When We Do Harm: A Doctor Confronts Medical Error by Danielle Ofri
My rating: 3 of 5 stars
Full disclosure: Danielle Ofri accepted my short story “5 Star Hotel” for inclusion in the literary magazine she edits, the Bellevue Literary Review a few years ago. She was a terrific editor to work with.
This is a rambling, passionate, sometimes utterly harrowing examination of errors in medical care. I’ve worked in health care for thirty years, and can attest to the truth of what she observes in the ongoing effort to provide the right care to the right person for the right reason at the right time. The patient safety mission – to its credit – is data-driven, trying to focus on figuring out what went wrong, and then checking to see if improvement efforts actually had an effect. Not so much to its credit, the data measured is often punctuated with $, and tends to ignore how human beings (and doctors, nurses, and patients ARE human beings!) function, emotionally and neurologically. Health care trumpets how well it followed the aviation industry model of aspiring to zero errors, but as Ofri astutely points out: airplanes of a given model are machines, with the same dials, gauges, and levers, so once a pilot masters one, he or she can master the others. In medicine, every “pilot” (doctor) and every single individual “plane” (patient) is different, so one-size most definitely does NOT fit-all. She exudes frustration with the holy grail of the electronic medical record (EMR): a system originally designed to track every single item or activity that can be billed for does not translate well into a system of tracking health, disease, and the continuum of care, leading to workarounds, copy/paste shortcuts, hasty box-clicking, and profane outbursts of frustration. She is critical of the ever-shifting attention span of the quality-tracking people, and I’ve seen it myself first hand. A few years ago, every search of the literature I was asked to do was about catheter-associated bloodstream infections (CLABSIs) for a task force. There were inservices, posters, training sessions, newsletter features, etc. There was some improvement, so yay! And it was on to catheter-associated urinary tract infections (CAUTIs). And then on to healthcare-associated pressure injuries. And a month or so ago, a new task force is announced: we’re back to CLABSIs as the numbers inched up again when the spotlight moved on.
Ofri also examines on the power of workload and staffing on errors. She describes an environment that sounds like sheer madness: lone physicians struggling to care for 40 patients at once, scheduling screwups, nurse shortages, EMR downtime, emergency admissions, overflowing waiting rooms, green interns, exhausted residents, and absolutely no time to THINK. She is a champion of nurses, extolling their value above rubies. One thing she does not address much is the high level of practitioner burnout – overburdened staff who are simply fed up, depressed, and angry, and how this might affect the care they give – or don’t. The horrific case report of Jay, a 39-year-old man who goes into a septic spiral after a leukemia diagnosis, demonstrates a level of staff disconnection and indifference that makes me wonder about the basic emotional status of the clinicians involved.
I’m not quite sure who this book is intended for. It is lucidly written enough for lay people; yet it delves into the nitty-gritty of quality / performance improvement, checklists, etc., that may cause their eyes to glaze over. And while I stocked my hospital’s medical library with books by Pronovost, Gawande, et al., (sometimes even at an administrator’s request), they were rarely touched by anyone. Victoria Sweet’s book Slow Medicine relates an appalling episode of her father’s inappropriate care in a hospital where she had previously been invited to speak to the medical staff. Her message of connection to patients obviously dissipated as the door closed behind her. So while I will certainly add Ofri’s book to the shelves where I work, I am not hopeful anyone will read it.
A couple minor things my copy-editing eye tripped on: even spell-check should have caught the several references to the medical chart as a “chronical.”(p. 84) And a line about how the questions of interns force their supervising attendings to explain their reasoning, confusing “dissemble” with “disassemble” turns the sentence on it head entirely (p. 127).
Important information, to be sure, including suggestions for patients and families about keeping notes, asking questions (and which ones), and resources for assistance. Ofri sees patients, teaches, and writes books and columns, edits a journal, and has teenaged kids – her driven, high-intensity persona is apparent in this book, which can be exclamatory, sometimes flippant, sometimes darkly funny. I hope she’s not heading for burnout – we need her.
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