Authors: Atul Gawande
And then, amazingly, O’Connor: “I’m in.” He had managed to slip a pediatric-size endotracheal tube through the vocal cords. In thirty seconds, with oxygen being manually ventilated through the tube, her heart was back, racing at a hundred and twenty beats a minute. Her sat registered at 60 and then climbed. Another thirty seconds and it was at 97 percent. All the people in the room exhaled, as if they, too, had been denied their breath. Ball and I said little except to confer about the next steps for her. Then he went back downstairs to finish working on the stab-wound patient still in the OR.
We eventually identified the woman, whom I’ll call Louise Williams; she was thirty-four years old and lived alone in a nearby suburb. Her alcohol level on arrival had been three times the legal limit, and had probably contributed to her unconsciousness. She had a concussion, several lacerations, and significant soft-tissue damage. But X rays and scans revealed no other injuries from the crash. That night, Ball and Hernandez brought her to the OR to fit her with a proper tracheostomy. When Ball came out and talked to family members, he told them of the dire condition she was in when she arrived, the difficulties “we” had had getting access to her airway, the disturbingly long period of time that she had gone without oxygen, and thus his uncertainty about how much brain function she still possessed. They listened without protest; there was nothing for them to do but wait.
Consider some other surgical mishaps. In one, a general surgeon left a large metal instrument in a patient’s abdomen, where it tore through the bowel and the wall of the bladder. In another, a cancer surgeon biopsied the wrong part of a woman’s breast and thereby delayed her diagnosis of cancer for months. A cardiac surgeon skipped a small but key step during a heart valve operation, thereby killing the patient. A general surgeon saw a man racked with abdominal pain in the emergency room and, without taking a CT scan, assumed that the man had a kidney stone; eighteen hours later, a scan showed a rupturing abdominal aortic aneurysm, and the patient died not long afterward.
How could anyone who makes a mistake of that magnitude be allowed to practice medicine? We call such doctors “incompetent,” “unethical,” and “negligent.” We want to see them punished. And so we’ve wound up with the public system we have for dealing with error: malpractice lawsuits, media scandal, suspensions, firings.
There is, however, a central truth in medicine that complicates this tidy vision of misdeeds and misdoers: all doctors make terrible
mistakes. Consider the cases I’ve just described. I gathered them simply by asking respected surgeons I know—surgeons at top medical schools—to tell me about mistakes they had made just in the past year. Every one of them had a story to tell.
In 1991, the
New England Journal of Medicine
published a series of landmark papers from a project known as the Harvard Medical Practice Study—a review of more than thirty thousand hospital admissions in New York State. The study found that nearly 4 percent of hospital patients suffered complications from treatment which either prolonged their hospital stay or resulted in disability or death, and that two-thirds of such complications were due to errors in care. One in four, or 1 percent of admissions, involved actual negligence. It was estimated that, nationwide, upward of forty-four thousand patients die each year at least partly as a result of errors in care. And subsequent investigations around the country have confirmed the ubiquity of error. In one small study of how clinicians perform when patients have a sudden cardiac arrest, twenty-seven of thirty clinicians made an error in using the defibrillator—charging it incorrectly or losing too much time trying to figure out how to work a particular model. According to a 1995 study, mistakes in administering drugs—giving the wrong drug or the wrong dose, say—occur, on average, about once every hospital admission, mostly without ill effects, but 1 percent of the time with serious consequences.
If error were due to a subset of dangerous doctors, you might expect malpractice cases to be concentrated among a small group, but in fact they follow a uniform, bell-shaped distribution. Most surgeons are sued at least once in the course of their careers. Studies of specific types of error, too, have found that repeat offenders are not the problem. The fact is that virtually everyone who cares for hospital patients will make serious mistakes, and even commit acts of negligence, every year. For this reason, doctors are seldom outraged when the press reports yet another medical horror story. They usually have a different reaction: That could be me. The important
question isn’t how to keep bad physicians from harming patients; it’s how to keep good physicians from harming patients.
Medical malpractice suits are a remarkably ineffective remedy. Troyen Brennan, a Harvard professor of law and public health, points out that research has consistently failed to find evidence that litigation reduces medical error rates. In part, this may be because the weapon is so imprecise. Brennan led several studies following up on the patients in the Harvard Medical Practice Study. He found that fewer than 2 percent of the patients who had received substandard care ever filed suit. Conversely, only a small minority among the patients who did sue had in fact been the victims of negligent care. And a patient’s likelihood of winning a suit depended primarily on how poor his or her outcome was, regardless of whether that outcome was caused by disease or unavoidable risks of care.
The deeper problem with medical malpractice suits is that by demonizing errors they prevent doctors from acknowledging and discussing them publicly. The tort system makes adversaries of patient and physician, and pushes each to offer a heavily slanted version of events. When things go wrong, it’s almost impossible for a physician to talk to a patient honestly about mistakes. Hospital lawyers warn doctors that, although they must, of course, tell patients about injuries that occur, they are never to intimate that they were at fault, lest the “confession” wind up in court as damning evidence in a black-and-white morality tale. At most, a doctor might say, “I’m sorry that things didn’t go as well as we had hoped.”
There is one place, however, where doctors can talk candidly about their mistakes, if not with patients, then at least with one another. It is called the Morbidity and Mortality Conference—or, more simply, M & M—and it takes place, usually once a week, at nearly every academic hospital in the country. This institution survives because laws protecting its proceedings from legal discovery have stayed on the books in most states, despite frequent challenges. Surgeons, in particular, take the M & M seriously. Here they can
gather behind closed doors to review the mistakes, untoward events, and deaths that occurred on their watch, determine responsibility, and figure out what to do differently next time.
At my hospital, we convene every Tuesday at five o’clock in a steep, plush amphitheater lined with oil portraits of the great doctors whose achievements we’re meant to live up to. All surgeons are expected to attend, from the interns to the chairman of surgery; we’re also joined by medical students doing their surgery “rotation.” An M & M can include almost a hundred people. We file in, pick up a photocopied list of cases to be discussed, and take our seats. The front row is occupied by the most senior surgeons: terse, serious men, now out of their scrubs and in dark suits, lined up like a panel of senators at a hearing. The chairman is a leonine presence in the seat closest to the plain wooden podium from which each case is presented. In the next few rows are the remaining surgical attendings; these tend to be younger, and several of them are women. The chief residents have put on long white coats and usually sit in the side rows. I join the mass of other residents, all of us in short white coats and green scrub pants, occupying the back rows.
For each case, the chief resident from the relevant service—cardiac, vascular, trauma, and so on—gathers the information, takes the podium, and tells the story. Here’s a partial list of cases from a typical week (with a few changes to protect confidentiality): a sixty-eight-year-old man who bled to death after heart valve surgery; a forty-seven-year-old woman who had to have a reoperation because of infection following an arterial bypass done in her left leg; a forty-four-year-old woman who had to have bile drained from her abdomen after gallbladder surgery; three patients who had to have reoperations for bleeding following surgery; a sixty-three-year-old man who had a cardiac arrest following heart bypass surgery; a sixty-six-year-old woman whose sutures suddenly gave way in an abdominal wound and nearly allowed her intestines to spill out. Ms. Williams’s case, my failed tracheostomy, was just one case on a list
like this. David Hernandez, the chief trauma resident, had subsequently reviewed the records and spoken to me and others involved. When the time came, it was he who stood up front and described what had happened.
Hernandez is a tall, rollicking, good old boy who can tell a yarn, but M & M presentations are bloodless and compact. He said something like: “This was a thirty-four-year-old female unrestrained driver in a high-speed rollover. The patient apparently had stable vitals at the scene but was unresponsive, and was brought in by ambulance unintubated. She was GCS 7 on arrival.” GCS stands for the Glasgow Coma Scale, which rates the severity of head injuries, from three to fifteen. GCS 7 is in the comatose range. “Attempts to intubate were made without success in the ER and may have contributed to airway closure. A cricothyroidotomy was attempted without success.”
These presentations can be awkward. The chief residents, not the attendings, determine which cases to report. That keeps the attendings honest—no one can cover up mistakes—but it puts the chief residents, who are, after all, underlings, in a delicate position. The successful M & M presentation inevitably involves a certain elision of detail and a lot of passive verbs. No one screws up a cricothyroidotomy. Instead, “a cricothyroidotomy was attempted without success.” The message, however, was not lost on anyone.
Hernandez continued, “The patient arrested and required cardiac compressions. Anesthesia was then able to place a pediatric ET tube and the patient recovered stable vitals. The tracheostomy was then completed in the OR.”
So Louise Williams had been deprived of oxygen long enough to go into cardiac arrest, and everyone knew that meant she could easily have suffered a disabling stroke or worse. Hernandez concluded with the fortunate aftermath: “Her workup was negative for permanent cerebral damage or other major injuries. The tracheostomy tube was removed on Day 2. She was discharged to home in good condition on Day 3.” To the family’s great relief, and mine,
she had woken up in the morning a bit woozy but hungry, alert, and mentally intact. In a few weeks, the episode would heal to a scar.
But not before someone was called to account. A front-row voice immediately thundered, “What do you mean, ‘a cricothyroidotomy was attempted without success’?” I sank into my seat, my face hot.
“This was my case,” Dr. Ball volunteered from the front row. It is how every attending begins, and that little phrase contains a world of surgical culture. For all the talk in business schools and in corporate America about the virtues of “flat organizations,” surgeons maintain an old-fashioned sense of hierarchy. When things go wrong, the attending is expected to take full responsibility. It makes no difference whether it was the resident’s hand that slipped and lacerated an aorta; it doesn’t matter whether the attending was at home in bed when a nurse gave a wrong dose of medication. At the M & M, the burden of responsibility falls on the attending.
Ball went on to describe the emergency attending’s failure to intubate Williams and his own failure to be at her bedside when things got out of control. He described the bad lighting and her extremely thick neck, and was careful to make those sound not like excuses but merely like complicating factors. Some attendings shook their heads in sympathy. A couple of them asked questions to clarify certain details. Throughout, Ball’s tone was objective, detached. He had the air of a CNN newscaster describing unrest in Kuala Lumpur.
As always, the chairman, responsible for the overall quality of our surgery service, asked the final question. What, he wanted to know, would Ball have done differently? Well, Ball replied, it didn’t take long to get the stab-wound patient under control in the OR, so he probably should have sent Hernandez up to the ER at that point or let Hernandez close the abdomen while he himself came up. People nodded. Lesson learned. Next case.
At no point during the M & M did anyone question why I had not called for help sooner or why I had not had the skill and knowledge that Williams needed. This is not to say that my actions were seen as acceptable. Rather, in the hierarchy, addressing my errors
was Ball’s role. The day after the disaster, Ball had caught me in the hall and taken me aside. His voice was more wounded than angry as he went through my specific failures. First, he explained, in an emergency tracheostomy it might have been better to do a vertical neck incision; that would have kept me out of the blood vessels, which run up and down—something I should have known at least from my reading. I might have had a much easier time getting her an airway then, he said. Second, and worse to him than mere ignorance, he didn’t understand why I hadn’t called him when there were clear signs of airway trouble developing. I offered no excuses. I promised to be better prepared for such cases and to be quicker to ask for help.
Even after Ball had gone down the fluorescent-lit hallway, I felt a sense of shame like a burning ulcer. This was not guilt: guilt is what you feel when you have done something wrong. What I felt was shame: I was what was wrong. And yet I also knew that a surgeon can take such feelings too far. It is one thing to be aware of one’s limitations. It is another to be plagued by self-doubt. One surgeon with a national reputation told me about an abdominal operation in which he had lost control of bleeding while he was removing what turned out to be a benign tumor and the patient had died. “It was a clean kill,” he said. Afterward, he could barely bring himself to operate. When he did operate, he became tentative and indecisive. The case affected his performance for months.