Brian Goldman: Doctors make mistakes. Can we talk about that?

I think we have to do something about a piece of the culture
of medicine that has to change. And I think it starts
with one physician, and that’s me. And maybe I’ve been around long enough that I can afford to give away
some of my false prestige to be able to do that. Before I actually begin
the meat of my talk, let’s begin with a bit of baseball. Hey, why not? We’re near the end, we’re getting
close to the World Series. We all love baseball, don’t we? (Laughter) Baseball is filled
with some amazing statistics. And there’s hundreds of them. “Moneyball” is about to come out,
and it’s all about statistics and using statistics to build
a great baseball team. I’m going to focus on one stat that I hope a lot of you have heard of. It’s called batting average. So we talk about a 300,
a batter who bats 300. That means that ballplayer
batted safely, hit safely three times out of 10 at bats. That means hit the ball into the outfield, it dropped, it didn’t get caught, and whoever tried to throw it to first
base didn’t get there in time and the runner was safe. Three times out of 10. Do you know what they call a 300 hitter in Major League Baseball? Good, really good, maybe an all-star. Do you know what they call a 400 baseball hitter? That’s somebody who hit, by the way, four times safely out of every 10. Legendary — as in Ted Williams legendary — the last Major League Baseball player to hit over 400 during a regular season. Now let’s take this back
into my world of medicine where I’m a lot more comfortable, or perhaps a bit less comfortable after what I’m going to talk to you about. Suppose you have appendicitis and you’re referred to a surgeon who’s batting 400 on appendectomies. (Laughter) Somehow this isn’t working out, is it? Now suppose you live in a certain part
of a certain remote place and you have a loved one who has blockages in two coronary arteries and your family doctor refers
that loved one to a cardiologist who’s batting 200 on angioplasties. But, but, you know what? She’s doing a lot better this year.
She’s on the comeback trail. And she’s hitting a 257. Somehow this isn’t working. But I’m going to ask you a question. What do you think a batting average for a cardiac surgeon
or a nurse practitioner or an orthopedic surgeon, an OBGYN, a paramedic is supposed to be? 1,000, very good. Now truth of the matter is, nobody knows in all of medicine what a good surgeon or physician or paramedic is supposed to bat. What we do though is we send
each one of them, including myself, out into the world with the admonition, be perfect. Never ever, ever make a mistake, but you worry about the details,
about how that’s going to happen. And that was the message that I absorbed when I was in med school. I was an obsessive compulsive student. In high school, a classmate once said that Brian Goldman would study
for a blood test. (Laughter) And so I did. And I studied in my little garret at the nurses’ residence
at Toronto General Hospital, not far from here. And I memorized everything. I memorized in my anatomy class the origins and exertions of every muscle, every branch of every artery
that came off the aorta, differential diagnoses obscure and common. I even knew the differential diagnosis in how to classify renal tubular acidosis. And all the while, I was amassing more and more knowledge. And I did well, I graduated with honors, cum laude. And I came out of medical school with the impression that if I memorized everything
and knew everything, or as much as possible, as close to everything as possible, that it would immunize me
against making mistakes. And it worked for a while, 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 a cardiology rotation. And it was my job, when the emergency staff called
for a cardiology consult, to see that patient in emerg. 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. This is a condition
in which the heart fails, and instead of being able
to pump all the blood forward, some of the blood backs up into the lung,
the lungs fill up with blood, and that’s why you have
shortness of breath. And that wasn’t a difficult
diagnosis to make. I made it 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 access 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. Actually, I made two more mistakes. I sent her home without speaking to my attending. I didn’t pick up the phone and do
what I was supposed to do, which was call my attending
and run the story by him so he would have a chance
to see her for himself. And he knew her, he would have been able to furnish
additional information about her. Maybe I did it for a good reason. 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. The second mistake that I made was worse. 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. 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 the emerg. staff
pulled out all the stops. They gave her medications
to raise her blood pressure. They put her on a ventilator. And 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 at 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. Over the next few weeks, I beat myself up and I experienced for the first time the unhealthy shame that exists in our culture of medicine — where I felt alone, isolated, not feeling the healthy kind
of shame that you feel, because you can’t talk
about it with your colleagues. You know that healthy kind, when you betray a secret that a best
friend made you promise never to reveal and then you get busted and then your best friend confronts you and you have terrible discussions, but at the end of it
all that sick feeling guides you and you say, I’ll never
make that mistake again. And you make amends and you
never make that mistake again. That’s the kind of shame
that is a teacher. The unhealthy shame I’m talking about is the one that makes you so sick inside. It’s the one that says, not that what you did was bad, but that you are bad. And it was what I was feeling. And it wasn’t because of my attending;
he was a doll. He talked to the family, and I’m quite
sure that he smoothed things over and made sure that I didn’t get sued. And I kept asking myself these questions. Why didn’t I ask my attending?
Why did I send her home? And then at my worst moments: Why did I make such a stupid mistake? Why did I go into medicine? Slowly but surely, it lifted. I began to feel a bit better. And on a cloudy day, there was a crack in the clouds
and the sun started to come out and I wondered, maybe I could feel better again. And I made myself a bargain that if only I redouble
my efforts to be perfect and never make another mistake again, please make the voices stop. And they did. And I went back to work. And then it happened again. Two years later I was an attending
in the emergency department at a community hospital
just north of Toronto, and I saw a 25 year-old
man with a sore throat. It was busy, I was in a bit of a hurry. He kept pointing here. I looked at his throat,
it was a little bit pink. And I gave him a prescription
for penicillin and sent him on his way. And even as he was walking out the door, he was still sort
of pointing to his throat. And two days later I came to do
my next emergency shift, and that’s when my chief asked
to speak to me quietly in her office. And she said the three words: Do you remember? “Do you remember that patient
you saw with the sore throat?” Well it turns out, he didn’t
have a strep throat. He had a potentially
life-threatening condition called epiglottitis. You can Google it, but it’s an infection, not
of the throat, but of the upper airway, and it can actually cause
the airway to close. And fortunately he didn’t die. He was placed on intravenous antibiotics and he recovered after a few days. And I went through the same period
of shame and recriminations and felt cleansed and went back to work, until it happened again
and again and again. Twice in one emergency shift,
I missed appendicitis. Now that takes some doing, especially when you work in a hospital that at the time saw
but 14 people a night. Now in both cases, I didn’t send them home and I don’t think there
was any gap in their care. One I thought had a kidney stone. I ordered a kidney X-ray. When
it turned out to be normal, my colleague who was doing
a reassessment of the patient noticed some tenderness in the right
lower quadrant and called the surgeons. The other one had a lot of diarrhea. I ordered some fluids to rehydrate him and asked my colleague to reassess him. And he did and when he noticed some tenderness in the right
lower quadrant, called the surgeons. In both cases, they had their operations
and they did okay. But each time, they were gnawing at me, eating at me. 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. (Laughter) Some of my doozies have
been in the last five years. Alone, ashamed and unsupported. Here’s the problem: 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? If I were to walk into a room — like right now, I have no
idea what you think of me. When was the last time
you heard somebody talk about failure after failure after failure? Oh yeah, you go to a cocktail party and you might hear
about some other doctor, but you’re not going to hear somebody talking about their own mistakes. If I were to walk into a room
filled with my colleages and ask for their support right now and start to tell what I’ve just
told you right now, I probably wouldn’t get
through two of those stories before they would start
to get really uncomfortable, somebody would crack a joke, they’d change the subject
and we would move on. And in fact, if I knew
and my colleagues knew that one of my orthopedic colleagues
took off the wrong leg in my hospital, believe me, I’d have trouble making eye contact with that person. That’s the system that we have. It’s a complete denial of mistakes. It’s a system in which there are two kinds
of physicians — those who make mistakes and those who don’t, those who can’t handle sleep
deprivation and those who can, those who have lousy outcomes and those who have great outcomes. And it’s almost
like an ideological reaction, like the antibodies begin
to attack that person. And we have this idea that if we drive the people
who make mistakes out of medicine, what will we be left
with, but a safe system. But there are two problems with that. In my 20 years or so of medical broadcasting and journalism, I’ve made a personal study of medical
malpractice and medical errors to learn everything I can, from one of the first articles
I wrote for the Toronto Star to my show “White Coat, Black Art.” And what I’ve learned is that errors are absolutely ubiquitous. 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. And here’s the thing. In a hospital system where medical knowledge is doubling every two or three years,
we can’t keep up with it. Sleep deprivation is absolutely pervasive. We can’t get rid of it. We have our cognitive biases, so that I can take a perfect history
on a patient with chest pain. Now take the same patient with chest pain, make them moist and garrulous and put a little bit
of alcohol on their breath, and suddenly my history
is laced with contempt. I don’t take the same history. I’m not a robot; I don’t do things the same way each time. And my patients aren’t cars; they don’t tell me their symptoms
in the same way each time. Given all of that,
mistakes are inevitable. So if you take the system,
as I was taught, and weed out all the error-prone
health professionals, well there won’t be anybody left. And you know that business about people not wanting to talk about their worst cases? On my show, on “White Coat, Black Art,” I made it a habit of saying,
“Here’s my worst mistake,” I would say to everybody from paramedics to the chief
of cardiac surgery, “Here’s my worst mistake,”
blah, blah, blah, blah, blah, “What about yours?” and I would point
the microphone towards them. And their pupils would dilate, they would recoil, then they would look down and swallow hard and start to tell me their stories. They want to tell their stories.
They want to share their stories. They want to be able to say, “Look, don’t make the same mistake I did.” 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. She shares her experience with others. She’s supportive when other
people talk about their mistakes. And she points out other
people’s mistakes, not in a gotcha way, but in a loving, supportive way so that everybody can benefit. 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. So the system is evolving to create backups that make it easier
to detect those mistakes that humans inevitably make 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. My name is Brian Goldman. I am a redefined physician. I’m human. I make mistakes. I’m sorry about that, but I strive to learn one thing that I can pass on to other people. I still don’t know what you think of me, but I can live with that. And let me close
with three words of my own: I do remember. (Applause)

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