Exceptionalism

For those who are aware of the risks inherent in our current system of medical practice, there is a dangerous cognitive trap – a trap that catches many good caregivers who otherwise have only the best intentions and the utmost concern for their patients. That trap is the trap of exceptionalism.

“I understand that central line placement is invasive and leads to many infections in the healthcare setting each year, but none of the central lines that *I* place get infected.”
Or, even more dangerously: “I don’t have a study to support this decision, but *every* time I’ve done this for a patient, things have worked out fine, so it *must* be the right decision.”

It’s easy to think, as a rising second-year medical student, that many of the issues I’m learning about this week *will* apply to me in my *future* practice, but are not sins of which I am personally guilty. After all, I am hardly responsible for any patient care at my home institution at this point in my training. What harm could I have brought to anyone as of yet? Do we not, half in jest, say that the movement for patient safety is about educating the young and regulating the old?

I may still be young, but I realized today that I have already made a critical error in judgment.

We devoted much of today’s morning session to the screening and discussion of the story of Lewis Blackman, a teenaged boy whose life was cut tragically short by a series of errors in clinical judgment, reasoning, and practice which stacked upon each other like a derailing train, horrifying to witness in hindsight. (Such a sense of horror, however, does not adequately describe the experience related by Lewis’s mother, Helen, who recounts his story as a patient advocate for reform.) Lewis’s doctors and other caregivers allowed their assumptions to snowball with terrifying force and momentum when even a reflection or careful double-check might have called due attention to his decompensating condition and impending crisis.

A tribal tendency persists among many physicians to protect our own from the accusation of wrongdoing or error, but the motivations underlying that tendency arise from multiple considerations. As a doctor, it is easy to think that if one protects his or her peers, those same peers will be more likely to reciprocally protect him or her. I believe the tendency toward protection goes deeper even than that. We defend our colleagues against accusations of wrongdoing or error because we trust them both implicitly and explicitly on the basis of our shared training and experience as physicians. Without that trust, no consult, collaboration, or cooperation would be possible, professionally. To press the point even further, there might be the sense that any doubt of a colleague’s conduct casts shadows on one’s own personal assumptions of competence. “He and I received the same training. Thus, we must be roughly equivalent in our capacity to provide high-quality care. If I were to doubt that capacity in *him*, on what basis could I assume it in myself?” Since self-doubt, or even a lack of self-confidence, are so frowned upon by the traditional ethos of the field, these thoughts are unthinkable.

Which brings me back to my own, personal assumption of responsibility for my error.

At the request of someone close to me, I sought out recommendations for a caregiver – a specialist in their field, this individual was considered exemplary in all respects, and a highly regarded expert in their subject matter. Even so, their chosen plan of care for the patient I brought to them did not go smoothly; adverse events were suffered which had not been discussed prior to decisions being made and prescriptions being written, and further adverse events were only avoided through the patient’s pursuit online of more information about their treatment. Frustrated, rather than returning to discuss what had happened with the doctor, this patient simply found another practice with a different plan of care.

Now, I can see this as the multileveled tragedy that it is, that
1) The patient was not offered adequate information about their treatment and what their expectations should be prior to clinical decisions being made on their behalf; and
2) The doctor was deprived of an opportunity to discuss the adverse events with the patient to better understand their experiences and potentially learn how such experiences might be averted for future patients.

At the time, however, I was at a loss for such perspective. How could I have failed so utterly to get necessary care for someone who needed it? How could everyone else have been so wrong in their estimations of this provider? Who was in the wrong, here? Me? The doctor? Could it possibly be the patient? My immediate instinct was to jump to the doctor’s defense. Surely something must be going on. I know this person by reputation, and they do not have a reputation for being a person who makes patients worse rather than better. But when I looked further into the caregiver’s choices, even I could admit that they were made on the basis of evidence that was shakily suggestive at best. Someone I knew very nearly suffered serious harm because of that feeling of exceptionalism – “If it works when *I* do it, I don’t need to support my decisions any further than that.”

Lewis Blackman’s doctors, who prescribed him a pain medication known in the literature at the time of his death to cause GI bleeding because it was their unexamined, unreviewed, and unrevised standard operating procedure to do so inflicted irreversible harm by their actions. However, not every patient who suffers an unsupportable decision pays with his or her life – and thank God for that. How many such stories of harm are missed by those of us who lose patients to followup? How many “near misses,” as we sometimes put it, or subacute events occur before a sentinel event forces us to take notice?

I cannot change my reactions of months or years ago, but I can learn from them, and I can do one more thing: I can say how truly, deeply sorry I am for the way I responded at that time. I understand now what I did not understand then: the importance of tempering professional trust with a healthy level of scrutiny that might advance the quality of care for all patients. It is altogether too easy to assume that the things we know about in the abstract will never happen to us or the people we love, in the same way that we assume that we are doing good work at fulfilling our responsibilities. Both assumptions can be tragically wrong when we succumb to exceptional thinking.

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