La Méprise (Mr Perfect)

Here are some people for whom I’ve made errors or failings over the last week (these are just the ones I am aware of!):

48yr old male with history of LBP (low back pain) following road traffic collision. History of milder version of Spina bifida and was concerned that “nerves have come out of his back”. Avoidant pain behaviours reported. Alongside unusual descriptive language “felt back was coming away from itself”. He had also seen a myriad of consultants who had told him of a dark disc but nothing more sinister (this was fairly sinister to him!). Initially I put some his symptoms down to catastrophisation and biomedical focus due to his concern about previous problems with Spina bifida as a child. He walked well and I would not have been suspicious of Spina bifida if it was omitted from his history. He then proceeded to google his symptoms which seem to correlate with sacroiliac pain area and symptoms. I obviously dismissed this. Then serendipitously I happened across some Spina bifida information. Ah! The spinal cord doesn’t close up you say. It affects the sacrum?! He was fully flexed at time of impact. I’m starting to feel like a doughnut at this point. To add to the story this chap could talk too. One of those that could easily get through a 20min appointment without doing anything. So a lot of the early stages we went through exercises but didn’t have too much time due to this. Needless to say he initially was making no progress but has since started to see some inroads.

32yr old male with 18 month history of ankle trauma and 8 week history of further minor trauma. Had 2 clear X-rays from attending A&E. Presents with no restriction in RoM but some painful inhibition of version and inversion resistance. Didn’t check Ottawa rules due to X-rays. Reports initially improving pain severity with active exercise program. Then rings in 2 weeks later requesting discharge as they are treating fracture at the ankle!

33yr old female with long history of episodic bilateral hip and LBP. Nil trauma or suspicious history other than some mild abdominal pain she puts down to IBS. On assessment she is globally hypermobile which can have abdominal symptomology and poor rotational strength particularly lateral rotation coupled with abduction. Her hip pain improved significantly over 10 weeks however her LBP and abdominal pain remained constant. I discharged to the GP for further investigation. She rings (to thank me) to say they found 7 spinal tumours some wrapped around the spinal cord. Could I have referred sooner?

62yr old male with right knee OA with capsular restriction. I progressed him to impact too quickly and it made his knee really sore.

45yr old female with LBP. I mistakenly called the wrong name and so assumed DNA. Reception staff contacted me 10mins later. This meant my intial assessment was more rushed than usual.

53yr old male with long history of LBP and leg pain. Complex history including abuse as a child, suicidal ideation, Addison’s disease, bipolar disorder, longterm unemployed. Physical activity levels massively connected with social isolation and depression. I have seen him on and off over 4yrs. This week he returned after another period of low mood due to family tragedy. Am I failing him?

Error is a human trait. The despised. Ingrained in our being. How can I possibly argue that this may be of benefit?! Read on……

The avoidance of error at all costs is tantamount to perfectionism. Is this what we should be aiming for? There are actually as many problems with lack of error as in its presence. Perfectionism can infiltrate any culture. Healthcare. Education. Science. Religion. Sports. (I feel well placed to see this as I live towards the other end of the continuum.)

Perfectionists strain compulsively and increasingly toward unobtainable goals, and measure their self worth by productivity and accomplishment. My last blog touched on productivity so I will address accomplishment and outcome more in this. Perfectionism has been associated with low productivity, procrastination, fear of failure, all or nothing attitude, workaholicism, unrealistic expectations, sleep disturbance, anxiety, depression and even suicide (1,2,3,4,5). 

Healthcare is becoming a perfectionist culture. Influenced by the users. People don’t want mistakes made on their health. ‘Do no harm’ is our motto. No one will disagree with that. But what do we mean by “harm”? Absolute harm? Potential harm? Intentional harm? This would stop all surgery and pharmaceuticals for a start. Probable harm? Maybe it’s a utilitarian harm. Overall is there more harm than help? That seems sensible. But how is this measured? Lots of tricky questions. We are in a predicament. We want the authority and trust that comes with perfection. But not the burden. Is there even an argument that some “harm” may be beneficial. Build resilience. Reduce frailty.

  
And Science. Science is one the dominant ideologies now in the western world. We must realise Science can only hint at our world. It is messy. Imperfect. But wonderful. It is acquainted with error. It relies on probability. But Science tries to prove itself wrong. Not exactly true. Science is not the findings. The data. Science tries to disapprove data (which is good). It is not critical of itself (and why would we expect this). Science is method. Observe. Make predictions. Test them. Science is meticulous. Control. Measure. Repeat. But can we agree on this. It seems the Scientific method has become a strained attempt at making Science more objective. The problem being is that it is not objective and we couldn’t get 100 people to agree on the Scientific method and what could be considered part of this. The infamous philosopher of science Karl Popper denied a Scientific method exists. Popper even asserts Science is fallible and has no authority! More contemporary Philosophers of Science Kuhn, Lakatos, Feyerabend criticised the machinations of Scientific method in favour of something more nuanced. Hanson highlights how data, observation and therefore scientific fact is laden with theory and history. Einstein denies any algorithmic method to Science or logic to discovery. Do we give up on Science? No! The presence of error is not to be despised. It is to be acknowledged. Not sought. Progress is possible in error. 

What does any of this matter? How does this apply to the real world? How does society view error and mistakes? Something to be despised. Eliminated. Do the public have an ideal of perfect healthcare? Or do they see imperfect people and systems trying to work for good? We are sold ideals of perfection. The perfect body. Holiday. Partner. Job. Wedding. The American Dream. There is a hope in objectivity that robots may be without error. They actually follow guidelines. They have all the latest resources. Evidence at their finger tips. This is unfounded and steeped in logical positivism (verificationism). That we can know with 100% clarity. Humans here hold the advantage. We are able to (though don’t always utilise) reasoning. We can be self aware. Consider error. The robot only knows it’s program and sticks to this unless re-programmed. It does not think of whether it makes an error. There is a greater thing than perfect. It is good. The pursuit of perfection is an illusion. The pursuit of good is something different altogether. It has not only value but ethics, nuance. 

There is a difference between a ‘failed’ outcome and failing a person. “Humanistic care can exist within a failed outcome” as Keith P succinctly wrote. Failing to treat someone as a person is the cardinal sin of healthcare. Not the failure of outcomes (of course these can overlap). Informed consent becomes crucial. It’s not a question of healthcare professionals making judgements. It is the person who will have to live with the outcome. Good or bad. So do we lose our veil of perfection in order to live with error? Or do we allow it to shape us, grow us, inspire us to greater good and not perfection? Our tendency is to downplay, ignore, erase our mistakes. A blogger may retract or delete a post as if it never existed. Health systems may ‘hide’ imperfections. Massage data. But when weaved into our story the narrative becomes stronger. It can lead us to make better decisions or create better systems.

Nothing is without error. Don’t pretend otherwise.

Be more human. Be less robot. 

Thanks for reading this far. 
Neil

Further reading:

The importance of failure to Google http://www.bbc.co.uk/news/technology-35589220

Part of flourishing is also making mistakes and learning and developing, so it’s not the idea that you simply prescribe some kind of a lifestyle…….. http://sociologicalimagination.org/archives/18307?utm_content=buffer01622&utm_medium=social&utm_source=twitter.com&utm_campaign=buffer

Featured content

Karl Popper: On the non-existence of scientific method. Realism and the Aim of Science (1983)

1) Teixiera et al 2016 http://www.ncbi.nlm.nih.gov/pubmed/26870911

2) Yu et al 2016 http://www.ncbi.nlm.nih.gov/pubmed/26838568

3) Kim et al 2016 http://www.ncbi.nlm.nih.gov/pubmed/26707347

4) Oddo-Sommerfeld et al 2016 http://www.ncbi.nlm.nih.gov/pubmed/26688497

5) Akram et al 2015 http://www.ncbi.nlm.nih.gov/pubmed/26465774

 

8 thoughts on “La Méprise (Mr Perfect)”

  1. Thanks again for sharing your experience and thoughts.

    Your post made me think of Gerd Gigerenzer book “Risk savvy: How to make good decisions”, more precisely the third chapter entitled “Defensive decision making” and this passage:
    “(…) That enables pilots to learn from the errors of others. Although safety il already extremely high, efforts are made to further reduce the number of accidents, as in the U.S. aviation program System Think, where all participants – pilots, mechanics, air traffic controllers, manufacturers, airlines, and regulators – get together to discuss errors and learn how to make flying even more safe.
    Nothing remotely like this exists in hospitals. The error culture in medicine is largely negative; systems of critical incidence reporting are rare. With the threat of litigation looming, hospitals are dominated by defensive medicine, where doctors view patients as potential plaintiffs and where errors are consequently often hidden. National systems of reporting and learning from serious errors, as in aviation, rarely exist.”

    The second thought come from my personal experience. Most of the times I heard a patient complaining of past surgical failure, he didn’t feel bitter about the bad surgical outcome (hopefully I don’t live in the US), his resentment was much more related to the surgeon not acknowledging for his mistake. Had the surgeon admitted he made an error, or something went wrong during surgery, the patient would have eventually accepted it and turned the page. I understand practitioners are afraid of legal consequences but paradoxically, admitting the mistake may sometimes happen to be the best way to manage the event with humanity and prevent lawsuits.

    Liked by 1 person

    1. Thanks for your excellent comments Marco!

      Some spheres naturally allow more error than others due to safety. Healthcare definitely can be in this category. Like you mention good systems are essential here!

      On reflection I think your experience rings true for me. A lot of patients although may hope for perfect understand that error is inevitable and they don’t expect perfect but they do expect us to admit mistakes and learn from them. Like you say this culture I do not recognise in healthcare much.

      Like

  2. Hello Neil,

    With so few errors anyone would think you are boasting.

    Making errors is normal human behaviour. Period. Owning up to them is admirable.

    Of course, putting everyone through every investigation known to us would help some but it is interesting to note that it would not have helped the majority of your patients.
    The 53 year old with LBP trusts you and values your care I think.

    The environment we have to work in at times can stack the odds against us as well.

    To quote Prof Lucian Leape; Humans make mistakes because the systems, tasks and processes they work in are poorly designed.

    I think this can reflect physiotherapy; some of the education/training and our working environments are due some serious thought.

    The gentleman above is spot on I think. The aviation industry is a great example of sharing information and constantly improving safety.

    Regards,

    Adrian

    Liked by 1 person

    1. 😂😂 like i said these were only the ones I was aware of! Like you say what consists a mistake or error is up for debate. Whether I failed them or there was a failed outcome is not always clear cut.

      You and Marco both bring up excellent points about the system or culture you work in. We can definitely learn from other culture/systems both inside and outside healthcare. It should be worth remembering that even the best systems aren’t perfect. But this should not stop us making good choices about the culture/systems we work in as well as personal decisions. We also have the added complexity of dealing with humans not aeroplanes.

      The difficulty with our mistakes is that we have no counterfactuals. We cannot know what would have been if we had acted differently. We can only conjecture.

      Thanks again for the comments always thought provoking!

      Neil

      Like

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