A Universe of Unavoidable Errors

A colleague, Robert Yoho, M.D., is writing a book about the practice of medicine. It included reflections on medical errors. I am sharing with his permission verbatim.

I had drinks with a sixty-year-old attorney who said he had never made a mistake with a client. I tried to be polite for a few minutes and asked him to expand on his statement. He said that he had worked for thirty-five years and he never had a bad result or even missed a deadline. I sat there for a while and probed—I wondered if he believed what he was saying. Perhaps he was checking how gullible I was. After a while, I realized I was sitting with a narcissist who had little self-awareness, a probable sociopath. I walked out in the middle of a sentence and did not look back.  

We physicians are continually reminded of our errors, sometimes by the species of lawyers who specialize in suing us. We make hundreds of decisions each day, and thoroughly understand the risks of a wrong decision. Although severe harms to our patients rarely happen, the possibility is with us always. Many of our errors are neither consequential nor result in damage, but most of us worry incessantly anyway. All of us have seen patients injured. Neurosurgeons, for example, face horrendous problems almost daily. Ophthalmologists see a blinding or two during their careers. General surgeons have a string of fatal and near-fatal woes every year (I do not think I could tolerate it). I had also heard around twenty stories from my plastic surgery colleagues about their patients’ fatalities. 

Puncture of internal organs when performing liposuction happens with some regularity, roughly in one case of 3,000. One of ten of these might die. Lipo requires two thousand strokes of the cannula instrument per case, and in some areas of the body, a fifteen (15) degree alteration in its angle produces an internal puncture. Some of these are serious, and some are never noticed.  

After a thousand cases, a surgeon has performed roughly two million cannula strokes. About 10,000 cases had been done in my offices by the end of my career. Since we by the end had performed over 10,000 liposuction cases—20 million strokes–I saw punctures more than once. I understood this and other complications through personal experience and the experience of others. But I never thought I would have a death. We have patients sign documents saying this disaster–and others, there are many others–are possible. But these days, when anything happens, there is a lawsuit. I have colleagues (a generous label) who will swear under oath that punctures are malpractice and that they should never happen with cautious technique. 

I often meditate about the following. Our primary goal is to do no harm, but this is a misconception. It should be to cautiously exchange risk for the best chances of helping our patients after evaluating whether the tradeoffs are reasonable.  

To understand the inevitability of medical risks, consider what rock climbers face. Like doctors, they use technology. They have devices that make a fatal activity almost safe. These systems are so reliable that when used properly, the trust in them is absolute. A single rope is relied upon to save a climber’s life over and over as she practices the difficult climbs and repeatedly falls.  

The person who uses this equipment high off the ground must follow easy rules and evaluate simple physics every moment to avoid death. Once in many hundreds of climbing days, fatigue or a small distraction might spawn a mistake. Common errors include tying the main knot incorrectly or reversing the rope handling device—this happens even though there are only two ways to attach it. The overwhelming majority of climbers’ fatalities—even for experienced climbers—are due to errors setting up basic safety systems. Although most of us endlessly check everything, fatalities and serious injuries still invariably occur because human performance is imperfect, even when the consequence of a mistake is death. 

Medical systems are much more complex; the number of variables seems infinite. But evaluation of error has devolved into a legal process occupied with assigning fault and compensating the ‘victims of malpractice’ and their championing lawyers. Humans are so fallible that a better approach might be collecting statistics about the (un)reliability of systems and individuals. A few are thinking along these lines, but the interlock of law, blame, and medicine has never been challenged. 

Getting to zero medical errors is as likely getting to zero accidents with motor vehicles. Both are lofty aspirational goals.  

If we want to decrease the number of deaths and injuries associated with cars, the first things we would do is cut the speed limit to 10 MPH and mandate donning helmets and flameproof clothing in addition to seat belts. Of course, then, the benefits of driving would dip.  

Society has calibrated the risk/benefit ratio of driving so that when accidents occur, the public, via ownership of insurance, picks up the tab. We have “nationalized” (through private insurance) the cost of auto accidents.  

Not so with health care. Perhaps we should consider some type of insurance where the cost of medical errors – or even risks/side effects of treatments, procedures, and medications- are distributed to all patients, bundling such coverage into health insurance. The marginal cost would not be unreasonable. The cost would then be spread out over 300 million people instead of 1M doctors.  

Doctors would still beat themselves up over bad outcomes and errors. But the process of seeking a remedy would be less adversarial. 

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