I can number on the fingers of one hand the times I have been explicitly corrected during my medical career. There was the time I treated a patient all night for septic shock when in fact he had cardiogenic shock – the fluid nearly drowned him. There was the time I performed a lumbar puncture on an obese patient, and put the needle three inches away from the correct inter-spinous space. There was the time I failed to check a gentamicin level before the weekend, and came back on Monday to find the patient in renal failure. And during higher training, the course where my endoscopic technique was picked apart against a list of errors that the assessor held in his hand; he described three issues, but I glimpsed the piece of paper and the list was at least ten items long. There are others, some of which are littered across this blog.
Each time I felt embarrassed and defensive. I reacted by rationalizing. The reasons, or excuses, were various, and included the way I had been trained, the pressure of time, the load of patients, the need to balance speed and vigilance, and plain bad luck. But each time the fact that I had been criticised ate away at me. I was not used to it. Few of us are.
Medical students tend to come from the highest strata of achievement in secondary education, where their performance requires very little correction. Most float through training in the middle of the pack, periodically struggling to stay above the flood of knowledge, neither excelling nor failing. They require little in the way of feedback, just the odd nudge back on track. They become competent in the early years on the job and deliver medicine safely. Errors occur, many due to weaknesses in the system rather than personal fallibility. Corrections happen, but they are infrequent. And then, before you know it… they are practising more or less independently. They are part of a team, but they are essentially ‘complete’. They habituate to many forms of stress, but one that they are not accustomed to is ‘constructive’ feedback. When it comes, if it comes, it hurts.
How else do we improve once we have arrived at our natural ceiling of seniority? Continuing professional education is mandatory, we do it, and our knowledge is augmented, but weaknesses are not identified by passive absorption. Appraisal? Somewhat routine, and focused more on our perception of ourselves than feedback. Revalidation – mmmm… we’ll see. So how do our weaknesses get identified? The answer is, by our peers – those whom we work with day in and day out. The difficulty with this is that they are the last people who wish to engage us on our deficiencies. They are colleagues and friends.
Most error is self detected and self corrected. Although I listed only a handful of occasions where mistakes were fed back to me, there are hundreds (well, let’s say ‘tens’) of similarly significant mistakes which I identified myself, and reflected on. Nobody came to tell me that such and such happened because I missed a clinical clue or performed a procedure incorrectly – there is no ubiquitous or all-seeing observer to perform this function. The continuous feedback loop of self-improvement requires attention to consequence, and the ability to accept that something bad has happened because of what you did or omitted to do. Without a willingness to seek the consequences of our decisions we will blunder on regardless. However, a safe culture cannot be expected to rely solely on such of subjective system.
Receiving feedback as a junior doctor in training is hard enough, but it is standard and expected. You rely on it. The discomfort that comes with receiving negative feedback from a colleague of equal seniority, at consultant or GP level, is even more acute. The same rationalisations occur, recourse to the same ‘excuses’ – the pressures, the pace, the reaction to diffuse responsibility that appears to have unjustly landed on your head just because your name was over the patient’s bed. So much for receiving; how about giving? It’s even worse. But becoming comfortable with discomfort seems an absolute requirement for a safe medical culture. It is easily described, but not so easily undertaken.
Soon after becoming a consultant I took on the task of reviewing the notes of patients who had suffered ‘hospital acquired’ venous thromboembolism (ie. DVT or PE). It sounded easy, and quite interesting. I flicked through the charts, identified possible lapses in prescriptions of anti-coagulant, and marked them as avoidable or unavoidable. The catch was… I had to interview the consultant in charge of patients deemed to have suffered avoidable events. I sent out emails, arranged convenient times to meet, and found myself addressing equally experienced or more established consultants. It was not easy. The key to converting it from a repeatedly painful and nerve-wracking exercise was this – I too had been called up to justify a similar lapse, months earlier. The discomfort, the access of humility, the acceptance that yes, it could have been done better, we (I) should have been more vigilant, served as a brief lesson in correction. That was the angle when it came to phrasing my own feedback:
‘It happens to all of us at some point, it’s bound to. Happened to me last year. And it worked. If I hadn’t been asked to attend the meeting I wouldn’t have known that so and so had a big PE three weeks after they went home from my ward. It worked. It made be think twice about checking it on ward rounds, brought it home. It’s not about criticism, it’s about focusing minds on the things that are easy to let slip through your fingers…’
You get the gist. Correction shouldn’t be exceptional; it’s inevitable.
If hospitals and surgeries are to witness more of those ‘difficult conversations’ we keep hearing about, in order to promote a safe culture, each of us has to find a way to get comfortable with starting those conversations. The best way – in my limited experience – is to bracket them in the context of our own fallibility, for none of us are perfect, and we are all bouncing from error to error as we move forward in our careers. That’s medicine.
New booklet, click picture to explore…