In a recent New York Times article, Dr. Peskin tells the story of one of her patients — Shirley.
The first time that Dr. Peskin saw Shirley, she had been taking shots on a daily basis to deal with her diagnosis of Multiple Sclerosis.
5 months later, Dr. Peskin saw her again because she had now suffered anaphylaxis from the shots. In the process of treating the anaphylaxis, another doctor ended up reviewing Shirley’s history and concluded that she didn’t have MS at all — indicating that the decades-long course of daily shots were actually unnecessary.
In other words, Shirley’s first doctor made an incorrect diagnosis; that diagnosis was confirmed by a second doctor; and a it wasn’t until a third doctor was involved that the mistake was revealed.
This story certainly isn’t unique. In fact, mistakes are often revealed at the junction point between two doctors — whether it’s during a handoff or because care has been taken up with a new doctor for a different reason.
To me, there are three important findings that relate to this story:
- Mistakes must be part of our medical experience.
The entire structure of our medical system and practice treats mistakes as an unpardonable, inexcusable part of care. That means that, as Dr. Peskin explains, doctors are left to deal with the intellectual and emotional aftermath of making a mistake on their own. And, I think, learnings from mistakes are limited. Far better would be to incorporate a thoughtful exploration of our mistakes into our practice — in a way that doesn’t necessarily make anyone “wrong” for having made the mistake in the first place. This is one crucial reason that all ClickCare cases are automatically archived and searchable for teaching and reflection.
- The more we collaborate, the better we do.
If you collaborate, you don’t need to wait until a mistake is found “after the fact” — another set of eyes (or two or six) can help us make better decisions and diagnoses in the moment.
- Handoffs are not collaboration.
It’s important to note that Shirley would likely have received more thoughtful, appropriate care if her three doctors had been able to work together, sharing perspectives. This type of collaboration creates far better, more sophisticated care than simply bouncing the patient between providers. It’s possible that her original doctor had important insights about her that informed the diagnosis of MS — and rather than reversing the original diagnosis, perhaps the final doctor would effect the change by integration or interpolation, while engaging together about the care.
Shirley's case didn't end badly, and all of her doctors had been working hard to provide the best care possible. But we believe that a better way is possible, easy, and doable -- if doctors have the right tools and the right mental framework. Doctors don't have to "go it alone" and be infallible -- they can collaborate and they can learn from their mistakes.