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Tuesday May 16, 2017

Disease Outbreak Shows What -- and Why -- We Can Learn From Mistakes

Many times during the course of my three-year family medicine residency, I watched one of my attendings do something well that I've struggled with my entire life: telling someone they're wrong in a caring and considerate but firm way -- that is, instructing gently.

I was on the receiving end of that admonition several times, but there were a few attendings who made it seem almost natural -- expected, even -- that I and my cohorts would (gasp!) make mistakes. They even grew appropriately angry if a patient's health or well-being might be threatened by my error.

During those times of tough love, I learned three important things about being a good physician, a good teacher and a good person.

Bordetella pertussis bacteria are isolated on a black background in this 3-D micrograph. As of May 10, nearly 60 cases of pertussis had been reported in Grant County, Kentucky, compared with just five cases in all of 2016.

First, it's OK to admit when we don't know something, but we owe it to everyone under our care to seek the right answer if it exists. There is no need to pretend we know everything. Truth trumps ego every time, and being wrong because of an incorrect assumption puts our patients at risk. We also have the world's knowledge at our fingertips, so there's little excuse for not seeking the correct answers and evidence-based plans of care.

Second, there is always something to learn from any mistake we make, but it improves us only if we actually pay attention. During medical school and residency, I had no clue what I was doing the vast majority of the time. We all started not knowing a fraction of what we eventually learned. There were many times when I spent an hour devising a plan for my patients that was subsequently "revised" extensively by my upper-level residents and attendings. I learned more from those errors in assessment and planning than I ever learned from a textbook. Being wrong -- and the fear of being wrong -- were huge motivators.

And last, failure is always an option. No matter how much I feared being wrong, I concluded early that the greatest growth comes from failure. It's baked into the scientific method. Why ask a question we already know the answer to? If we seek only the knowledge we already have, we'll never gain anything. There are also multiple factors far beyond our control that affect the health and well-being of each of our patients. They are autonomous beings, after all.

I say all of that not to justify poor outcomes or mistakes. It's the opposite, in fact. We must all learn from our mistakes, become better because of them and help those around us do the same, whether through evidenced-based information or helpful encouragement.

During the past few weeks, I've had the opportunity to practice my gentle admonishment -- and even my righteous indignation -- as my community deals with an outbreak of pertussis(www.wlwt.com). As medical director for a four-county health department system, I deal constantly with public health problems and their application at the level of the individual patient. I also see -- all too often -- the fallout of clinicians' failure to apply evidence-based best practices.

Throughout our careers as physicians, whether because of ignorance or arrogance, miscommunication or negligence, we all make errors in clinical judgement that could potentially harm a patient. A few clinicians in our area have communicated outdated information about both treatment and transmission of pertussis, allowing several infected students to return to school too soon and putting many others at risk.  Nearly 60 cases had been reported as of May 10(www.nkyhealth.org).   

I was tasked with determining the best way to educate community physicians about the latest evidence-based testing and treatment strategies. I don't know yet how effective the plan has been, but I'm learning. And if I fail, I'll most assuredly learn from that, since failure increases the likelihood that the disease will spread.

As I've written before, family medicine remains inextricably interwoven with public health. We care for populations that span all walks of life, through all ages and stages. During the lifespan, each of our patients faces a myriad of health concerns. Some concerns are universal, others are specific to a population of individuals with similar characteristics. Many of the concerns revolve around disease prevention and health maintenance.

We also treat patients unlucky enough to develop illness. All the while, we have the opportunity to collect data about each of these patients that can be used to further our knowledge and improve our interventions. Taken in aggregate, these experiences can be used to describe the overall health of a community, a country or even the whole of humanity.

As lofty as that sounds, this is the real realm of public health: using the quantified data of intervention and outcomes to plan for future interventions that will lead to new -- and, hopefully, better -- outcomes and so on, ad infinitum. We create a never-ending loop of experiments using the scientific method. Along the way, we also help people.

The two don't have to be mutually exclusive. We can both collect data and assist people in improving their health. We can respect autonomy -- both in our patients and in our colleagues -- and still offer evidence-based scientific facts. We can be honest about what we don't know and openly acknowledge our limitations. We can engage in scientific debate and admit when we are wrong. We can gently instruct when our colleagues seek a path that contradicts strong evidence and admit when we have done the same.

Gerry Tolbert, M.D., is a board-certified family physician who practices in northern Kentucky. A lifelong technophile, his interests include the intersection of medicine and technology. You can follow him on Twitter @DrTolbert(twitter.com).

Posted at 10:29AM May 16, 2017 by Gerry Tolbert, M.D.

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