Physicians must be aware of what they know they don’t know

St. Augustine: “Fallor ergo sum”

When I was in charge of the medical residency programs in Grand Rapids, Michigan, David Leach introduced me to the expanded Dreyfus Model of how physicians can progress from beginners to masters.

I was always struck by how master physicians freely admitted their mistakes and used them as a teaching tool.  As a young surgical and cytopathologist, my sanity was saved more than once by University of California San Francisco’s Dr. Theodore R. Miller, a true master of cytology, being willing to share with me some of his mistakes.  I do not honestly think I could have survived in diagnostic pathology without his guidance and wisdom.  Years later, I still remember Dr. Miller showing me a breast fine needle aspiration biopsy slide of fat necrosis that mimicked ductal carcinoma and a case of wrongly diagnosed pancreatic cancer that turned out to be inflammatory atypia.

Mistakes and errors are on my mind because I just finished reading some extraordinary works.

Kathryn Schulz’s Being Wrong: Adventures in the Margin of Error has convinced me that we should replace our usual pessimistic model of error with an optimistic model of error.  All physicians make mistakes and are familiar with the former model and the accompanying feelings of worthlessness, shame, and depression.  Recalling cases where I got the diagnosis wrong still make me want to throw up years later.  Schulz is right when she writes, “being wrong runs a narrow, unhappy gamut from nauseating to worse than death.”

Some of my own errors formed the basis for my chapter “Pitfalls in Cytology of the Breast” in Errors and Pitfalls in Diagnostic Cytology, and I still remember being uncomfortable giving the lecture to the International Academy of Pathology in Washington, DC in 1997.  Admitting to mistakes might mean I was a bad pathologist; being a bad pathologist felt a lot like being a bad person. That day at the Hilton Hotel on the podium I did not feel like a master pathologist.

Schulz contrasts this pessimistic reaction to error with an optimistic reaction where one can be baffled, fascinated, amused, excited and delighted by owning up to a mistake.  She quotes both William James and Henri Bergson to great affect.

“Our errors are surely not such awfully solemn things.  In a world where we are so certain to incur them in spite of all our caution, a certain lightness of heart seems healthier than this excessive nervousness on their behalf.”  — James

“Look upon life as a disinterested spectator.  Many a drama will turn into comedy.” — Bergson

Henry Petroski’s Success Through Failure: The Paradox of Design argues for the optimistic view of mistakes in examples such as bridge design, tall building architecture, bicycle lock design, and NASA’s Challenger tragedy.  Over and over again, Petroski shows how success teaches us very little and failure teaches us a lot. The creed at IDEO, the famous design company, is “Fail early, fail often.”  Professor Jack Matson believes so strongly in the role of failure in design that he expects students in his Innovative Engineering Design course at Penn State University to fail in order to pass.  “Innovation requires that you go beyond the known into the unknown, where there might be trap doors and blind alleys.  You’ve got to map the unknown.  You map it by making mistakes.”

What really got me thinking about error in a new way was Schulz’s treatment of illusions.  I was already familiar with the two faces/vase and old woman/young woman visual illusions, but I was blown away by Scottish explorer John Ross discovering the illusory Croker Mountains in Lancaster Sound and American Robert Peary who saw a mirage of an entire continent in northern Canada.  Although Ross’ illusion ruined his career, our usual response to illusions is amusement and wonder.  Illusions really do upend our conventional reaction to being wrong.

This amazing book by Schulz made me think about life in a new way.  Her thoughts on St. Augustine, Dadaism, zealotry, groupthink, Ben Franklin, and the Talmud convince me that to be human is to make mistakes.  Just one example: according to the Talmud, “if there is an unanimous guilty verdict in a death penalty case, the defendant must be allowed to go free – a provision intended to ensure that, in matters so serious that someone’s life is on the line, at least one person has prevented groupthink by providing a dissenting opinion.”

In The Invisible Gorilla: And Other Ways Our Intuitions Deceive Us Christopher Chabris and Daniel Simons expanded my appreciation for humans making mistakes by explaining the brain’s illusion of knowledge.  Examples include the world’s leading geneticists predicting that humans have between 25,747 to 153,478 genes when the right answer is 20,500. Leon Rozenblit and Frank Keil did dozens of experiments which all showed that we are “blissfully unaware of the shortcomings in our own knowledge.” For example, The Big Dig in Boston cost 250% more than originally planned because the civil engineers thought they knew more than they really did about putting streets underground.  The authors also remark that our illusions all tend to cast an overly favorable light on human mental capacities. “There are no illusions of blindness, amnesia, idiocy, and cluelessness.”  Later in this blog, we will see they may be wrong here. It is also sobering to note that people with depression are said to have a more accurate view of their relationship to reality than others who are not depressed.

I zeroed in on Jonah Lehrer’s treatment of mistakes in How We Decide, and I think Schulz would be happy with his effort.  Bill Robertie, a world-class expert at chess, poker, and backgammon, claims that the way to improve is to focus on mistakes.  The famed physicist Niels Bohr defines an expert as “a person who has made all the mistakes that can be made in a very narrow field.”  I was impressed by Carol Dweck’s studies at Stanford that showed that praising students for their intelligence resulted in worse performances than praising students for their effort.  However, I was most impressed by the story of Michael Riley of the Royal Navy and how he used his intuition to correctly differentiate a silkworm missile from a friendly airplane by listening to his intuition and his dopamine receptor.

Since mistakes are such a central part of human life, one would think we would get really good at apologizing.  Think again.  Lisa Belkin nicely summarizes how difficult it is for us to say sorry sincerely.  Although apologies are “the most profound of human interactions” that can heal and resolve guilt and anger, some now see many non-apology apologies that do not satisfy either the sinner or the victim.  Think recent apologies by Tiger Woods or BP’s Tony Hayward.  Or maybe an even better example of non-apology apologies is GOP Congressman Joe Barton apologizing to BP and then apologizing for apologizing to BP.

According to Belkin, some states have passed laws making a doctor’s apology inadmissible as evidence in a lawsuit, in the belief that patients find solace when a doctor admits a mistake, and that doctors are more likely to do so if they are taking part in a conversation and not a confession. “These laws might well free doctors to speak more honestly with patients and families and allow for a chance to truly repair their relationship. Or they might have the opposite effect entirely. With less at stake for the doctors, could apologies become pro forma and, as a result, less powerful?”

My friends, family, and co-workers were getting tired of me raving about the above four books, when I stumbled upon something even more mind boggling: Errol Morris’ The Anosognosic’s Dilemma:  Something’s Wrong but You’ll Never Know What It Is (Parts 1-5).

This article ricochets from Donald Rumsfeld to McArthur Wheeler (a hapless bank robber who thought lemon juice would make him invisible) to the famed neurologist Joseph Babinski to President Woodrow Wilson to Marcel Proust to surrealism.  The starting point is the Dunning-Kruger Effect which was described in a landmark article titled “Unskilled and Unaware of It: How Difficulties of Recognizing One’s Own Incompetence Lead to Inflated Self-assessment.”

Anosognosia (from the title of the Morris article) is a condition in which a person who suffers from a disability seems unaware of or denies the existence of his or her disability; it was first described by Babinski in patients who were paralyzed but refused to acknowledge their problem.

Morris thinks deeply and creatively about “known unknowns,” “unknown unknowns,” and “unknowable unknowns.”  In interviewing David Dunning, he discusses how the mediocre doctor is not aware of diagnostic possibilities and treatments that he never considers.  More disturbing is a study of medical students which shows that those at the bottom of the class cannot learn by being shown what the smart students are doing to progress along the Dreyfus model of competence.  They are like McArthur Wheeler who was too stupid to know that he was too stupid to successfully rob banks.

Morris’ epilogue states:

I have to admit my fondness for the Dunning-Kruger Effect.  But is it a metaphor for existence? For the human condition?  That we’re all dumb and delusional?  So dumb and delusional that we can never grasp that fact?  It’s so profoundly depressing and disturbing.  Even sad.  Dunning gives us no hope.  The McArthur Wheelers of this world will never understand their limitations.  But aren’t we all McArthur Wheelers?

I think we are all McArthur Wheelers, but I am comforted by V. S. Ramachandra’s observation that “It may well be our brains are wired up to be slightly more optimistic than they should be.”

For any physician to be a master diagnostician he or she must learn from mistakes and also be acutely aware of what they know they don’t know.  They must also admit that some things about people and their ailments are just unknowable.  Making mistakes does not make you a bad doctor or a bad person.  Making mistakes makes you a human being.  Get used to it.  And learn how to apologize sincerely.  You might want to read On Apology by Aaron Lazare, MD.  I just did, and I have a lot of work to do.

Kent Bottles provides health care leadership consulting and blogs at Kent Bottles Private Views.

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