Clinical Leadership 2: Sorry is the Hardest Word

Henry Marsh CBE,MA,FRCS Consultant Neurosurgeon

St George’s Hospital,London

UK General Medical Council: Duty of Candour 2015

• “You MUST apologize when a mistake has been made”.

• This will usually be the duty of the most senior responsible clinician, irrespective of who has made the mistake

• “For an apology to be meaningful it must be genuine”

Health and Social Care Act 2008. Regulations 2014. Regulation 20

• “Providers must be open and transparent” • If a notifiable safety incident occurs the

patient must be informed both verbally and in writing and an apology (“an expression of sorrow or regret”) given.

• Providers must promote a culture that encourages candour,open-ness and honesty at all levels.

Honesty

• Honesty with patients • Honesty with colleagues • The doctor’s honesty with himself/herself

21 international editions published or in preparation Best seller in 4 countries to date

“…a self-lacerating document…” (New Statesman) “..A long apology to the patients…he has wrecked” (Literary Review) “…doesn’t flinch from admitting disasters..” (The Observer) “Marsh is the most honest author I've ever come across with regard to his own failings... “ ( Independent on Sunday) “Again and again Marsh trains… heat-seeking missiles on himself” (The Sunday Times) “…will have you on the edge of your sunlounger” (Sandra Parsons DAILY MAIL 'Summer Reading')

Mistakes

• We learn most from mistakes ( as Harvey Cushing once observed)

• We learn little from success. Success can corrupt us.

• For doctors to know when a bad result is due to bad luck or a bad mistake requires that we are honest with ourselves.

Why is it difficult and unusual for doctors to be honest? 1

• When we are ill we want to be given hope. We are frightened and fear the truth.

• Doctors learn to pretend, to deceive both in order to please their patients and to avoid a painful conversation.

• Empathy hurts • The best way of deceiving others is to deceive

yourself

Why is it difficult and unusual for doctors to be honest .2

• As a surgeon, if you don’t take on the difficult cases, how will you become a better surgeon, even if another surgeon has more experience than you do?

• Fear of the patient losing faith in you. • Competition – professional and financial • Power corrupts and absolute power corrupts

completely • We don’t like to think badly of ourselves • Cognitive biases

MISTAKES

• Errors of clinical judgement – “It was a difficult case”

• Carelessness

32 year old woman in coma with fixed dilated pupils and a 3 day history of headaches.

• We must operate because we don’t have a diagnosis and therefore we don’t know if she might make a good recovery or not.

• But we do know that the chances of a good recovery are very small.

René Leriche 1879 – 1955

“Every surgeon carries within himself a small cemetery to which he must go from time to time to contemplate. It is a place full of bitterness and regret. A place where he must look for an explanation for his failures.”

Rene Leriche. La Philosophie de la Chirurgie. Paris. Flammarion. 1950.

MP – 40 year old female with Chiari malformation

• Uncomplicated f. magnum decompression. Home within three days of surgery.

• Phone call on my mobile from husband one week later, on a Sunday morning while I am dealing with an emergency in the hospital.

• “She’s in bed , feeling a bit rough”. • I prescribe steroids, making a diagnosis of aseptic

meningitis and tell him to bring her to see me if she is no better.

• Just at the end of the conversation he says “What about the way the wound is leaking a bit?”

Post-op f. magnum decompression

Theenglishsurgeon1

Shunt revision

COGNITIVE BIASES

• We are inconsistent in estimating probability

and risk, and other people’s qualities.

• We jump to conclusions too quickly and make mistakes (“System 1 and System 2”)

An analogy for cognitive biases – the Muller-Lyer Illusion

• A bat and ball together cost $1.10 • The bat costs one dollar more than

the ball.

• What does the ball cost?

Cognitive biases Confirmation effect

Halo effect Hindsight bias

Availability heuristic Framing effect

Anchoring Optimism bias

And many more……..

Availability heuristic

• The availability heuristic is a mental shortcut that uses the ease with which examples come to mind to make judgements about the probability of events.

• The ease will be influenced by the emotional consequences of similar previous events – which may well be out of proportion to the probability.

Anchoring

• Simple large L5/S1 disc with Left sciatica. • Consented by myself for Left microdiscectomy. • PACS breakdown – no scan in Theatre. Two

other discs to do – both on the right side. • I remove large fragment from a Right-sided

fenestration, entirely certain that all three cases were right-sided.

Framing effect

“The Asian disease problem” • An outbreak of an unusual Asian disease is

expected to kill 600 people. Assume that the exact scientific estimates of the consequences of two different programmes to combat it are as follows:

• A: 200 people will be saved • B: 1/3rd chance 600 will be saved and 2/3rds

chance everybody will die.

Asian Disease Problem 2

• A: 400 people will die • B: 1/3rd chance everybody will be saved,

2/3rds chance that nobody will be saved.

You have an epileptic fit. The MRI scan shows a non-enhancing left

insular tumour.

You see Dr.X the famous low grade glioma surgeon who offers you:

• Option A: without surgery you have an 80% chance of being dead within ten years.

• Option B: With surgery you have a 50% chance of being alive in ten years time (but a 15% risk of suffering a severe stroke)

You see Dr Y, elderly and less famous, who offers you:

• Option A : a 20% chance of being alive at 10

years without any treatment. • Option B: a 50% chance of being dead within

10 years if you undergo surgery and a 15 % risk of a major stroke.

Halo Effect

• “The tendency to like (or dislike) everything about a person…”

Mis-placed posterior fossa craniectomies x2 Trans-sphenoidal – carotid injury. Resection of L5 root for L5/S1 discectomy. 26 year old male with a huge meningioma Division of the vertebral artery for an MVD

We cannot entirely avoid cognitive biases

What can be done about biases?

“Recognize that you are in a cognitive minefield,

slow down….(but) more doubt is the last thing you want when you are in a minefield. The upshot is that it is much easier to identify a minefield when you observe others wandering onto it than you are about to do so (yourself)..”

Kahneman. Thinking,Fast and Slow p.417

A fundamental rule of human nature:

Other people are better at identifying my mistakes than I am.

How can we avoid making mistakes?

• By having good colleagues who feel able to

criticize us! • By being a good colleague!

How can we encourage honesty and open-ness among doctors?

• Enforcement – duty of candour • Exhortation. • Example

• With difficulty. Doctors will be honest if they

have less to lose – professionally or financially.

EXHORTATION

By Example

Informed Consent

• University of Virginia • Don’t specify everything • The management of complications starts with

the first conversation with the patient and family

• Should not be left to the junior doctors • Trust

What have I learned ?

• Balance is everything • Compassion v. professional detachment • Individualism v. team working • Personal responsibility v. collective duty • Bravery( recklessness) v. caution (cowardice) • Making money v. altruism • Optimism v. realism • Invention v. protocols and guidelines • Trust v. regulation