- Email: [email protected]
can't…breathe
DISSECTING ROOM
Primum non nocere
Websites in brief
Complications: Decisions and Dilemmas of a Surgeon’s Life Atul Gawande. Profile Books: London, 2002. Pp 269. £12.99. ISBN 1 861 97413 2. hat do doctors remember decades after their first plunge into the fray, after the shock of fallibility has worn off, and they have become inured to incompetence, simple mistakes, ethical misconduct, and deliberate malpractice of which they, and their colleagues, are capable? What do necrotising fasciitis, hyperemesis gravidum, thoracic spine metastases, chronic pain, and obesity have in common, apart from being personally memorable cases for the author, and good but arbitrary examples of the profession’s current limitations? When invited to recall their worst errors, do doctors prevaricate, confess to having inadequately supervised a junior, or do they come up with a series of plausible, and distressingly repetitive, case histories? The essays in Complications: Decisions and Dilemmas of a Surgeon’s Life (some published in the New Yorker or at http://www.slate.com) belong to the latter category. Atul Gawande, a surgical resident and health-policy adviser to the Clinton administration, reflects on the imprecision of human judgment and the practice of medicine, in the tradition of self-examination, castigation, and justification exemplified by The House of God (1978) and Dr X (1972). Gawande may, however, be a step closer to revealing patterns that underlie medical error as, despite laudable attempts to “change minor identifying details of individuals” to protect patients’ confidentiality, his book is resolutely nonfiction. The inevitability of medical error is broached, but not resolved, in these punchy stories peppered with summaries
W
can’t . . . breathe In tense moments I wish my stethoscope was all they want it to be: two steely serpents unwound from the physician’s staff, whispering answers in my ears. Reflected in the sterile metal I see this differently: forehead tethered to a frown by ostentatious earrings weighing me down like question-marks in lead. Tim Metcalf
of peer-reviewed research, relevant to the chaos in any large hospital. Gawande was well advised to keep a diary during his intern year, and perhaps doing so should be a prerequisite for postgraduate examinations—not necessarily for content, but as proof of purpose, and capacity of reflection. When The Lancet started its Uses of error section (Lancet 1999; 353: 422–23), the many people assumed that no one would write for it. Embarrassment, the statute of limitations, career advancement, professional liability, and patients’ confidentiality were all evoked. But the column has been published for more than a year, and has no shortage of submissions. Given an appropriate forum, doctors are willing, it seems, to publish their mistakes; although not many will have the energy, inclination, and spare time to write the sort of book Gawande has. Existing conventions for acknowledging and dealing with medical error are insufficient, and although Gawande tries to make a case for the enduring value of morbidity and mortality conferences in American hospitals, he does not attempt to compare the rates of fatal mistakes in hospitals that hold such conferences, with those that don’t. Such a study that would have to account for many confounders, including billing practices, aggressive intervention by community paramedics, staffing levels, turnover rates, disease-burden of the populations served, bed capacity and occupancy, and case load. Even between-hospital variations in the way morbidity and mortality conferences are run could result in big differences in error rates and reporting. I remember a chief of surgery chastising a senior resident who announced at one such conference, that the “third-year resident did the emergency thoracotomy, and the patient died, as usual”. The message was that each failure must be presented as an idiosyncratic mistake, perpetrated by a tired and overwrought individual, who, in the relentless hierarchy of hospital structure, is continually seeking advancement, and is continually suspect. Complications is a welcome antidote to such obstinate myopia; a model synthesis of personal confession, introspection, and systems analysis on which the serious work of reducing medical error could be based. Laragh Gollogly The Lancet, London, UK
THE LANCET • Vol 360 • November 9, 2002 • www.thelancet.com
Scoop on drugs in sport Jim Young of the Welsh charity, Wired International, wrote to tell us about Drugs in Sport, a site that presents up-todate news on doping and antidoping measures in sports, as well as relevant reports and resources. The site, which is well maintained and easy to navigate, should be of interest to physicians, writes Young, “because many doctors are involved with both therapeutics and preventive medicine in sports [and the] statutory medical supervisory compliance as laid down by various governing bodies”. http://www.drugsinsport.net Medical whistleblower site Medical student and web editor Joel Newman (http://www.joelnewman. com) wrote to tell us about a website he developed “that allows free and anonymous whistle-blowing to members of the medical profession—something that the Junior Doctors Committee of the British Medical Association has been asking for”. The site uses encryption methods “to make it as safe as possible to blow the whistle on malpractice”. The site aims to act as a go-between, shuttling information from the whistleblower to the appropriate organisations, while preserving the anonymity of the information provider. http://www.thewhistle.org Child-friendly health advice The UK Institute of Child Health and Great Ormond Street Children’s Hospital in London have launched a health-advice site aimed at children aged 5–15 years, with separate areas for tots, young children, and teens and young adults. Children can take a virtual hospital tour, find information about specific diseases, read about other children’s experiences with various illnesses, and share their own stories. The site includes age-appropriate dictionaries and interactive games and quizzes. http://www.goshkids.nhs.uk Helping children cope with disaster The American Academy of Pediatrics launched a new area of their website to help physicians, parents, community leaders, and others in preparing for and meeting children’s needs in a disaster. Included are timely information on emerging bioterrorist threats, research articles, and advice on communicating with children. http://www.aap.org/terrorism Marilynn Larkin e-mail: [email protected]
1523
For personal use. Only reproduce with permission from The Lancet Publishing Group.
Primum non nocere
Websites in brief
Complications: Decisions and Dilemmas of a Surgeon’s Life Atul Gawande. Profile Books: London, 2002. Pp 269. £12.99. ISBN 1 861 97413 2. hat do doctors remember decades after their first plunge into the fray, after the shock of fallibility has worn off, and they have become inured to incompetence, simple mistakes, ethical misconduct, and deliberate malpractice of which they, and their colleagues, are capable? What do necrotising fasciitis, hyperemesis gravidum, thoracic spine metastases, chronic pain, and obesity have in common, apart from being personally memorable cases for the author, and good but arbitrary examples of the profession’s current limitations? When invited to recall their worst errors, do doctors prevaricate, confess to having inadequately supervised a junior, or do they come up with a series of plausible, and distressingly repetitive, case histories? The essays in Complications: Decisions and Dilemmas of a Surgeon’s Life (some published in the New Yorker or at http://www.slate.com) belong to the latter category. Atul Gawande, a surgical resident and health-policy adviser to the Clinton administration, reflects on the imprecision of human judgment and the practice of medicine, in the tradition of self-examination, castigation, and justification exemplified by The House of God (1978) and Dr X (1972). Gawande may, however, be a step closer to revealing patterns that underlie medical error as, despite laudable attempts to “change minor identifying details of individuals” to protect patients’ confidentiality, his book is resolutely nonfiction. The inevitability of medical error is broached, but not resolved, in these punchy stories peppered with summaries
W
can’t . . . breathe In tense moments I wish my stethoscope was all they want it to be: two steely serpents unwound from the physician’s staff, whispering answers in my ears. Reflected in the sterile metal I see this differently: forehead tethered to a frown by ostentatious earrings weighing me down like question-marks in lead. Tim Metcalf
of peer-reviewed research, relevant to the chaos in any large hospital. Gawande was well advised to keep a diary during his intern year, and perhaps doing so should be a prerequisite for postgraduate examinations—not necessarily for content, but as proof of purpose, and capacity of reflection. When The Lancet started its Uses of error section (Lancet 1999; 353: 422–23), the many people assumed that no one would write for it. Embarrassment, the statute of limitations, career advancement, professional liability, and patients’ confidentiality were all evoked. But the column has been published for more than a year, and has no shortage of submissions. Given an appropriate forum, doctors are willing, it seems, to publish their mistakes; although not many will have the energy, inclination, and spare time to write the sort of book Gawande has. Existing conventions for acknowledging and dealing with medical error are insufficient, and although Gawande tries to make a case for the enduring value of morbidity and mortality conferences in American hospitals, he does not attempt to compare the rates of fatal mistakes in hospitals that hold such conferences, with those that don’t. Such a study that would have to account for many confounders, including billing practices, aggressive intervention by community paramedics, staffing levels, turnover rates, disease-burden of the populations served, bed capacity and occupancy, and case load. Even between-hospital variations in the way morbidity and mortality conferences are run could result in big differences in error rates and reporting. I remember a chief of surgery chastising a senior resident who announced at one such conference, that the “third-year resident did the emergency thoracotomy, and the patient died, as usual”. The message was that each failure must be presented as an idiosyncratic mistake, perpetrated by a tired and overwrought individual, who, in the relentless hierarchy of hospital structure, is continually seeking advancement, and is continually suspect. Complications is a welcome antidote to such obstinate myopia; a model synthesis of personal confession, introspection, and systems analysis on which the serious work of reducing medical error could be based. Laragh Gollogly The Lancet, London, UK
THE LANCET • Vol 360 • November 9, 2002 • www.thelancet.com
Scoop on drugs in sport Jim Young of the Welsh charity, Wired International, wrote to tell us about Drugs in Sport, a site that presents up-todate news on doping and antidoping measures in sports, as well as relevant reports and resources. The site, which is well maintained and easy to navigate, should be of interest to physicians, writes Young, “because many doctors are involved with both therapeutics and preventive medicine in sports [and the] statutory medical supervisory compliance as laid down by various governing bodies”. http://www.drugsinsport.net Medical whistleblower site Medical student and web editor Joel Newman (http://www.joelnewman. com) wrote to tell us about a website he developed “that allows free and anonymous whistle-blowing to members of the medical profession—something that the Junior Doctors Committee of the British Medical Association has been asking for”. The site uses encryption methods “to make it as safe as possible to blow the whistle on malpractice”. The site aims to act as a go-between, shuttling information from the whistleblower to the appropriate organisations, while preserving the anonymity of the information provider. http://www.thewhistle.org Child-friendly health advice The UK Institute of Child Health and Great Ormond Street Children’s Hospital in London have launched a health-advice site aimed at children aged 5–15 years, with separate areas for tots, young children, and teens and young adults. Children can take a virtual hospital tour, find information about specific diseases, read about other children’s experiences with various illnesses, and share their own stories. The site includes age-appropriate dictionaries and interactive games and quizzes. http://www.goshkids.nhs.uk Helping children cope with disaster The American Academy of Pediatrics launched a new area of their website to help physicians, parents, community leaders, and others in preparing for and meeting children’s needs in a disaster. Included are timely information on emerging bioterrorist threats, research articles, and advice on communicating with children. http://www.aap.org/terrorism Marilynn Larkin e-mail: [email protected]
1523
For personal use. Only reproduce with permission from The Lancet Publishing Group.