It should have been resolved as a mild case of swimmer's ear. The boy and his mother paid a visit to their primary care physician after school. The physician greeted them with reassuring levity. The boy explained that he had been feeling some minor discomfort in his right ear and suspected he had caught an ear infection. The physician proceeded to examine his ear with an otoscope, noting that the boy's ear canal was tiny—as small as a baby's. He said at the very least he could irrigate the ear to offer some relief. After drawing a large, silver syringe with water, he placed its opening in the boy's ear and began to push. But what no one in the room could foresee was that the boy's ear would fit the syringe too snuggly, leaving no exit for the torrent. Before the boy could signal distress, the building pressure burst through the eardrum. Tearing from the pain, the boy looked to his physician for an explanation.
However, the physician told his mother that this was a routine outcome. When she called, after spotting blood and pus began draining from his ear, he reassured her. They believed him and thus did not seek emergency care. The next week, the boy endured intractable pain, unable to go to school or sleep. Since the error had not been correctly addressed earlier, the boy did not receive the right diagnosis or pain medication, and thus was left deaf in his ear until he undertook corrective surgery. He has yet to receive a follow-up call from his primary care physician.
A decade has passed since the incident and that boy has now become a fourth-year medical student. I still think back on the helpless, injured child I once was, and feel that I have not yet found closure. Why did my physician find it so difficult to admit his mistake? Was he unaware? Was he afraid of being sued? As trainees, we are told repeatedly that all physicians inevitably make mistakes. There is extensive literature on the value of owning up to one's mistakes.1–3 So why did my physician fail to do it?
On the first week of my internal medicine rotation, I took care of a 65-year-old woman who had been admitted to the hospital with symptoms suggestive of a pulmonary embolism. Due to her underlying sarcoidosis, it was difficult to discern whether her dyspnea and chest pain were secondary to an embolus. Before going home, the team debated whether a computerized tomography (CT) scan would be of benefit. We would wait and see. The next morning as I reviewed her data, I noticed there was a report of a CT scan from the prior evening, which ruled out the embolus. Quickly assuming the overnight team had decided to pursue imaging and encouraged by the new data, I presented this finding on morning rounds and reassured the team that she was fine and ready for discharge. “Are you sure?” my resident asked. “I didn't see anything the last time I checked.”
“I'm sure,” I replied.
But as I perused the patient's chart in preparation for discharge, I came to a heart-stopping realization. In a moment of early morning carelessness, I had mistakenly reported a study from the same date several years prior. In fact, there had not been a new CT scan that ruled out her pulmonary embolism. I remained silent, riveted to my seat and drenched in sweat, mortified of my own mistake. Only after agonizing for hours was I able to muster enough courage to apologize to the team and rectify my error. Although it had delayed my patient's diagnosis by half a day, thankfully the scan did ultimately rule out a pulmonary embolus.
This experience has given me greater insight into why physicians struggle with admitting their errors. Acknowledging my mistake took me through a constellation of dreadful feelings, such as ineptitude, the fear of being negatively judged by my team, and the guilt of having potentially harmed another person. In the process, I learned an important distinction between not knowing what is right and not having the emotional fortitude to do the right thing. I used to believe that admitting an error would be straightforward after defining what constitutes one, but it was the contrary. Despite having blamed my pediatrician all these years for his unwillingness to be forthcoming, I also found myself unprepared to overcome the emotional distress and fear of repercussions. I ultimately failed to find the courage to disclose my error to the patient and her family.
This kind of fear grabs us from the inside and renders us speechless. It is a formidable multifactorial barrier, stemming from our desire to preserve our job, institution, prestige, and self-esteem. Medical schools have recognized this difficulty, and have begun to implement standardized patient encounters to encourage inward reflection and elicit negative feelings so that physicians at all levels of training can continually refine their interpersonal skills.4 Virtual curriculums on this topic also exist. Yet, these classes are infrequently offered as singular modules, which may explain why they are often underused. What if these opportunities to practice and prepare for difficult encounters were more readily available to medical trainees in times of need? When I realized that I had made a mistake, I lacked the confidence in my own ability to disclose the error to my team and patient. Speaking to another person for advice on how to approach the conversation and to receive feedback on my delivery would have greatly reduced the fear that initially drove me to inaction.
In a good clinical team, the members are its greatest resources. However, many attributes of the culture of medicine, including hierarchy and fear of poor evaluations, can stand in the way of disclosing errors. Perhaps, senior team members emphasizing their receptiveness and offering to help those who wish to rehearse difficult conversations might alleviate the vulnerability junior staff may experience.5–7 Over time, this atmosphere could engender a culture in which members of the same team feel comfortable asking each other for help. Occasional in-house standardized patient support may be useful to prepare learners for cases requiring extra guidance. Ultimately, increasing the number of conversations on the topic of error disclosure will help train physicians who are truly versatile and humanistic in any clinical setting. Through practice we forge habits of routinely advising patients to quit smoking or increase their weekly exercise. Admitting error, too, can become a habit.
Not all healing comes from perfect medical practice. A physician admitting his or her own error provides healing and closure as well. The disappointment I felt, and the injury I received from my physician 10 years ago, did not constitute the mistake he had made; rather, the error was his failure to acknowledge and disclose this mistake. Although my initial belief was that my physician lacked morals or did not know any better, my opinions have grown more nuanced after failing to disclose my own error. I understand now that there is a theory-execution gap in medicine that physicians must confront and overcome with courage and practice. As I look forward to my own career, I know there will be moments when I make errors. I hope that instead of turning away in shame and guilt, I will offer honest disclosure to help rebuild trust and move forward.