The merit of second thoughts

Chris Hogan

19/02/2019 2:12:03 PM

Reflecting on his clinical career, Dr Chris Hogan realises the importance of making – and learning from – mistakes.

The ability to reflect on your career is a great luxury.
The ability to reflect on your career is a great luxury.

It is a great luxury to be able to sit and think about your clinical career in retrospect. You have completed your tasks, nothing else is asked of you. But there is one aspect that can be challenging.
You cannot change the past.
It is in our nature that our thoughts are filled with the situations that could have had a better outcome. Not necessarily our failures, for so much is beyond our control, but more our lack of success.
Now that I have left my work as a GP and moved into academia, I have spent a lot of time thinking about mistakes. I was taught to do my best and keep improving. However, so much of our time now is spent trying to reduce risk and to do a perfect job.
‘Do not make a mistake’ is a mantra of modern times. While this initially seems to be an ideal outcome, on second thought, it is disastrous.
Experience is what you are left with when you survive your mistakes    
I am reminded of the training given to those who build, construct or assemble: ‘The person who never made a mistake, never made anything’.
In my training, my teachers taught me wisely about dealing with dire emergencies. I believe this also applies to routine practice – you never really know what illness a patient will bring into your consulting room.
General practice is sometimes derided as ‘coughs, colds and sore holes’. Would that it were so simple. I distinctly remember those who walked in but were not well enough to walk out.
What I have come to realise is that experience is what you are left with when you survive your mistakes.
You did not cause the emergency, you responded to it.
You cannot expect to salvage everyone. If you save even one, you have done your job.
You can only make decisions with the information available to you at the time. If further data becomes available later, it does not affect the validity of your initial decisions.
Mistakes are inevitable because you are often dealing with the most difficult of cases in the most difficult of circumstances.
So, learn from them, keep good notes and add to the profession’s knowledge. 
You are human, and if you deny your humanity you will pay for it with burnout – or worse.
Do better next time
A better rule than ‘make no mistakes’ is to never make the same mistake twice.
Never make a mistake from ignorance, stupidity or impairment from illness, exhaustion or intoxication.
When I was starting out, I saw too many colleagues in the emergency services who paid the ultimate price for denial, stubbornness and self-management with alcohol, pharmaceuticals or drugs.
In later years I worked for a disaster coordination group with access to on-call psychologists who were also part of our planning group. We also each had a buddy to contact if we needed emotional support or advice. We had debriefing sessions after each disaster response, so that we recorded what actually happened. One person has a single opinion but, as a group, we gained an overview of our strengths and weaknesses
What I took from that was to learn from each incident to do better next time – and that there was always a next time. It was a no-blame system, designed to improve rather than punish.
Once we had completed our debriefing, it was not unusual for us to prepare or contribute to reports for the coroner or governmental investigations. Attending a court case or inquiry was not a punishment for mismanagement, it was part of our job to report the truth and to improve future responses.
As GPs, we are often expected to attend court. I have attended for domestic violence, assaults and workers’ compensation, as both a witness and an expert witness.
What I learned from these experiences was that concentrating on avoiding mistakes rather than doing our best is bad. It is defensive medicine, not good medicine.
In practice, extreme mistake avoidance means we decrease our range of activities and skills.
It means we do only that of which we are certain, and only attempt actions at which we expect to succeed.
We do not attempt to improve or experiment to improve our skills.
We over-investigate, over-treat, over-manage and engender uncertainty rather than confidence.

We are effectively paralysed by fear, concentrating more on self-preservation than on our patient’s needs.
In all my wildest dreams I never thought I would see a contraction of our scope of practice. Instead of doing more than our predecessors, we are doing less and less.
Nor did I expect the guidelines I helped develop to become a foundation of practice from which we could expand would become the upper limit of our activities. I was involved in formulating guidelines on a range of topics, including cancer, respiratory medicine, first aid and resuscitation.
I was taught to distrust the obvious and look a little deeper. The best test to check a diagnosis was the passage of time – observation over minutes, hours, days or weeks depending on the circumstances. I relied heavily on the cooperation of the patient or parents or carers to contact me or return if a situation was other than I expected.
Sure enough, when the patient was reviewed I often had second thoughts about the diagnosis and/or treatment. And I am glad I did.
Almost as glad as they were.

General Practice career Learning Mistakes

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DK   20/02/2019 11:01:06 AM

Well written, thankyou. I agree wholeheartedly. The difficulty I have, only 15 years into my career, is knowing how to push back against the forces that tell us we can't make mistakes and should not act unless we are already experts (which makes skill acquisition tricky). We have insurers, litigators, government bodies and (increasingly) patient expectations increasingly expecting the right answer every time, with significant punishment for any doctor who "misses" a diagnosis - even if that diagnosis is sufficiently rare that to look for or test for it would be hugely wasteful the vast majority of the time.
No wonder the cost of healthcare, and the attrition rate of GPs, is rising so quickly.

A.Prof Christopher David Hogan   20/02/2019 5:27:56 PM

Seeing as you asked Combatting the very dear, dangerous , disaster of defensive medicine needs a community wide approach
* Education to the profession & the community of its burden
* In depth research
* Expansion of the role of NDIS/ No fault insurance
* Removal of automatic institution of legal precedence based on one court case that affects the practice of medicine .
* Such generalisation from one case should only come from considered legislation from parliament. This decision would have ALL the evidence considered by the resources of parliament , along with consideration of the implications on the whole health system
* Stress on the role of reasoned confidence in clinical practice

Dr Claire Elizabeth Cupitt   20/02/2019 9:33:28 PM

Well thought out and well said. Thank you Chris.

Deb Sambo   20/02/2019 10:30:02 PM

Excellent write up Chris.
The man/woman who has never made a mistake is either " not born yet" or is dead!.
We are humans.
The key as you say is to learn from our mistakes rather than becoming defensive.

About doing less as a GP; we have only ourselves to blame as we constantly talk about being "time poor", leaving aspects of our core responsibility's as GPs for others to do.
then we cry when everyone all of a sudden thinks there are as experienced as GPs and in fact want equal pay,

Dr.Gnanasegaran Xavier FRACGP N0.519256   20/02/2019 11:43:24 PM

You can never be right all the time.Learning from your mistake and tring not to make the same mistake again, I believe IS THE WAY TO GO.