COVID-19 has put enormous stress on physicians but even in normal times, one in three experience burnout or depression and one in five have suicidal thoughts. The fear and shame of making clinical errors is a major cause of this psychological turmoil.
Clinical errors are alarmingly prevalent. The Patient Safety Institute says 28,000 patients die in Canada annually as a result of preventable medical mistakes, making it the third leading cause of death. Although there is an active movement to reduce this through checklists, Morbidity and Mortality (M&M) rounds and training students to competently disclose medical errors to patients, there are few conversations about the lingering effects of these mistakes on the trainees themselves.
Studies have exposed significant consequences such as depression, burnout, social isolation and suicide. A 2018 study by the Canadian Medical Association reported that medical residents and physicians experience the highest level of burnout in their first five years of practice.
Screenshot of Dr. Goldman’s Ted X talk from YouTube
Brian Goldman, an Emergency Medicine physician at Mount Sinai Hospital and speaker of the popular Ted X Toronto Talk Doctors make mistakes. Can we talk about that?, says shame is magnified in this generation of students and residents. “It’s because of survivor guilt,” he says, “this sense that they are such high achievers and so many other people have failed to get to this place that somehow they better be perfect.”
The medical culture is built on the premise of perfection. We are ingrained to avoid failure, rightly so, as we are responsible for peoples’ lives. But this perfection-driven training magnifies our reactions to medical errors. Learners feel constant pressure to ensure positive evaluations from their supervisor while simultaneously diving into the rollercoaster of new presentations, new procedures and new patients.
Even M&M rounds, discussion groups led by physicians about mistakes, may contribute negatively to this narrative.
“M&M rounds is a term that gets thrown around in a shameful way,” says Lucy Luo, a second-year resident in Orthopaedic Surgery. When there is the possibility of a poor outcome, “M&M” can be used in an almost threatening manner, she says. The fear that your case or your mistake may be presented to the entire department creeps in.
Ask any physician and most have vivid memories of their first big clinical mistake.
“There is obviously that imposter syndrome in your first year where you feel that you are not fully equipped to handle the floor,” says Yaqeen Abduallah. “Everyone feels the same way except no one talks about it.”
Abduallah experienced this first-hand in her first year of Internal Medicine residency. During the night shift, an eager but exhausted Abduallah admitted the sickest patients to the hospital. The next morning, one of these patients took a turn for the worse. Abduallah had simply re-prescribed the patient’s medications but did not realize that extra monitoring was required. What followed for a drained Abduallah was painful public condescension and, less overtly, feelings of shame.
“When you feel guilt over a mistake, you want to talk about it,” says Goldman. “You want to make improvements in the system. You want to apologize for what you’ve done. When you feel that toxic shame, shame as a total body experience, you feel as if you are unworthy of love and unworthy of acceptance. You fear being excluded by the group.”
Trainees view themselves as inherently flawed after making a mistake instead of placing blame on a specific action.
“When you are in a state of guilt, you don’t believe that you are a bad person. You believe you’ve done something bad,” says Goldman. “Many health professionals have an unhealthy relationship to shame and that unhealthy relationship to shame makes it difficult for them to want to talk about mistakes.”
Thus, he says, shame disempowers them from speaking up.
Milena Forte, a Family Medicine physician at Mount Sinai Hospital, says she hopes her trainees learn from their clinical errors rather than avoiding the circumstances in which they occurred.
“The definition of being a good doctor isn’t that you haven’t made a mistake in 10 years but it is how you manage it and learn from it,” says Forte. “It takes a lot of determination and courage to fuel doing better at this. You can only do that in a supportive space.”
Luo says that we must be more transparent about our clinical errors with our patients and among ourselves as well.
“It is difficult to critically analyze past experiences because the feelings you have are usually negative and you suppress them,” she says. “You bury them.”
Luo adds that specialties such as Emergency Medicine that provide dedicated time for feedback at the end of each shift can help foster non-judgemental environments to discuss clinical errors. Without assigned time, these moments for growth can be missed. Sharing critical experiences turns destructive events into learning opportunities.
Elizabeth Miazga, a clinical fellow in Minimally Invasive Gynecologic Surgery, says as a surgeon, she was trained in a supportive environment.
“As surgeons, there is an age-old adage that says if you are not making mistakes, you are not operating,” says Miazga. She explains that in surgeries, risks and complications are often not only disclosed to patients but also acknowledged by providers. In normalizing clinical errors, trainees are able to constructively reflect on these experiences.
Miazga outlines the necessary steps to take after a clinical error:
- Debrief minutes to hours after the clinical incident, not days to weeks.
- Highlight a learning point. Suggest a skill to improve on or a change to make so that the trainee feels empowered and does not withdraw if a similar event recurs, which often happens in medicine.
- Finally, as a mentor, reassure learners that mistakes do not make them bad medical students or physicians, or bad people for that matter.
Miazga adds that when she made an error, her mentors would often disclose mistakes that they had made in similar situations, normalizing mistakes and, in turn, creating a less isolating experience.
Goldman says that speaking about errors “will have a more powerful and profound effect on learners.”
“Being humble, not rationalizing it away, talking about how they feel when it happens. What would be more powerful than having the smartest, most revered people in the system talking about a mistake they made last week?” he asks.
Michael Fralick, a clinician scientist and a general internist at Mount Sinai Hospital, champions vulnerability in his Mike’s Mistakes talks. He starts his Mondays on the patient floors reviewing his trainees’ management plans. He sometimes then candidly acknowledges a mistake he previously made in the management of a similar patient.
From Twitter
“If we are not talking about mistakes, the perception will be that they do not occur,” says Fralick. “It’s hard to change culture. It’s on all of us to start talking about it.”
As well as the high stakes and fixed hierarchy of the medical culture, there are personal factors and past experiences that may make trainees more likely to internalize their clinical mistakes.
Fralick says creating dedicated time in the medical curriculum to reflect on internal factors would have significant impact. The current curriculum teaches learners to recognize and validate their patients’ emotions but there is much less attention devoted to learning how to recognize their own emotions and how to cope with them.
“Reframing the way in which learners perceive injuries around them would be helpful,” Fralick says.
To reduce burnout and depression in medicine, we need to reframe the narrative around clinical errors; change the tendency to bury our mistakes and speak more openly about them; provide dedicated time for trainees to explore the deep-rooted emotions that underlie their actions; and, importantly, ask our mentors and supervisors to show that same vulnerability.
Physicians will inevitably make mistakes. It is how they grow from these moments that shapes how they care for their patients and for themselves. As Abduallah recalls learning from her first clinical error: “It takes gaining perspective.”
“You have to be OK with making mistakes,” she says. “That’s how you learn to be a physician.”
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Such an insightful article that gets to the roots of the issue and presents a simple solution.
Another great (and powerful) read on this topic is Danielle Ofri’s latest, When We Do Harm
https://danielleofri.com/books/when-we-do-harm/
Shame and fear connected to discussing medical errors increase rates of burnout; burnout increases (quite dramatically) rates of medical errors. There are so many vicious cycles in medicine now and I am grateful for the courageous voices willing to speak about our need to transform into a healthier culture.