MistakesMistakes

I once found myself in a room full of medical students who were busy justifying a lie. It was a hypothetical lie, not a real one, but it alarmed me nevertheless. These 30 students were discussing an imaginary patient: a young man whose physician had given him the wrong injection to treat syphilis. The students were trying to decide what this patient's physician should do. Having determined (with my help) that this particular mistake was unlikely to harm the patient, the students decided that the physician should simply order the correct treatment without revealing his initial error. Standing at the edge of the group with his hand on his hip, a third-year student suggested a plausible (but false) justification for the extra injections required to correct this mistake. Full disclosure would benefit neither physician nor patient, the group believed. In fact, honesty would imperil the patient's trust in his physician. The students reached this conclusion smoothly, in just a few minutes, with no discernible dissent. The room was quiet, the mood calm. I searched the students' faces with growing dismay, looking for the one or two anxious expressions that might help me shatter the apparent consensus. I did not want the “right” answer to come from me. I wanted the group to find its own way of dealing with the hypothetical mistake I had presented them—but certainly not the deceptive course so easily chosen.

I searched the room again and remembered the one student of the 30 who had personal experience with a medical mistake. After briefly alluding to this experience at the beginning of our lunchtime seminar, this student remained silent. Although her body language indicated that she preferred not to talk, I asked her to share her perspective. At low volume and with obvious difficulty, she told her story. Her grandfather was admitted to the hospital, and his physicians made a mistake in treating him; the family believed that this mistake hastened his death. Observing her increasing distress, I nevertheless asked her, “What happened next? Did your grandfather's physicians talk about the mistake with your family?” She described the physicians' evasiveness and her family's anger. As she briefly relived this experience for the benefit of her classmates, she began to cry. Once again, the room fell silent. I remember little of what happened next. What concerned me most at the time was that the students ultimately confronted the ethical implications of this situation, and changed their original conclusion. My own relief seemed directly proportional to the weeping student's pain.

I have given the same seminar several times now to medical students, family medicine residents, nurses, and practicing physicians. The same hypothetical case—a young man with syphilis, given two intramuscular injections of the wrong kind of penicillin—has led to several interesting discussions. The false closure of the first seminar has never repeated itself. I have encountered no other group willing to agree (hypothetically) to deceive a patient. But in spite of those subsequent, easier experiences, the first one still troubles me.

What bothered me most, I suppose, was the ease with which a group of medical students defended a kind of deception. Or not the ease, exactly, but the rationale: their idea that the physician's status mattered more than honesty—and that the patient's trust in his physician depended on an illusion of perfection, of inviolability. Setting aside the fundamental moral issues at stake here—and recognizing that, faced with potential humiliation, many fine human beings have at least considered the option of lying—I was left with a culture clash between myself and the students. They were ensconced in a prestigious tertiary-care center. Their teachers and role models were highly renowned subspecialists and academic researchers, who for the most part expected students to provide clear answers to questions of form and fact. In this bastion of ivory-tower medicine, scientific integrity was paramount, but humility was not an important virtue. I was an uncredentialed outsider here, a community physician offering seminars and clinical exposure through a small, grant-funded program; I represented a kind of basic, low-tech, humanistic medicine (and a field: family medicine) that did not exist in this medical center. As a visitor from the world beyond the university, I counted on reaching these students' open, idealistic side—the aspect not yet fully socialized by their training process. If that youthful openness had left them, and they had already chosen to emulate a pompous stereotype, I had nothing to give them. Thus my panic.

Of course, my own conduct in that room also troubled me. (Why else would I still be brooding over this episode years later?) This experience forced me to confront some of the ethical dilemmas of teaching: Is it ever appropriate to sacrifice one student's comfort or privacy for the benefit of the group? When should a teacher impose her own ideology—her own solution to a problem—rather than allowing students to stick with their conclusion? By facilitating a discussion instead of lecturing, I had hoped to model an approach to learning that might serve students throughout their careers, no matter which path they took. I sought to demonstrate flexibility, empathy, and an emphasis on process over definitive answers. This approach must include, of course, a high tolerance for uncertainty—a kind of tolerance I’ve found essential for dealing effectively with the vicissitudes of clinical practice. However, in that room, on that day, I found myself so distressed by moral uncertainty that I broke my own rules.

In teaching, as in therapeutics, we all have our limits. I can't explain my need to impose my own view on those students without returning to the moral issues that motivated me. At the time, the most important lesson was not honesty, but rather humility. What struck me was the students' aplomb, the false confidence with which they approached the problem before them. It is quite possible that I misread them: that I missed the terror lurking beneath a thin layer of self-assurance. In order to reach the fear that motivated these students' deceptive strategy, I would have needed more time than the hour I had with them. In fact, I would have needed the kind of continuity that a regular faculty member has with his students or that a family physician has with her patients. Lacking that continuity, I resorted to a sort of shock tactic. And really, it's the shock that worries me—because I believe that to be effective, teachers must be gentle with students.

I hesitate to draw a clear lesson from this experience. Faced with the same situation in the future, I may be unable to handle it better. However, one point seems clear: we need more open discussion of mistakes in clinical practice, both during medical school and beyond. Otherwise, we risk creating a generation of clinicians who are so frightened by their own fallibility, they are willing to lie, even to themselves.