Swiss cheese & the power of saying sorry

Ben Hoban is a GP in Exeter.

When things go wrong in medicine, we are expected to learn and adapt our practice in order to protect patients.¹ Learning and adaptation are not unique to doctors, but it is perhaps worth considering what form they take in general practice in the wake of any kind of adverse event. Such events vary enormously, from the trivial or near-miss to something much more serious, and can generate strong feelings. Our response tends to follow a standard format, focussed on reestablishing the smooth running of the practice machinery: mistakes were made; lessons should be learnt; something must be done. Reasonable though this is in principle, it sometimes fails to address the real issues or the needs of those affected.

To start with, the complexity of healthcare means that it is generally easier to take token remedial action or attribute blame than to understand what has actually gone wrong. Even when proximate causes such as prescribing errors can be addressed, there are likely to be other factors behind them such as time pressure or conflicting directives, which are beyond our reach.

The Swiss Cheese Model describes how adverse events occur through an accumulation of system failures, like holes lining up in a stack of Emmental slices.² Responsibility for an event seems to lie with whoever made the last mistake, when really, it belongs to a system that allows such errors to align in the first place. The way to stop things going wrong is to make the holes smaller, but what often happens instead is that the slices are simply rearranged: we can avoid repeating the same mistake, but only at the cost of making others.

Another snag in the tidy process of learning and adapting relates to how we approach cognitive bias, a system problem at the level of the human mind; individual, but also universal. Every diagnosis or decision we make is arrived at cognitively, and each misdiagnosis or mistake is necessarily the endpoint of a cognitive process. It is tempting therefore to view these things as aberrations, when the reality is that thinking is an inherently risky business. The issue is not how to fix our mind so that it works properly, but how it works in the first place.

Consider the existence of pairs of complementary biases in our thinking, pulling us in opposite directions along the same axis. For example, base rate neglect means focussing on how well a diagnosis fits the case, regardless of how common or rare it is, while Sutton’s slip involves choosing only the most obvious or prevalent diagnoses.³ In fact, either “bias” acts as a counterweight to the other, ensuring that we take into account both the prevalence and clinical features of a condition. Other examples broadly reflect tensions between the context and the content of a clinical encounter; we might do better to think of them simply as paired cognitive tendencies rather than biases. The lesson here is that our brain works as it does, and that error comes not from faulty thinking, but from a lack of balance or integration. In order to think clearly, we need to train our cognitive muscles, not restrain them.⁴

The idea that we can learn from our mistakes until we eventually stop making them is beguiling and clearly contains some truth. It also obscures a larger truth, however: just as holes and cognitive bias are intrinsic features of Swiss cheese and thinking, so there is a core of irreducible uncertainty in medicine; it is only ever in hindsight that we can claim to have all the answers.⁵

My final objection to viewing adverse events primarily in terms of learning is that we risk fundamentally mistaking the nature of healthcare: it is only incidentally a technical business; it is first of all interpersonal. By all means let us reflect and do better, but let us also recognise that when the wheels come off, we should still put people before process. We regularly emphasize the importance of relational care in general practice, and it is perhaps inevitable that when things go wrong, the resulting pain is felt, and expressed, at a relational level. The danger of trying to avoid this is that the learning process becomes a means either for doctors who feel guilty to hide from their patients, or for patients who feel let down to punish their doctors. GPs, many of whom already suffer from Impostor Syndrome, may see themselves as helpless in this situation, victims of circumstance, as indeed may their patients.⁶ There is power, though, in an apology made in good faith, and power in accepting one; both demonstrate that we can still work together in the light of our shared and fallible humanity. It is obviously best to avoid making the same mistake twice, but we cannot honestly promise not to make others in future. Our response to an adverse event may include learning and change, but it should always recognise too the things we cannot change, promote a better understanding of what happens between our ears, and affirm the relationships on which we depend to navigate a dysfunctional system in an uncertain world.

References

1. Openness and honesty when things go wrong: The professional duty of candour, GMC, Encouraging a learning culture by reporting errors – professional standards – GMC (gmc-uk.org)
2. Reason J. 1990 The contribution of latent human failures to the breakdown of complex systems, Trans. R. Soc. Lond. B327475–484 http://doi.org/10.1098/rstb.1990.0090
3. Crosskerry P, The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them, Acad. Med. 2003;78:775–780
4. Risk and Reasoning in Clinical Diagnosis: Process, Pitfall and Safeguards, Cym Anthony Ryle, Oxford University Press, 2019
5. Uncertainty in Medicine: a Framework for Tolerance, Paul K. J. Han, OUP USA, 2021
6. Bravata DM, Watts SA, Keefer AL, Madhusudhan DK, Taylor KT, Clark DM, Nelson RS, Cokley KO, Hagg HK. Prevalence, Predictors, and Treatment of Impostor Syndrome: a Systematic Review. J Gen Intern Med. 2020 Apr;35(4):1252-1275. doi: 10.1007/s11606-019-05364-1. Epub 2019 Dec 17. PMID: 31848865; PMCID: PMC7174434.

Featured image: Cheese with holes, by Andrew Papanikitas, 2024