Managing Risk: Don’t get burnt, a singe will do #WILTW

This is the 158th #WILTW

I recently published some thoughts on how Nassen Talebs’s book “The Black Swan” may influence clinical practice in Emergency Medicine. The books title is derived from the discovery of Black Swans in Western Australia. Despite being a very unexpected event that had a profound impact at the time, in retrospect the evidence was probably available  to have suggested such a thing was possible. A Black Swan event is, by definition, not predictable until it has occurred. Taleb argues understanding their existence is vital to understand economic theory (he was originally a market trader) but I think it is also an extremely useful concept in Medicine.

With Black Swan events are two states of mind that probably are relevant to patient safety. The first is that we think of written history as linear and easily described. Taleb argues this gives us unfounded confidence when we review events and how we think we responded to them. In serious case reviews the reasons why different systems failed are themselves interwoven with interdependencies, which fluctuated in real time i.e. the act of writing a sequence of events down can never truly describe why things happen. The second that we too often confirm ‘No evidence of disease’ rather than ‘Evidence of no disease’. This is a well known phenomenon in healthcare and describes a tendency to seek a particular test and use it as the sole process in which to make a diagnostic decision. This patient can’t have sepsis because their blood tests are normal or this patient can’t have appendicitis because they don’t have a temperature etc.

After the PERUKI annual meeting this week a group of us discussed how we can improve teaching about risk management to  doctors in the early stages of their careers. “Once you’ve made that mistake you won’t make it again” may well embed learning in a particular doctor but it is of absolutely no benefit to the patient who may have been harmed. However this is not an easy problem to solve as a result of Black Swans and related issues:

i) Some events aren’t predictable, or only possibly can be, in retrospect.

ii) It is very difficult to learn from the errors of others, as what might have been presented as the route cause of an issue may not actually have been the underlying problem in that case.

iii) We are still generally beholden to a model of practice that implicitly rewards a “Treat this patient with that presentation and this test as this…” pathway of care.

I pondered with Chris Gough about how being burnt by a particular case was an excellent re-inforcement of the above principles but not a adequate or acceptable education methodology. What Chris suggested was that trainees needed to be ‘singed’.

via #BigGreenEgg

This is still a practical challenge but there are things that educators can facilitate.

  • Highlight minor cases in which a correct diagnosis doesn’t determine outcome but where errors have been made (e.g. non-specific rashes)
  • Seek out ‘what if’ scenarios (what would you have done if the white cell count had been normal)
  • Actively discuss cases in forums conducive to open learning

All of us need the experience of being singed to avoid patients being burnt.

What have you learnt this week #WILTW

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