Learning from Medical Errors: Clinical Problems

Abstract

These two books tell a remarkable series of stories. The first is the authors' own. Dr Anh Nguyen and his elder brother Dung Nguyen were born in Saigon, Vietnam, and grew up in Florida. Both graduated in engineering and then medicine and have been in clinical practice in the US for a decade, collecting a vast anthology from their own and others' practice. With multiple true-life examples, the clinical pitfalls and legal challenges that confront us are graphically shown. They emphasise the value of these parables so that we can avoid, trap and mitigate our errors. Each book runs to over 200 pages in which hundreds of cautionary tales are separated by the authors' commentary and advice. Much is the reiteration of sound clinical principles and a useful reminder of what we all should know. The stories certainly help to dramatise and motivate our learning and the chapters are a series of practical tips, for example, ‘what you should not place in a progress note’ (legal issues) and ‘low back pain’ (clinical problems). Those looking for proof of the adage that ‘if it can go wrong it will’ are sure to find these volumes a handy reference to prove their point. The books have much to commend them and they can be sampled very conveniently to research a particular problem; however, for the reviewer who feels duty-bound to read them from end to end, they present a serious challenge. Simply put, they are difficult to read. At first, I felt my pedantic English criticism was the cause of the discomfort, seasoned as it was with a traditional dislike of defensive medical practice. The profligate use of investigations and the aggressive, litigious atmosphere which pervades some North American practice is here displayed. There are also long sentences of medical jargon that easily offend. However, it is not really these characteristics of practice that make it hard to digest so much as the style. To write well requires knowledge, technique, practice and rigorous editing. The subtleties of our enormous English vocabulary constantly challenge us to reach for an authoritative definition and simultaneously offer the opportunity for near-infinite subtlety. Here, the text reads as though it has been dictated rather than written and has been spared the invigorating benefits of critical review by a meticulous editor. This is a great pity because so much hard work has been done and the result appears unfinished. Atul Gawande, the author of Complications: A surgeon's notes on an imperfect science, produced a book about the misfortunes of North American practice that contains far less material but is compulsive reading and difficult to put down. Even he admitted how difficult it was to write well and how much he had been helped by tuition from the staff of The New Yorker, who made his prose vibrant and accessible. His book was of course much less of a technical manual and more a guide to the personal journey of a surgeon developing maturity and wisdom by the challenging and often distressing experience of his craft. By contrast, these books do not expose the authors as individuals nor do they bring out any of the philosophical or emotional consequences of this litany of catastrophes. We need to learn about that too if we are to remain effective, vigilant, compassionate and sane. Surgeons will find much to engage them in these two volumes but I recommend frequent tasting rather than attempting to drain the bottle at one session.