Medical Mistakes: Second-Guessing Myself

"Dr. Parker," the Neonatal Intensive Care nurse pressed urgently. "Baby Y is going sour. Her oxygen levels are falling fast. You've got to figure what is going wrong STAT and fix it! Quick, I think she's dying."

And I'm thinking to myself as she is talking, "Who is Baby Y? I've never heard of her... OHMYGOD. I've totally forgotten about Baby Y! I've completely been neglecting her care and now she is going down the tubes! I have no idea who she is! I have no idea what to do! I've completely screwed up!"

I then awaken with a racing pulse, hyperventilating, and relieved beyond measure that it is only a dream. Welcome to Dr. P's recurring nightmare, which plagued me throughout my pediatrics residency training (and for many years thereafter).

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Like most docs, I live in terror of screwing up. Certainly, there is no lack of opportunity to do so.

Take the call I got last night from a worried parent whose child had a high fever. Sure, it sounded like a virus and that it could wait until the morning. But what if it were a serious bacterial infection? What if it required immediate diagnosis and treatment? Could I have missed a subtle clue? Could this be meningitis I sat on?

What about the child in my office with a chronic bellyache? Sure it's usually not due to anything serious, but could this be the rare time that it is? Am I missing something? Did I miss appendicitis when she first came in with this complaint a few weeks ago? Lordy, lord. Am I screwing up?

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Many years ago, fresh out of pediatric training, I was caring for a child with a complicated and confusing picture (Was the persistent vomiting related to a problem in the head or the stomach? How seriously should I take the dizziness? Was this due to stress or to medical illness?). It wasn't clear to me how far to pursue it, if I might be missing something, and if I should admit him for an inpatient evaluation, etc. etc.

In the course of my obsessive worrying about the case, I asked a wise and experienced clinician, "Do you ever get to the point in your career where you are completely confident and you don't worry so much about if you are doing things right?" "No." was his succinct reply. "You never do."

That feedback was among the most helpful and prescient I ever received. I have come to believe that recognizing my own uncertainty and maintaining an openness to being wrong in my clinical care has been my best defense against my making bad errors.

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There is a wonderful article in the current New Yorker magazine by Jerome Groopman (an oncologist and writer). He notes that we "infallible" doctors make the wrong diagnosis at least 15% of the time (ouch!). Why might this be?

Research shows that most physicians already have a few limited hypotheses of what might be going on within minutes of meeting the patient. Then, as in all aspects of life, "believing is seeing" as we unconsciously contort any further history or examination findings to conform with that initial hypothesis. As Dr. Groopman writes:

" Doctors make such errors when their thinking is overly influenced by what is typically true; they fail to consider possibilities that contradict their mental templates of a disease, and thus attribute symptoms to the wrong cause."

In short, we're good at picking up the most common and usual cause of symptoms (like the flu in the middle of a flu outbreak), but not so great when thrown a curve (like a child with bacterial pneumonia during that same outbreak). Add an overweening self-confidence in one's opinion and an ego that precludes even considering one might be wrong, and the ingredients for an ongoing misdiagnosis are all in place.

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Here's another rub. Many of you want your doctor to be totally self-assured and confident, to appear to know exactly what is going on and what to do at all times. Hey, so do I! It's quite reassuring to put your child's well-being in the hands of such a physician, but beware the potential downside.

I've made my share of mistakes, but my abiding sense of uncertainty and insecurity (which I sometimes share with parents, sometimes not) has usually led to an insistence on following things up -- "just be sure" -- and to being open to reconsidering my initial diagnosis in the face of new evidence or an unexpected clinical course. I try hard not get my nose out of joint when parents question my judgment and advice, when they insistently ask "if it could be something else?", when they want a second opinion if I just can't seem to figure things out. That is, after all, what informed and empowered patients and parents should do.

Living with uncertainty is not a lot of fun and can be brutal on the ego, but I believe it has served me and my patients well. Don't be put off if your pediatric provider sometimes admits to being unsure about what is going on. She is just being honest and it is just that lack of certainty that may someday allow her to diagnose pneumonia in your child in the midst of a flu epidemic.

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Article cited:
"What's the trouble? How doctors think"
Jerome Groopman The New Yorker 1/29/07

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Your child and discipline: Who is raising whom?

It's always nice when research confirms what you have been preaching, as in the following headline that caught my eye: "Parents don't think discipline works in 1/3 of kids."

The study:
2,134 parents of children ages 2--11 years completed a questionnaire on their approach and feelings about how they discipline their kids.

What the study found

• 54% said they did not discipline their kids as they had been disciplined as a child; 38% said they were following their parents' example.
• The discipline techniques they were asked to report having used in the past month included: removal of privileges (31%), yelling (22%), sent to bedroom (19%), spanking (17%) and time-out (5%).
• One third described their disciplinary techniques as "never" or only "sometimes" effective; 21% said their discipline was "always effective".

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Dr. P comments
This statistic confirms Dr. P.'s 'Rule of thirds': "All discipline techniques work well in 1/3 of children, fair to middling in 1/3, and not at all in 1/3." (Actually the rule of thirds holds true for lots of other areas of pediatrics -- like the treatment of colic -- but let's stick with discipline for now).

Why should this be? Simple: there is no one-size-fits-all, perfect way to raise your child. Some kids do better with tight behavioral control, others when you ease the reins. Some respond well to punishment, others just need a cross look for them to do what you want. Some do best on a rigid schedule, others need to be allowed to hang loose, etc., etc...

Here's my bet: the 22% "perfect" parents have kids with easy dispositions, who are a piece of cake compared to the struggling 1/3 whose kids are temperamentally much more difficult. Who is raising whom? Are parents ineffectively yelling because the child is tough to manage (or else, why yell?) or is the child tough to manage because the parents are yellers? Or is it a combination of the two?

I contend that in order to provide proper discipline you first need to understand who and what your child is. Alas, that is easier said than done because, folks, this is rocket science. Children are complex and mysterious beings. The interplay of nature and nurture guiding your child's development is far more complicated than the physical laws governing rocket propulsion.

Only when you really 'get' your child can you fashion the kind of environment that will bring out his natural talents and allow him to overcome his behavioral and developmental challenges, can you make certain he grows up feeling loved and cherished for who he is (regardless of how he may not have met your fantasies of the perfect child), and can you accept that, in many ways, your child -- his own person from the start, with his own tempermanent, with his own wonderful and flawed way of being in the world -- is raising you as much as you are raising him.

Forget the usual discipline bromides touted as 'magic' by the gurus. You are (or should be) the true expert when it comes to what kind of discipline will be best for your child because you are the one who knows him best. Just work more on discovering him than inventing him and you'll do OK.

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Article cited:
Detrminants of Parental Discipline Practices: A National Sample From Primary Care Practices

Barkin S, et al. Clinical Pediatrics, January 2007

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Technorati Tags: parenting, discipline