TED演讲稿-----医生犯错能说吗.docx

Before I actually begin the meat of my talk,lets begin with a bit of baseball.Hey, why not?Were near the end, were getting close to the World Series.We all love baseball, dont we?(Laughter)Baseball is filled with some amazing statistics.And theres hundreds of them.Moneyball is about to come out, and its all about statisticsand using statistics to build a great baseball team.Im going to focus on one statthat I hope a lot of you have heard of.Its called batting average.So we talk about a 300, a batter who bats 300.That means that ballplayer batted safely, hit safelythree times out of 10 at bats.That means hit the ball into the outfield,it dropped, it didnt get caught,and whoever tried to throw it to first base didnt get there in timeand the runner was safe.Three times out of 10.Do you know what they call a 300 hitterin Major League Baseball?Good, really good,maybe an all-star.Do you know what they calla 400 baseball hitter?Thats somebody who hit, by the way,four times safely out of every 10.Legendary -as in Ted Williams legendary -the last Major League Baseball playerto hit over 400 during a regular season.Now lets take this back into my world of medicinewhere Im a lot more comfortable,or perhaps a bit less comfortableafter what Im going to talk to you about.Suppose you have appendicitisand youre referred to a surgeonwhos batting 400 on appendectomies.(Laughter)Somehow this isnt working out, is it?Now suppose you livein a certain part of a certain remote placeand you have a loved onewho has blockages in two coronary arteriesand your family doctor refers that loved one to a cardiologistwhos batting 200 on angioplasties.But, but, you know what?Shes doing a lot better this year. Shes on the comeback trail.And shes hitting a 257.Somehow this isnt working.But Im going to ask you a question.What do you think a batting averagefor a cardiac surgeon or a nurse practitioneror an orthopedic surgeon,an OBGYN, a paramedicis supposed to be?1,000, very good.Now truth of the matter is,nobody knows in all of medicinewhat a good surgeonor physician or paramedicis supposed to bat.What we do though is we send each one of them, including myself,out into the worldwith the admonition, be perfect.Never ever, ever make a mistake,but you worry about the details, about how thats going to happen.And that was the message that I absorbedwhen I was in med school.I was an obsessive compulsive student.In high school, a classmate once saidthat Brian Goldman would study for a blood test.(Laughter)And so I did.And I studied in my little garretat the nurses residence at Toronto General Hospital,not far from here.And I memorized everything.I memorized in my anatomy classthe origins and exertions of every muscle,every branch of every artery that came off the aorta,differential diagnoses obscure and common.I even knew the differential diagnosisin how to classify renal tubular acidosis.And all the while,I was amassing more and more knowledge.And I did well, I graduated with honors,cum laude.And I came out of medical schoolwith the impressionthat if I memorized everything and knew everything,or as much as possible,as close to everything as possible,that it would immunize me against making mistakes.And it workedfor a while,until I met Mrs. Drucker.I was a resident at a teaching hospital here in Torontowhen Mrs. Drucker was brought to the emergency departmentof the hospital where I was working.At the time I was assigned to the cardiology serviceon a cardiology rotation.And it was my job,when the emergency staff called for a cardiology consult,to see that patient in emerg.and to report back to my attending.And I saw Mrs. Drucker, and she was breathless.And when I listened to her, she was making a wheezy sound.And when I listened to her chest with a stethoscope,I could hear crackly sounds on both sidesthat told me that she was in congestive heart failure.This is a condition in which the heart fails,and instead of being able to pump all the blood forward,some of the blood backs up into the lung, the lungs fill up with blood,and thats why you have shortness of breath.And that wasnt a difficult diagnosis to make.I made it and I set to work treating her.I gave her aspirin. I gave her medications to relieve the strain on her heart.I gave her medications that we call diuretics, water pills,to get her to pee out the access fluid.And over the course of the next hour and a half or two,she started to feel better.And I felt really good.And thats when I made my first mistake;I sent her home.Actually, I made two more mistakes.I sent her homewithout speaking to my attending.I didnt pick up the phone and do what I was supposed to do,which was call my attending and run the story by himso he would have a chance to see her for himself.And he knew her,he would have been able to furnish additional information about her.Maybe I did it for a good reason.Maybe I didnt want to be a high-maintenance resident.Maybe I wanted to be so successfuland so able to take responsibilitythat I would do soand I would be able to take care of my attendings patientswithout even having to contact him.The second mistake that I made was worse.In sending her home,I disregarded a little voice deep down insidethat was trying to tell me,Goldman, not a good idea. Dont do this.In fact, so lacking in confidence was Ithat I actually asked the nursewho was looking after Mrs. Drucker,Do you think its okay if she goes home?And the nurse thought about itand said very matter-of-factly, Yeah, I think shell do okay.I can remember that like it was yesterday.So I signed the discharge papers,and an ambulance came, paramedics came to take her home.And I went back to my work on the wards.All the rest of that day,that afternoon,I had this kind of gnawing feeling inside my stomach.But I carried on with my work.And at the end of the day, I packed up to leave the hospitaland walked to the parking lotto take my car and drive homewhen I did something that I dont usually do.I walked through the emergency department on my way home.And it was there that another nurse,not the nurse who was looking after Mrs. Drucker before, but another nurse,said three words to methat are the three wordsthat most emergency physicians I know dread.Others in medicine dread them as well,but theres something particular about emergency medicinebecause we see patients so fleetingly.The three words are:Do you remember?Do you remember that patient you sent home?the other nurse asked matter-of-factly.Well shes back,in just that tone of voice.Well she was back all right.She was back and near death.About an hour after she had arrived home,after Id sent her home,she collapsed and her family called 911and the paramedics brought her back to the emergency departmentwhere she had a blood pressure of 50,which is in severe shock.And she was barely breathing and she was blue.And the emerg. staff pulled out all the stops.They gave her medications to raise her blood pressure.They put her on a ventilator.And I was shockedand shaken to the core.And I went through this roller coaster,because after they stabilized her,she went to the intensive care unit,and I hoped against hope that she would recover.And over the next two or three days,it was clear that she was never going to wake up.She had irreversible brain damage.And the family gathered.And over the course of the next eight or nine days,they resigned themselves to what was happening.And at about the nine day mark, they let her go -Mrs. Drucker,a wife, a motherand a grandmother.They say you never forget the namesof those who die.And that was my first time to be acquainted with that.Over the next few weeks,I beat myself upand I experienced for the first timethe unhealthy shame that existsin our culture of medicine -where I felt alone, isolated,not feeling the healthy kind of shame that you feel,because you cant talk about it with your colleagues.You know that healthy kind,when you betray a secret that a best friend made you promise never to revealand then you get bustedand then your best friend confronts youand you have terrible discussions,but at the end of it all that sick feeling guides youand you say, Ill never make that mistake again.And you make amends and you never make that mistake again.Thats the kind of shame that is a teacher.The unhealthy shame Im talking aboutis the one that makes you so sick inside.Its the one that says,not that what you did was bad,but that you are bad.And it was what I was feeling.And it wasnt because of my attending; he was a doll.He talked to the family, and Im quite sure that he smoothed things overand made sure that I didnt get sued.And I kept asking myself these questions.Why didnt I ask my attending? Why did I send her home?And then at my worst moments:Why did I make such a stupid mistake?Why did I go into medicine?Slowly but surely,it lifted.I began to feel a bit better.And on a cloudy day,there was a crack in the clouds and the sun started to come outand I wondered,maybe I could feel better again.And I made myself a bargainthat if only I redouble my efforts to be perfectand never make another mistake again,please make the voices stop.And they did.And I went back to work.And then it happened again.Two years later I was an attending in the emergency departmentat a community hospital just north of Toronto,and I saw a 25 year-old man with a sore throat.It was busy, I was in a bit of a hurry.He kept pointing here.I looked at his throat, it was a little bit pink.And I gave him a prescription for penicillinand sent him on his way.And even as he was walking out the door,he was still sort of pointing to his throat.And two days later I came to do my next emergency shift,and thats when my chief asked to speak to me quietly in her office.And she said the three words:Do you remember?Do you remember that patient you saw with the sore throat?Well it turns out, he didnt have a strep throat.He had a potentially life-threatening conditioncalled epiglottitis.You can Google it,but its an infection, not of the throat, but of the upper airway,and it can actually cause the airway to close.And fortunately he didnt die.He was placed on intravenous antibioticsand he recovered after a few days.And I went through the same period of shame and recriminationsand felt cleansed and went back to work,until it happened again and again and again.Twice in one emergency shift, I missed appendicitis.Now that takes some doing,especially when you work in a hospitalthat at the time saw but 14 people a night.Now in both cases, I didnt send them homeand I dont think there was any gap in their care.One I thought had a kidney stone.I ordered a kidney X-ray. When it turned out to be normal,my colleague who was doing a reassessment of the patientnoticed some tenderness in the right lower quadrant and called the surgeons.The other one had a lot of diarrhea.I ordered some fluids to rehydrate himand asked my colleague to reassess him.And he didand when he noticed some tenderness in the right lower quadrant, called the surgeons.In both cases,they had their operations and they did okay.But each time,they were gnawing at me, eating at me.And Id like to be able to say to youthat my worst mistakes only happened in the first five years of practiceas many of my colleagues say, which is total B.S.(Laughter)Some of my doozies have been in the last five years.Alone, ashamed and unsupported.Heres the problem:If I cant come cleanand talk about my mistakes,if I cant find the still-small voicethat tells me what really happened,how can I share it with my colleagues?How can I teach them about what I didso that they dont do the same thing?If I were to walk into a room -like right now, I have no idea what you think of me.When was the last time you heard somebody talkabout failure after failure after failure?Oh yeah, you go to a cocktail partyand you might hear about some other doctor,but youre not going to hear somebodytalking about their own mistakes.If I were to walk into a room filled with my colleagesand ask for their support right nowand start to tell what Ive just told you right now,I probably wouldnt get through two of those storiesbefore they would start to get really uncomfortable,somebody would crack a joke,theyd change the subject and we would move on.And in fact, if I knew and my colleagues knewthat one of my orthopedic colleagues took off the wrong leg in my hospital,believe me, Id have troublemaking eye contact with that person.Thats the system that we have.Its a complete denial of mistakes.Its a systemin which there are two kinds of physicians -those who make mistakesand those who dont,those who cant handle sleep deprivation and those who can,those who have lousy outcomesand those who have great outcomes.And its almost like an ideological reaction,like the antibodies begin to attack that person.And we have this ideathat if we drive the people who make mistakesout of medicine,what will we be left with, but a safe system.But there are two problems with that.In my 20 years or soof medical broadcasting and journalism,Ive made a personal study of medical malpractice and medical errorsto learn everything I can,from one of the first articles I wrote for the Toronto Starto my show White Coat, Black Art.And what Ive learnedis that errors are absolutely ubiquitous.We work in a systemwhere errors happen every day,where one in 10 medicationsare either the wrong medication given in hospitalor at the wrong dosage,where hospital-acquired infections are getting more and more numerous,causing havoc and death.In this country,as many as 24,000 Canadians dieof preventable medical errors.In the United States, the Institute of Medicine pegged it at 100,000.In both cases, these are gross underestimates,because we really arent ferreting out the problemas we should.And heres the thing.In a hospital systemwhere medical knowledge is doublingevery two or three years, we cant keep up with it.Sleep deprivation is absolutely pervasive.We cant get rid of it.We have our cognitive biases,so that I can take a perfect history on a patient with chest pain.Now take the same patient with chest pain,make them moist and garrulousand put a little bit of alcohol on their breath,and suddenly my history is laced with contempt.I dont take the same history.Im not a robot;I dont do things the same way each time.And my patients arent cars;they dont tell me their symptoms in the same way each time.Given all of that, mistakes are inevitable.So if you take the system, as I was taught,and weed out all the error-prone health professionals,well there wont be anybody left.And you know that businessabout people not wantingto talk about their worst cases?On my show, on White Coat, Black Art,I made it a habit of saying, Heres my worst mistake,I would say to everybodyfrom paramedics to the chief of cardiac surgery,Heres my worst mistake, blah, blah, blah, blah, blah,What about yours? and I would point the microphone towards