By Charles A. Pilcher MD FACEP
September, 2017
I need your stories.
Let me explain. Over the past 3 years I have occasionally written – some would say ranted – about the sorry state we in healthcare find ourselves when it comes to learning from our mistakes. I’ve written about patients who sue physicians to “teach them a lesson.” I’ve written about patients who believe that a lawsuit is the only way to assure that what happened to them won’t happen to anyone else. I’ve written about doctors (many of whom insured by the same med mal carrier) who commit a medical error by making the same stupid mistake a colleague made only months before. Put simply, no one ever told them what happened to their colleague, how common that mistake is and how easy it is to make.
It’s a sad myth that we in healthcare learn from our mistakes. The problem is that “we,” when we’re talking about mistakes we make, is a singular pronoun. The only person who learns from their mistake is the person who made it. If “I” make a mistake, hopefully I learn. Hopefully I remember. And hopefully I will never make the same mistake ever again.
But “we” learning? It rarely happens. Sometimes other physicians in the same practice group don’t ever discover that a partner is being sued. And the chances of the staff of a hospital knowing of the lawsuit? Very slim. How about other physicians in the same specialty across the state? Next to zero. Only those who made the mistake, who were victims of the mistake, litigated the mistake, defended the mistake or insured for the mistake learn anything.
Unless the mistake was made by an anesthesiologist.
Anesthesiology has been the poster child for learning from mistakes for the past 40 years. No learning opportunity is ever lost in that specialty because decades ago its leaders committed to a program of absolute safety. As a result, in recent years one rarely hears of patients being injured or dying as the result of a mistake by an anesthesiologist. Yes, it happens, but far less often than one would expect for such a high risk specialty. And as a side benefit of the specialty’s safety program, malpractice premiums have decreased .
But what about the rest of healthcare? Why can’t other specialties do as well?
Fear.
Physicians and hospitals may argue with me when I say this, but based on my 35+ years working with attorneys, insurers, plaintiffs and defendants as a medical expert, I see a system that is more concerned about anonymity, non-disclosure, privacy, embarrassment, ridicule and protection of reputation than it is about patient safety.
Mistakes are for learning, not repeating. Our mistakes are the low-hanging fruit of the whole patient safety movement. Our worst mistakes become lawsuits. Our least defensible lawsuits become settlements. Our settlements become confidential; if anyone in healthcare ever hears what happened, it is likely either a brief summary hidden in an otherwise boring “white paper” or an aggregation of similar cases appearing in a report with a title like “The most common causes of medical error.” BOR-ING!
We don’t learn from facts. We learn from stories. Dr. Jennifer Aaker, Professor of Marketing at the Stanford Graduate School of Business, teaches that “stories are 22 times more memorable than facts.” Perhaps you read that and think (as I did) “Wow! That makes sense! But 22 times!” Looking back on my own career, I certainly remember stories more than I do facts. Maybe that’s why the Bible is a book of stories more than it is a book of facts. We need to do a better job of telling our med mal stories and learning from them.
And thus the title of this “Perspective.” Lawsuits aren’t enough. We need to capture the learnings from those lawsuits. Attorneys, both plaintiff and defense, working with their clients and med mal insurers, must find a way to tell these stories. We don’t have to name names. We don’t have to disclose the amounts of settlements. But we do have to tell the story. We owe it to injured patients, so that their injury not be in vain. We owe it to future physicians, who can learn from the mistake of a colleague. We owe it to the house of medicine to do whatever it takes to achieve absolute patient safety. Anesthesiology is approaching that goal. Aviation has nearly achieved it. We can too.
For the past 3 years I have shared med mal “stories” with now 1600+ colleagues around the world in a monthly newsletter called Medical Malpractice Insights – Learning from Lawsuits. Readers tell me that the stories are helping them to think more clearly, document more thoroughly and practice more safely.
You – both defense and plaintiff attorneys – possess the “stories.” Please share them with me at medmalinsights@gmail.com. They will be anonymized, settlement amounts redacted and the stories used for teaching purposes only. Together we can improve patient safety.