In the other book, surgeon Atul Gawande described how he almost lost an Emergency Room patient who had crashed her car when he fumbled a tracheotomy only for patient to be saved by another surgeon who successfully got the breathing tube inserted. Gawande also has a chapter on doctors’ errors. His point, documented by a paper in the New England Journal of Medicine (1991) and subsequent reports is that nearly all physicians err.
If nearly all doctors make mistakes, do they talk about them? Privately with people they trust, yes. In public, that is, with other doctors in academic hospitals, the answer is also yes. There is an institutional mechanism where hospital doctors meet weekly called Morbidity and Mortality Conferences (M & M for short) where, in Gawande’s words, doctors “gather behind closed doors to review the mistakes, untoward events, and deaths that occurred on their watch, determine responsibility, and figure out what to do differently (p. 58).” He describes an M & M (pp.58-64) at his hospital and concludes: “The M & M sees avoiding error as largely a matter of will–staying sufficiently informed and alert to anticipate the myriad ways that things can go wrong and then trying to head off each potential problem before it happens” (p. 62). Protected by law, physicians air their mistakes without fear of malpractice suits.
cmmarqua on 25 Jan 17Verbose article weighing the effectiveness of pedagogy first, technology second or technology first and educational process second
