Mrs Drucker died as result of a doctor’s error.
Who says so?
Dr Brian Goldman was a resident in the Emergency Department of a teaching hospital at the time he sent a “wife, mother, grandmother” home when she should have stayed put.
As a highly motivated and successful Med School student, Dr Goldman’s reaction to his first experience of fallibility was to “redouble my efforts to be perfect and never make another mistake again”.
But it wasn’t enough. Decades later he admits to further errors committed throughout his career.
In a TED talk, remarkable for its humility, honesty and passion, the Canadian physician pleaded for a reformed medical culture in which doctors are free to talk about their mistakes and learn from each other by having that discussion.
He described a system in which “mistakes are inevitable” and where it is tacitly assumed the way to free the institution of its flaws is to remove the individuals responsible.
Not so, he says. “If you take the system, as I was taught, and weed out all the error-prone health professionals, well there won’t be anybody left.”
Yet, he says, an atmosphere of “complete denial” conceals the issue.
He confessed he didn’t know whether the TED audience would love or hate him for revealing “failure, after failure, after failure” in health care provision. But it was impossible not to be moved by his candour and his desire to make a difference by encouraging a new paradigm. It consists of what he calls “the redefined physician”, someone who “works in a culture of medicine that acknowledges that human beings run the system and when human beings run the system they will make mistakes from time to time”.
In the event, the audience loved him. He got a standing ovation.
But it is hard to imagine they loved hearing of the status quo he was revealing.
How then can the element of “human error” be kept to a minimum?
In recounting his story of Mrs Drucker, Dr Goldman touched on a quality which he clearly felt would have made all the difference that day: the humility to trust intuition.
He recalled that in sending her home prematurely he “disregarded a little voice, deep down inside, that was trying to tell me ‘Goldman, [that’s] not a good idea, don’t do this'”.
A comment posted by another physician about her own Med School experience echoes this need to listen to that intuitive sense. “I was never warned against my inner voice during my training, just that intuition should be backed by study, sound medical evidence, and experience.”
The acknowledgment that an “inner voice” and knowledge are both viable components of health care is significant. And the idea the latter backs the former, rather than the other way around, is intriguing.
Could heeding intuitions more consistently improve decision-making within medical practice and reduce mistakes? Might medical care change markedly if this were normal practice?
It would certainly highlight a quality that finds favour among many who use less material approaches to health care.
In the prayer-based health care I practise that references Jesus as its model exponent, intuition is pinpointed as a starting point on a mental journey that climbs through hope and faith to an understanding that brings spiritual resolution and practical change.
Like all qualities that are key components of a successful health practice, such intuition needs to be honed through usage – through expecting it, recognising it, acting on it and, like Dr Goldman, through honestly assessing the success or failure of one’s engagement with it.
Whether we study medical texts or sacred Scriptures, whether our experience is of the workings of the body or of the spiritual capacities of the mind, whether our reference point is “sound medical evidence” or our own and others’ healing narratives, we can all benefit our patients by nurturing such intuition.
This blog originally appeared in the Huffington Post UK on 2 April, 2012