When We Do Harm: A Doctor Confronts Medical Error
Anyone familiar with Dr. Danielle Ofri’s books or blogs knows that she is in the company of other physician writers who share a deep commitment to ensuring that humanity is always at the heart of health care. Her readers know, too, that she is a skilled and compassionate healthcare provider.
A clinical professor of medicine at the New York University School of Medicine, an attending physician at New York’s famed Bellevue Hospital, and editor in chief of the Bellevue Literary Review, Ofri is a prolific writer who shares the moments that matter in her practice and the growing challenges of her profession.
In her seventh book she explores the difficult and important issue of medical mistakes and how to reduce if not avoid them. Drawing on research, professional experience, extensive interviews, and her own values as they relate to health care, Ofri explores diagnostic, systemic, and cognitive causes of medical errors and offers recommendations for how to address them.
Ofri begins her book with a clear introduction to its topic. “Patient safety and avoidance of medical error is a complex mix of how individual medical professionals interact and communicate with one another, how they do so with patients and family members, and how state-of-the-art medical systems can nevertheless allow small things to fall through the cracks.” To explore these important issues, she begins with an empirical question: Is it true that preventable medical error is the third leading cause of death in the United States? Could there actually be as many as 98,000 deaths per year from medical error?
Ofri approaches her topic systematically, aided as always by humanizing an urgent topic in medicine. In this book she shares the stories of a patient with severe leukemia whose wife, an emergency room nurse, futilely attempts to get her husband the care he needs, and another of a wife and daughter who try for years to understand exactly why their husband and father died from his severe burns.
In the chapter titled “Making—or Missing—the Diagnosis,” Ofri uses a personal experience as well as the work of other physicians who share her concern about mistakes to discuss the importance of “differential diagnosis.” This refers to the fact that in a large number of cases, as researchers discovered, doctors fail to consider possible alternative diagnoses. “Experienced doctors are so fast at recognizing common medical conditions that we jump to a diagnosis in seconds,” Ofri explains. “And the minute we find a diagnosis that seems to explain the findings, we stop looking for any other explanation. We stop thinking.”
This problem can be exacerbated by a lack of “diagnostic thinking,” which requires clinicians to ask themselves questions, Ofri points out. In the case of the leukemia patient, for example, was the problem ineffective treatment? Delayed treatment? Possible complicating medical conditions? Did systemic issues come into play, such as an overreliance on computerized diagnosis tools?
Ofri doesn’t simply ask questions and identify problems, she researches them and deconstructs what she discovers with a view to reducing or eliminating them. She finds the learnable moment to share with her students. She helps healthcare consumers—patients and their families—understand what is happening and instructs them in how to monitor care and ask appropriate questions. And she recognizes the larger context in any given issue.
“Reducing diagnostic error will ultimately require a shift in healthcare,” she notes. This will involve, as a research colleague pointed out, “acknowledging uncertainty and associating humility rather than heroism with our diagnostic decision-making capabilities.” Adds Ofri, “There are few diagnoses more rare in the medical species than intellectual humility. There are few allergies more common than that of doctors to uncertainty.” Who wouldn’t want a doctor who thinks like that?
All of the problems articulated in this book, including the horrors of working with Electronic Medical Records, or EMRs, reveal systemic overlays as well as individual personalities and practices that contribute to medical errors. Ofri’s contribution is not only to identify them, expose them, own them, and think hard about ways to reduce them. Her biggest contribution is to put medical errors into the larger context in order to tackle them in useful ways that always bear in mind “The Human Consequences,” as one chapter is titled.
Acknowledging in her conclusion that “medical errors and adverse effects are more pervasive than we think,” while offering the comforting thought that they may not ultimately be terribly harmful, she underscores the fact that “the issue needs to be front and center in healthcare today.” She also reminds us that “medicine is a team sport” comprised not only of providers but also of patients and their families and friends. “Too often we can feel like we are on opposing teams, but really there is just one goal: helping patients get better. The responsibility for making sure it all works falls to the humans.”
No wonder her closing line is to quote Hippocrates: “As to diseases, make a habit of two things—to do good or at least to do no harm.”