Healthcare: Make Better Mistakes

I saw an expression the other day that I quite liked. I’m not sure who first said it, and there are several versions of it, but it goes something like this: let’s make better mistakes tomorrow.

Boy howdy, if that’s not the perfect motto for healthcare, I don’t know what is.

Health is a tricky business.  It’s a delicate balancing act between – to name a few -- your genes, your environment, your habits, your nutrition, your stress, the health and composition of your microbiome, the impact of whatever new microbes are floating around, and, yes, the health care you happen to receive.

Health care is also a tricky business. We’ve made much progress in medicine, developed deeper insights into how our bodies work (or fail), and have a multitude of treatment options for a multitude of health problems. But there’s a lot we still don’t know, there’s a lot we know but aren’t actually using, and there’s an awful lot we still don’t know.

It’s very much a human activity. Different people experience and/or report the same condition differently, and respond to the same treatments differently. Everyone has unique comorbidities, the impact of which upon treatments is still little understood. And, of course, until/unless AI takes over, the people responsible for diagnosing, treating, and caring for patients are very much human, each with their own backgrounds, training, preferences, intelligence, and memory – any of which can impact their actions.

All of which is to say: mistakes are made. Every day. By everyone.

Patients don’t disclose pertinent information, or don’t follow recommendations.  Clinicians get tired, don’t make important connections, don’t see/remember applicable research. People input incorrect information, or information gets processed incorrectly. Algorithms fail to take into account differing populations. Some people just aren’t very good at their jobs; perhaps they never were, perhaps they’ve failed to keep up, perhaps physical or mental issues have degraded their abilities.

No one really knows how many mistakes are made in healthcare, or exactly what the implications of those mistakes are on patients (although many estimates have been made for both), but on this we should all be able to agree: there’s too many.  Maybe someday we’ll have perfect health and perfect health care – such as when our uploaded digital twins are treated by AI clinicians – but until that time we have to accept that there are going to be mistakes.  

We should strive for no mistakes, or at least to minimize them, but, for heaven’s sake, the very least we should resolve is to try to make better mistakes.

There are many things we would probably agree on to help accomplish this. Clinicians and other health care workers should get the appropriate amount of training, on an ongoing basis. We shouldn’t work them to the point of burnout. We should improve patients’ health literacy and health habits. None of that is controversial, but, unfortunately, we probably wouldn’t get a passing grade on any of them.

Mistakes are still going to happen. But if we’re still going to make them, here are some suggestions for people working in healthcare to keep in mind to at least make them better mistakes:

• Does what you are doing make things simpler or more complex?  Some complexity is inevitable, but, by and large, making things simpler should result in fewer (and better)  mistakes. And, of course, one of my favorite pieces of advice: do simple better.
• Does what you are doing giving patients more agency, or less?  Historically, patients have been expected to follow physicians’ advice, without question, but those days are over, or they should be.  Helping patients help themselves should lead to better mistakes.
• Does what you are doing treat the condition, or the person?  Over a hundred year ago, Dr. William Osler said: “The good doctor treats the disease; the great doctor treats the patient who has the disease.” That kind of “greatness” should lead to better mistakes. The role of the primary care physician to oversee and coordinate all of a patient’s conditions and care has largely been lost, as has anyone’s overall view of the patient. Trying to have as broad an understanding of patients should lead to better mistakes.
• Do people complain a lot about something you do? If enough people tell you they don’t like something, maybe you shouldn’t be doing that, in that way. The classic example is mammograms; no woman I know likes them, although they’re relentlessly urged to get them, so why haven’t we figured out less unpleasant options?  Pre-authorizations fall into the same category, as would narrow networks, excessive charges, or requiring redundant/excessive forms.  Reducing complaints should lead to better mistakes. Again, a great piece of advice: stop doing stupid stuff.
• Does what you are doing make patients’ lives worse? If you’re taking patients to collections, you’re not making their lives better. If they have to choose between eating or buying prescriptions, you’re not making their lives better. If patients have to spend hours on the phone to make appointments or get questions answered, you’re not making their lives better. Thinking about making patients’ lives, not just their immediate health, better should lead to better mistakes.
• Does what you are doing protect the people/institutions providing the care, or the people receiving it?  There are lots of examples for this, but the overarching one to me is that instead of a culture to identify and remediate mistakes, we have a malpractice culture that seeks to cover them up and forces an adversarial system on patients. Similarly, those forms patients blindly sign before care is rendered aren’t there to protect patients. The healthcare system is supposed to serve patients, not exist to support health care workers and institutions.  Remembering that should lead to better mistakes.

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Reform comes slowly, if at all, to our healthcare system. Many of us would like to completely revamp and rebuild it, but at this point it’d be like trying to rebuild a plane while in flight. We can’t get off the plane and we’re not prepared to have it crash. So, if we can’t have a whole new healthcare system, one without all the perverse incentives and structural mistakes, perhaps the least we can strive for is to make better mistakes in the one we have.