On Mistakes

Everybody makes them. For us, though, they’re a matter of life and death.

Kevin F. D’Mello. Photograph by Colin Lenton

I am a physician, and I make mistakes. It’s scary. What’s scarier at this moment, though, is what you might think of me for my confession. I probably don’t make mistakes more often than any other physician, but I feel like a terrible doctor with each error. The shame is isolating. My head ruminates over every poor decision, big or small. My stomach sinks with a sensation somewhere between nausea and pain. And my heart breaks from the clash of my desire to help people and my natural human tendency to make mistakes while doing so. The truth is that medical errors are inevitable. It took the medical community a long time to come to that realization. For most of the 20th century, physicians were seen as infallible practitioners of a noble craft. To make a mistake was to be labeled a “bad doctor.” Added to that shame was the fear of litigation. The consequence of this mentality was a ubiquitous unofficial policy of hiding medical errors — of denying that they happen and avoiding responsibility for them.

Eventually, the repercussions of this dysfunctional medical culture became evident. In 1999, the Institute of Medicine published “To Err Is Human,” a summary report on medical errors estimating that they were responsible for about 100,000 patient deaths per year. A more recent evaluation by Johns Hopkins University has an even higher estimate of 250,000 patient deaths per year.

Over the past two decades, with the realization that medical errors are inevitable, there has been a revolution in medicine. There is a focus on improving the practice of medicine by building transparency into our health-care delivery systems, so flaws in patient care can be identified and addressed. Just as an alcoholic must be honest with herself about her addiction in order to better her life, those in the medical profession have come to realize that transparency is the path to improving health care.

And in the process of individuals trying to be better physicians — even, perhaps, in the midst of the devastation of making a medical error — honest self-evaluation is vital. In a speech in 1889, William Osler, considered by some to be the “Father of Modern Medicine,” stated that the most important mental quality of a physician is equanimity. This state of mind accepts that there will be successes as well as failures. The expectation of failure allows us to prepare to improve upon our deficiencies. This mind-set helps us battle the shame that comes with making errors and view each mistake as an opportunity to become a better physician.

For both systems of care and the physicians working within them, this process of quality improvement in medicine is long and arduous. What, then, motivates us to engage in it? According to Avedis Donabedian, a 20th-century pioneer in quality improvement in medicine, the answer was simple: “The secret of quality,” he said, “is love.” Improving quality in health care involves love for one’s patients, one’s colleagues and one’s hospital. “If you have love,” Donabedian continued, “you can then work backward to monitor and improve the system.”

Ultimately, my personal struggle to be a better physician requires the ability to persevere through the agonizing guilt of inevitable failures and an altruistic drive to help others. My honesty about my mistakes helps me improve as a physician and also helps others learn from my mistakes. I’ll continue to make mistakes, but I strive to never make the same mistake twice. To be a great physician, I must have a head ruled by equanimity and a heart ruled by love.

Kevin F. D’Mello is an academic hospitalist at Hahnemann University Hospital and the director of quality improvement and patient safety in the Department of Internal Medicine at Drexel University College of Medicine.

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Published as “The Stories They Tell … ” in the May 2018 issue of Philadelphia magazine.