“When do you want to do that elective electrical cardioversion?”

“What cardioversion?”

“Mr. Brugada.”

“I thought he had decided he didn’t want Ontario Hydrotherapy.”

“He telephoned just now to say he’s changed his mind.”

“Hang on. I’ll check.”

I called the OR and worked out a date with our anaesthetist. The nurse took down the information and departed. Before I could get out of the Medical Records department our transcriptionist asked me to help her figure out a muffled word on one of her tapes. The mystery word turned out to be “dysphoria.” Hmm… .

On my way to the medical ward I stole a look at my watch. It was already 9:30 and I hadn’t even started rounds yet. Now I had six patients to see, two of whom were allegedly falling apart. Cripes! So much for my carefully laid plans. I was within arm’s reach of the door to the ward when the respiratory therapist tackled me.

“Would you be able to help me get approval for a sleep study for Mr. Ondine?”

I don’t even recall the details of the conversation. I just remember a sudden moment of clarity in which a single thought crystallized in my mind: Now I know how those carnival ducks felt.

When I was a kid, every summer a couple of travelling carnivals would come to our town for a few days. Armed with the contents of our piggy banks, my friends and I would wander through the amazing chaos together. We’d go on all the rides, eat loads of candy and try our luck at the games. One of our favourite games was Shoot the Duck. For a dime you’d get to shoot pellets at a metal duck at the far end of the booth. It was “swimming” from one side to the other, but if you nailed it just right it would spin around and go back in the opposite direction. Each time you hit it a loud Ding! would reverberate throughout the booth. Ding! Ding! Ding! Ding! It kept trying to get to the other side, but somehow it never made it. Some days I feel like that duck.

Eventually I arrived at the ward. I had just cracked open my first chart when one of the ambulance attendants bellied up to the counter beside me. He looked annoyed.

“So your guy’s not DNR anymore,” he said.

“That’s right.”

“You know that means we’ll be doing a complete resuscitation on him if he goes sour while we’re on the road, right?”

“Go for it.”

“Does his family know his code status has been changed?”

I lost it.

“The whole world knows, okay? Go ahead and run a full code! Do a heart transplant if you have to! Just do the goddamn transfer!”

“Okay, okay, take it easy,” he muttered. “Just making sure.”

I got home at noon with a newfound understanding of the relief Xenophon must have felt when he and his fellow warriors finally clawed their way to the Black Sea. Thálatta, thálatta! (The sea, the sea!) I was so exhausted, I went straight to bed. Sleep claimed me within seconds. Half a minute later the bedside telephone shrilled. I nearly jumped out of my skin.

“Hi, Sweetie,” said my wife. “I’m stuck in a meeting and Ellen just called to say she forgot her lunch at home this morning. Do you think maybe you could run it down to the school for her?”

The Simple Math of Medical Errors

Medicine’s a tough gig. For one thing, there are so many diseases out there it’s almost impossible to learn them all. Although we physicians spend the majority of our time treating a core group of relatively common disorders, we still encounter the bizarre and unexpected often enough to keep us on our toes.

Next, some diseases are protean. It’s not uncommon for two people with the same ailment to have entirely different presentations. The converse is also true – unrelated diseases can sometimes generate remarkably similar signs and symptoms.

Another stumbling block is the fact that some patients are poor historians. A portion bury vital clues beneath mountains of irrelevant trivia. When that happens, we have to dig like archaeologists to excavate the information we need. Others have a frustrating tendency to withhold critical details when relating their histories. And then there are always those who just can’t seem to remember exactly what it was they came in to see us for. That never portends well.

On the other side of the coin, there are certainly times when we doctors impede the diagnostic process. Sometimes things like being hungry, tired, stressed or swamped reduce our effectiveness. Sometimes we’re lazy. Occasionally we develop tunnel vision and fail to consider other potential diagnoses. And sometimes we just plain screw up. How could we not? We’re made of the same flesh and blood as everyone else.

In my office I see about 40 patients a day. By the end of most of these encounters I have to make several management decisions. Is this person sick, or not? Is their illness primarily physical or psychological? Do they need investigations? If so, which ones? In what sequence? Within what time frame? Should their medications be adjusted? Do they need to be started on something new? Would they benefit from a visit to an allied health professional or a specialist? What type? How soon? I have approximately 15 minutes to extract an accurate history, perform a relevant examination and come up with a game plan. Does that sound like a tall order? Well, it isn’t. It’s just business as usual.

In addition to the continuous flow of patients, dozens of reports cross my desk every day. Blood tests, urinalyses, cultures, stool studies, EKGs, x-rays, ultrasounds, CT and MRI scans, bone scans, bone density studies, mammograms, Pap smears, pathology reports, pulmonary function tests, ambulatory blood pressure readings, cardiac monitor reports… . The list is endless. As I review each report I have to try to recall why the test was ordered. If the result is normal it can usually be filed away. Significantly abnormal results are flagged and dealt with promptly. Mildly abnormal results are tricky, because they require an answer to the question: Can this be safely filed, or are further investigations required? Not every abnormal test result needs to be acted upon. Part of the art of medicine is knowing when it’s appropriate to ignore a result that falls slightly outside the normal range. “Incidentalomas” abound in clinical medicine, and they don’t all require a million-dollar workup.

For as long as history has been recorded, most societies have held their healers in high esteem. This respect has usually been accompanied by a certain degree of tolerance vis-à-vis medical errors. We physicians have always been extremely grateful for this unspoken buffer zone of forgiveness. Doctors are human beings, and all human beings make mistakes. If the guy at Domino’s makes a mistake, someone could end up getting anchovies instead of mushrooms on their pizza. If I make a mistake, someone could end up dead. It’s a terrifying responsibility.

Over the past 30 years there has been a seismic shift in our collective attitude towards mistakes in North America. All of a sudden errors are no longer permissible. Now if something goes wrong, someone has to be held accountable. Our current zeitgeist fosters the belief that if you look hard enough, eventually you’ll find someone to blame. Someone to blame equals someone to sue. Successful lawsuit equals big money.

Given the prevailing cultural mindset, it’s no surprise the public’s tolerance for medical errors has all but evaporated. Nowadays if a physician makes a mistake, there’s a fair chance their patient may be more angry than forgiving. Even sympathetic patients are often tempted to initiate litigation when family, friends or the media inundate them with stories of lucrative malpractice settlements. I’ve seen sweet little old grandmothers morph into near-psychotic greedheads after having been advised what their injury might be “worth.” It’s not a pretty sight.