did well. I graduated with honors, cum laude.

GOLDMAN: I wanted to be the smartest physician I could be so that I wouldn't be like those other physicians who were less competent, who didn't learn as much as I did, and — it's interesting, I, you know, when I talk to medical students today, many of them, you know, have that look in their eyes that, you know, they're pristine, they've never made a mistake, and they never will, and, you know, and of course, until it happens.

RAZ: Today on the program, mistakes. They happen. We're going to talk with TED speakers about why they have to happen and, when they do happen, how we deal with being wrong. The way doctors deal with mistakes, well, that's what Brian Goldman is really interested in, because doctors don't just hate making mistakes, they also hate talking about them. So, aside from his day job as an ER doc ...

(SOUNDBITE OF "WHITE COAT BLACK ART")

GOLDMAN: This week, on White Coat Black Art ...

GOLDMAN: I'm the host of White Coat Black Art, a show about the culture of modern medicine on CBC Radio One.

RAZ: As he described in his TED Talk, over the past few years, Brian Goldman's used his radio show to focus on mistakes. And he'd bring doctors onto the show and he'd ask them one question. He'd ask, what's the worst mistake they ever made?

(SOUNDBITE OF BRIAN GOLDMAN TED TALK)

GOLDMAN: And I would point the microphone towards them and their pupils would dilate and they would recoil. Then, they would look down and swallow hard and start to tell me their stories ...

(SOUNDBITE OF "WHITE COAT BLACK ART")

UNIDENTIFIED SPEAKER 1: Well, unfortunately, I was involved in a medication error, in which a resident I was supervising, and hence, I was responsible, administered a drug which caused a very serious side effect.

UNIDENTIFIED SPEAKER 2: I missed a subarachnoid, a brain bleed, and I was really devastated. I actually went home and dissolved into a puddle of tears. I was really, really upset. Now, thank God, the outcome was fine ...

RAZ: There was another story that somebody told you at a town hall.

GOLDMAN: Yeah, that was the CEO of a hospital.

(SOUNDBITE OF "WHITE COAT BLACK ART")

GOLDMAN: Do you have a personal story?

UNIDENTIFIED SPEAKER 3: I do and ...

GOLDMAN: A very respected guy, who told the story of the time that he missed a fracture ...

(SOUNDBITE OF "WHITE COAT BLACK ART")

UNIDENTIFIED SPEAKER 3: ... It was a missed fracture in a child. And it was a circumstance ...

GOLDMAN: And oh, how terrible it was that that child had to suffer...

(SOUNDBITE OF "WHITE COAT BLACK ART")

UNIDENTIFIED SPEAKER 3: ... Regrettably, unnecessary pain for an extra day ...

GOLDMAN: Until the fracture was discovered and could be properly treated, presumably with a cast. And I thought to myself, if that's the worst mistake you've ever made, boy, you've had a really soft career.

RAZ: So, yeah doctors don't really want to talk about this sort of thing. But, in his TED Talk, Brian Goldman did, and here's where the story really starts. He was a few years out of medical school where, remember, he was an "A" student. No slip ups, no shortcomings, no mistakes.

(SOUNDBITE OF BRIAN GOLDMAN TED TALK)

GOLDMAN: Until I met Mrs. Drucker. I was a resident at a teaching hospital here in Toronto, when Mrs. Drucker was brought to the emergency department of the hospital where I was working. At the time, I was assigned to the cardiology service on the cardiology rotation, and it was my job when the emergency staff called for a cardiology consult, to see that patient in "emerge" (ph) and to report back to my attending. And I saw Mrs. Drucker, and she was breathless and when I listened to her she was making a wheezy sound. And when I listened to her chest with a stethoscope, I could hear crackly sounds on both sides that told me that she was in congestive heart failure. And I set to work treating her. I gave her aspirin, I gave her medications to relieve the strain on her heart, I gave her medications that we call diuretics, water pills, to get her to pee out the excess fluid, and over the course of the next hour and a half or two, she started to feel better, and I felt really good. And that's when I made my first mistake. I sent her home. Maybe I didn't want to be a high maintenance resident. Maybe I wanted to be so successful and so able to take responsibility that I would do so and I would be able to take care of my attending's patients without even having to contact him. In sending her home, I disregarded a little voice, deep down inside, that was trying to tell me, Goldman, not a good idea, don't do this. In fact, so lacking in confidence was I that I actually asked the nurse who was looking after Mrs. Drucker, do you think it's okay if she goes home? And the nurse thought about it and said, very matter-of-factly, yeah, I think she'll do okay. I can remember that like it was yesterday. And so I signed the discharge papers and an ambulance came; paramedics came to take her home and I went back to my work on the wards.

All the rest of that day, that afternoon I had this kind of gnawing feeling inside my stomach. But I carried on with my work, and at the end of the day, I packed up to leave the hospital, and walked to the parking lot to take my car and drive home, when I did something that I don't usually do. I walked through the emergency department on my way home and it was there that another nurse, not the nurse who was looking after Mrs. Drucker before, but another nurse said three words to me that are the three words that most emergency physicians I know dread. Others in medicine dread them as well, but there's something particular about emergency medicine because we see patients so fleetingly. The three words are, do you remember. Do you remember that patient you sent home, the other nurse asked matter-of-factly. Well, she's back, in just that tone of voice. Well, she was back all right. She was back and near death. About an hour after she had arrived home after I'd sent her home, she collapsed, and her family called 911 and the paramedics brought her back to the emergency department, where she had a blood pressure of 50 which is in severe shock. And she was barely breathing and she was blue. And they gave her medications to raise her blood pressure, they put her on a ventilator. And, you know, I was shocked and shaken to the core and I went through this roller coaster because, after they stabilized her, she went to the intensive care unit, and I hoped against hope that she would recover. And, over the next two or three days, it was clear that she was never going to wake up. She had irreversible brain damage. And the family gathered and over the course of the next eight or nine days, they resigned themselves to what was happening and about the nine day mark they let her go. Mrs. Drucker. A wife, a mother, and a grandmother. They say you never forget the names of those who die, and that was my first time to be acquainted with that.

RAZ: What did you tell her family? I mean, did you speak with them?

GOLDMAN: No, I didn't, and I'm sorry about that. It was a different time and the cardiologist was incredibly supportive.

RAZ: This was the attending physician who knew the family.

GOLDMAN: Yeah. His first reaction was to have a pained look on his face, but he spoke to the family and I gather they were very understanding.

RAZ: You say you'll never forget her name?

GOLDMAN: Yes.

RAZ: Mrs. Drucker.

GOLDMAN: Well, that's not her name, of course. But, no, I could give you her name off line, but that would be violating confidentiality. And, yes, no, I do remember her name.

RAZ: How long did it take you before you were prepared to talk about that mistake publicly?

GOLDMAN: Decades. It took me decades.

(SOUNDBITE OF BRIAN GOLDMAN TED TALK)

GOLDMAN: And I'd like to be able to say to you that my worst mistakes only happened in the first five years of practice, as many of my colleagues say, which is total B.S. Some of my doozies have been in the last five years. If I can't come clean and talk about my mistakes, if I can't find the still small voice that tells me what really happened, how can I share it with my colleagues? How can I teach them about what I did, so that they don't do the same thing? We live in a - we work in a system where errors happen every day, where one in 10 medications are either the wrong medication given in hospital or at the wrong dosage. Where hospital acquired infections are getting more and more numerous causing havoc and death. In this country, as many as 24,000 Canadians die of preventable medical errors. In the United States, the Institute of Medicine pegged it at 100,000. In both cases, these are gross underestimates because we really aren't ferreting out the problem as we should. You know that business about people not wanting to talk about their worst cases? What they need is an environment to be able to do that. What they need is a redefined medical culture, and it starts with one physician at a time. The redefined physician is human, knows she's human, accepts it, isn't proud of making mistakes, but strives to learn one thing from what happened that she can teach to somebody else. And she works in a culture of medicine that acknowledges that human beings run the system and when human beings run the system, they will make mistakes from time to time. And also fosters, in a loving, supportive way, places where everybody who is observing in the health care system can actually point out things that could be potential mistakes and is rewarded for doing so. And especially people like me, when we do make mistakes, we're rewarded for coming clean.

RAZ: You said in your talk we have this idea that if we drive the people who make mistakes out of medicine, will we be left with but a safe system, and a bad system?

GOLDMAN: We would be left with a system that has all the flaws that it has today and it would be a very lonely system because there would be very few people in it.

RAZ: And few people taking risks? I mean, risks that might save a life?

GOLDMAN: Now that's an interesting question. Most of the greatest successes in medicine come from failure. They don't get planned out and executed perfectly the first time. You know, there are wondrous treatments that exist today on the backs of people who died. And I can tell you, I've saved a lot of people off the backs of the people who paid for my mistakes.

RAZ: Brian Goldman. I'm Guy Raz. On the show today, making mistakes. Why we have to. Stay with us, it's the TED Radio Hour from NPR. Transcript provided by NPR, Copyright NPR.

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