I reflected on a recent case after reading Abhi Pal’s blog – Why bother listening to patients? – on the automatisation of medicine and the reduction of the human interaction between the patient and clinician. My case involved a non-English speaking patient who presented with vomiting on a background of complex co-morbidities in the Emergency department. The intern who saw the patient initially couldn’t find an obvious cause of vomiting. Upon my review, I noted that the vomiting was associated with vertigo and asked the intern to complete a more thorough neurological examination in which he identified lateral nystagmus and mild ataxia but no peripheral cerebellar signs. A CT brain was ordered under my instruction given a history of paroxysmal AF and no anticoagulation. The CT brain was normal and there was a mild improvement with stemetil.
The neurologist was in the department seeing another patient and I referred the patient to him. All good so far…
But following his review, the neurologist walked towards me on the staff base. He looked disappointed (why?) and politely explained that the patient had a positive head impulse test on examination (which is very suggestive of a peripheral cause of the vertigo) and they likely had vestibular neuritis. She was admitted for management of her symptoms.
Why was the neurologist disappointed? I think he was disappointed in me. I hadn’t spent the extra few minutes to perform a head impulse or head thrust test (which performs part of the HINT exam (1)) in a patient presenting with vertigo.
“More is missed by not looking than by not knowing.” – Thomas McCrae, 1870-1935
I felt embarrassed because I know how to perform a head thrust test and it usually forms part of my examination in a patient with vertigo. It led to some navel-gazing and introspection on why I didn’t in this case. Busy? Forgetful? Distracted?
Or could this be symptomatic of the barriers created between patients and clinicians by computers as we spend more time entering data than speaking with our patients? There is evidence that the increasing implementation of electronic medical records has fueled the removal of the clinician from the patient’s bedside. A recent study of physicians showed that clinicians spent 44% of their time on data entry, 28% on direct patient care, 13% in consultation with staff and consultant and 12% in review of test results (2).
Not that I am recommending that we go back to a paper-based system. The electronic medical record has many advantages such as accurate records of recent medications and associated medical problems. It holds the promise of improved communication and patient safety and error reduction. But we need to recognize that there are unintended consequences with electronic medical records and one of them is reducing the time that we spend at the bedside.
I have also noted a trend, especially amongst junior doctors, to place a greater emphasis on laboratory findings or radiological investigations than clinical examination or the patient history. We are also reassured by investigations with normal results and under-recognise their limitations.
Going back to the case, vestibular neuritis is a clinical diagnosis that could (and should) have been made quickly following presentation. No imaging was required.
But more importantly, vertigo with a normal or negative head impulse test is a stroke until proven otherwise. A CT brain does not exclude a cerebellar stroke so don’t be falsely reassured by a normal CT brain. It illustrates the fallacy of placing more importance on the results of diagnostic tests over our clinical diagnosis.
So is this blog about the automatisation of medicine? Yes, but this is also about physician error and how I (and others) respond to error.
Anyone who has been asked the question, “Do you remember that patient you discharged yesterday?” will know your immediate response.
Even before you know which patient they are asking you about!
Your initial response to error is often denial.
Another response following an error is distancing. This is what I was trying to do by shifting the blame to the computerisation of medicine as the cause of my error. This is not to ignore that there are often underlying system issues that contribute to error but the failure to acknowledge personal responsibility may delay your recovery.
Finally, I have described an error in which there was no adverse outcome, the patient was appropriately admitted and they were likely grateful for the “thorough” workup. The diminution or downplaying of error is another common strategy following the recognition of a mistake.
(This is also the type of error that you mention at a job interview; it shows that you are a reflective practitioner but one that doesn’t cause any patient harm or one that you write about in a blog rather than an error with a more serious adverse outcome.)
I have described a number of (maladaptive) strategies for coping with an error. If you don’t move on, a vicious cycle can occur where errors lead to burnout and depression, in turn provoking increased involvement in errors. Involvement in a harmful error can also lead to difficulty sleeping, reduced job satisfaction, and anxiety about future mistakes (3). These emotions may persist for months or years and contribute to the already substantial stress of medical training by triggering burnout and depression.
But don’t worry about me. I will follow up this blog with some suggestive strategies for coping following an error and describe the natural course of recovery.