Friday, May 13, 2011

The Tyranny of Infallibility

Why is it so hard for we physicians to acknowledge that we’re human, prone to mistakes, misstatements, lapses in judgment, fatigue, or failure? I’ve had a most amazing week criss-crossing the country, doing presentations and having discussions with very interesting people.

One of those people was Jeff Skiles, co-pilot of USAir Flight 1549 that landed on the Hudson River in January 2009. I guess we say “on” instead of “in” because it didn’t sink - for awhile, at least. In the year and a half since I’ve known Jeff, he’s developed a very effective presentation on the impact of moving from autonomy to teamwork in commercial air transport. It’s that teamwork which contributed to the miraculous result for the passengers and crew.

A key point of Jeff’s comments is acknowledging fallibility, and dealing with it by building a team of people who learn how to communicate without “taking it personal” when they’re questioned by a team member. He said authority used to be based on fear or intimidation by the senior pilot. It’s now role-based authority.

When Capt. Sullenberger declared, “my aircraft” after the A320 hit the geese (Jeff was flying the plane), it was clear that the captain was taking responsibility for bringing the aircraft down. Jeff would go through the checklist to start the engines, if possible. Once it was clear that a crisis was occurring, the cabin crew began their respective autonomous actions to secure the cabin.

Jeff says his training in aviation comes in handy in his other roles as general contractor, husband and father. Now that’s a powerful testament to the effectiveness of these concepts!

I joined other ACPE faculty for some on-site teaching last week, and the topic of human error was discussed as a key component of the engineering science of reliability. I don’t know about you, but my instinct from years of being a physician is to believe that “human error” doesn’t apply to me – I’m a physician and not supposed to be fallible like other humans. That’s crazy!

Once we start talking about human error and the physician’s role, whether in full time clinical practice, or in system leadership, typical comments turn to our inability to admit we make mistakes because of the legal system. Are we using the legitimate but separate issue of the tort system to avoid discussion of our own human foibles, and appropriate methods of building safer care? Maybe we could find humor in our foibles, and have some fun with the topic instead of avoiding a necessary discussion!

Like many of you, and like some of the physicians with whom I teach, on certain occasions I’ve deliberately ignored the advice of a malpractice attorney to not admit I made a mistake in diagnosis or treatment. Knowing the truth of what happened and my role in it, withholding that truth from any human being isn’t right, and it eats away at me.

Most studies of physicians conclude that we do not like to be controlled or directed by others. If we don’t like the control that the tort system and lawyers have over us, then why do we exhibit learned helplessness by agreeing with them that we must not admit our fallibility?

Frankly, it’s liberating to discard the illusion that I should be immune from human error and weakness. That holds true for both clinical care, and in leadership or management roles. It’s self-imposed tyranny to think otherwise. Best yet, I believe that the key to improving safety, reliability – and changing the tort system – is in throwing off the chains of infallibility and perfection that we expect of ourselves, and adopting many of the concepts that helped other industries become much safer.