A little while ago, I had a very humbling experience. I had a case of a newborn infant who died at home. At autopsy he had a necrotic and congested liver as well as a sizeable atrial septal defect. I became convinced that the liver showed fulminant congestive hepatopathy, and decided that that ASD was the cause. Admittedly, ASDs are rarely clinically significant very early in life, but they can result in fulminant congestive heart failure with congestive hepatopathy. I thought I had brought all the findings together quite nicely.
The case went to peer review, and I had missed an important finding — viral inclusions the liver. This was not congestive hepatopathy, it was TORCH due to Herpes. When my colleagues looked at the slide in peer review, they picked up on the inclusions right away. Of course, as always happens when you are looking at these kinds of things, once they are pointed out, you see them all over the place. I blew it.
I had to ask myself how I could have made this mistake. It was not a matter of knowledge — I’ve been looking at viral inclusions for 40 years and certainly know what they look like. At this point I don’t remember looking at the slides originally, so I don’t know if I looked at them too quickly, jumped on the lower power fulminant hemorrhagic pattern rather than more carefully looking at the higher power views, if I was distracted, tired, rushed, or what. I do know that I did this case during a period where I was distracted and fatigued in the general sense. My wife had fallen ill near to death, was bed bound and invalid, and I was spending a lot of effort focusing on her needs (she’s much better now, by the way, thanks to God). But, whatever. I made a rookie mistake.
I make a fair number of mistakes, truth be told, though (again, thanks to God) the vast majority are not significant. I am, unfortunately, a horrible proofreader, and I base my reports on a template. It is not too uncommon for me to have accidentally left in “something” in my report that does not apply to a specific case. It’s usually a template based negative finding that is relatively insignificant, such as “The appendix is unremarkable” in a case where the appendix was not present (i.e. I forgot to edit “unremarkable” to “not noted.” ) I see this a lot in reviewing cases as a consultant as well. It sometimes makes the news when an office decides to hang a pathologist out to dry. That’s not an error of knowledge, that’s an error of proofreading and using a template (which almost everybody does). I remember a case from the 1990s where a pathologist noted that a male decedent had a normal uterus and ovaries. Those who were attacking the pathologist in the press ridiculed him as not knowing that a man didn’t have a uterus. Of course that wasn’t the case — he was using a templated report and made a copyediting mistake.
For those kinds of errors, my only solace is a couple of studies I’ve read that suggested that the probability of making that kind of proofreading error is highly correlated with one’s knowledge of the subject. The reason is that we tend to read what we *think* we are saying instead of what we *actually* write. It’s a function of how we read — by reading phrases and sentences as units rather than individual words. It’s worse for me because I was trained in elementary school in “speed reading,” and tend not to read individual words at all, most of the time. I have the advantage of being able to read and enjoy a 400 page novel in an afternoon, but it also means that I simply don’t read every word.
But whatever. This was not that kind of mistake. This was a basic perceptual error. No matter how good or experienced one is, one will make errors. And in our jobs, there are consequences to error. So, I have three points to make about it, since it is, unfortunately, part of my practice.
First we should be quick to acknowledge error. Second, we should be quick to accept reasonable consequences for the error. Third, we should welcome review.
Acknowledging error is a basic part of professionalism, and as a Christian, it is a fundamental part of my world view. My profession is my calling and my ministry. Any failure to achieve perfection is a sin. Most people think of sin as doing something mean, dishonest, cruel, spiteful, or involving some sort of malignant motivation. All of those are sins, of course. But sin, at its core, is simply failure to do what is right in any situation. Failure to achieve perfection, even with good intent, is a sin.
This is the lesson of the story of Uzzah and the Ark of the Covenant. For those of you who don’t remember (or never knew), in two passages of the Old Testament (or in the Jewish classification, both in the Prophets and the Writings) — 2 Samuel 6:3-8 and 1 Chronicles 13:7-11– there is a story where King David attempted to move the Ark of the Covenant to Jerusalem. As he was moving the Ark, the oxen pulling the cart stumbled and the Ark started to tilt. Uzzah, a member of David’s army, raised his hand to stabilize it. God had said that anybody who touched the Ark would die, and Uzzah was struck dead on the spot. David was angry at God for this — he didn’t think it was fair.
David didn’t understand, I think, the impassable nature of sin and God’s judgment. God’s laws of behavior are like His physical laws — they are about actions and consequences, not motive. A law of God is not negated by intent any more than gravity disappears because one did not intend to fall out of a window. I won’t discuss that at length here, but did so in my post on worldview and faith .
So, not performing your job to the best of your ability is a sin and, moreover, making an error even if you are doing your best is a sin. But Christians like me have a guide to approaching it — confession and repentance. Confession is obvious. We should not hide our imperfections, but we should be open about them and constantly try to do better. As the writer of 1 John noted “If we say we have no sin, we deceive ourselves, and the truth is not in us. If we confess our sins, he is faithful and just to forgive us our sins and to cleanse us from all unrighteousness. If we say we have not sinned, we make him a liar, and his word is not in us.” And as Paul noted in 2 Corinthians “But he said to me, “My grace is sufficient for you, for my power is made perfect in weakness.” Therefore I will boast all the more gladly of my weaknesses, so that the power of Christ may rest upon me.” The writers of the Old Testament agree.
Of course, we don’t like to admit we are wrong. But hiding one’s errors just makes the consequences worse. In the secular world, the trope is that “The cover up is worse than the crime.” That’s true in every realm. Repentance means looking for causes and making corrections. In quality terms, of course, one looks for “root causes” and takes “corrective actions.” In God’s word, it’s the same, but uses different terms of art.
Back when I was a teenager, I had a summer job doing handyman work. One day a homeowner came to our team leader complaining about how a job was done. It was clear the customer had a valid complaint. The team leader became enraged. He said “This is completely unacceptable. I apologize to you about this. We will make it right. Not only that, this kind of work will not be allowed on my team. Rest assured that [the guy] will be fired and will never work in this town again!” The woman looked shocked. She said “No, wait. Look, he probably did his best. Just fix it. There’s no reason to fire anybody.” The team leader said “Well, if you are sure…” She replied “No, really. It’s fine.” Satisfied, she walked away.
I talked to my boss about it shortly afterwards. He said that when you are in a situation like that, there are always two sides of the conversation. There’s one side that tries to minimize the problem and says that things are not so bad. The other side says that it’s horrible and the worst thing in the world. When a customer comes in, and it’s a valid complaint, you basically only get to choose which side of the conversation you are on. If you choose the angry side, the customer will reflexively choose the mitigating side. That means the customer not only gets the problem fixed, but walks away feeling good about himself or herself because they had the opportunity to be gracious and forgiving. Everybody’s happy.
I don’t know if that would work as well today. Outrage and exaggerated victimization are considered virtues by so many — with the associated demand for hateful and draconian consequences for those who offend — but for most of my life I’ve found that giving the aggrieved party the opportunity to be gracious worked fairly well. Not always, of course, but as an initial tactic it’s been useful. In contrast, denial and stonewalling when you are clearly in the wrong often makes things much worse. As the writer of Proverbs notes “Whoever conceals his transgressions will not prosper, but he who confesses and forsakes them will obtain mercy.”
A corollary of this point is that we should be quick to amend a report. I have no problem doing that. I don’t know why, but a lot of pathologists seem driven to go to great lengths to avoid an amendment. It’s no big deal to me. I probably amend a report for my autopsy work every three months or so. In fact I amended a report this morning — I had misread part of the clinical summary and wrote that the decedent went to one hospital, when in fact he had gone to a different one. Many pathologists would say that this is not big enough of an error to make an amendment to an autopsy report, but one of the people reading the report noticed it and mentioned it. It was important to him, which means it’s worth fixing. And, when fixed quickly (I amended the report two days after publishing it), the problem is solved without repercussions.
Second, we have to recognize that error can *and should* have consequences. These can usually be minimized by rapid acknowledgement and honest efforts at correction, mitigation, and changing how you do things. But error will out. As the author of Proverbs writes “Blows and wounds scrub away evil, and beatings purge the inmost being.” This does not mean that all consequences are just, nor does it mean that we cannot object to unjust consequences. Nonetheless, as Proverbs also states “Accept correction, and you will find life; reject correction, and you will miss the road.” Or, as the Psalmist wrote “Blessed is the man whom you discipline, O Lord, and whom you teach out of your law.” In the best case, that discipline is corrective, and organizations should focus on correction rather than painful punishment. We should welcome those corrections and use them to learn and change course. Once again, it has been my experience that the most painful consequences I have had came from trying to avoid appropriate consequences, and that avoidance was the real problem.
The purpose of consequences is, or at least should be, correction. Accepting it can be hard. It means you accept responsibility *and* embrace corrective actions to minimize the likelihood that you will do it again. I see a lot of people “accepting responsibility” who are then horrified and offended when consequences follow. They are part of the same package.
In this context it mean error analysis, retraining, etc. As Peter said in Acts, “Repent therefore, and turn back, that your sins may be blotted out,…” People think this applies only to “moral” issues, but it applies to all error. Learning from errors is exactly that — a learning experience. While one can attempt to reduce errors it is unlikely that one will become perfect, but each error becomes another learning opportunity. As Jesus told us, “Pay attention to yourselves! If your brother sins, rebuke him, and if he repents, forgive him, and if he sins against you seven times in the day, and turns to you seven times, saying, ‘I repent,’ you must forgive him.” We will continue to make errors, but each time we do, we can improve. We have to face our errors straight on, try to figure out why we made them, and learn to do better. As the writer of Proverbs notes about his teachings, “Let the wise listen and add to their learning, and let the discerning get guidance.”
Finally, the fact that we are doomed to make mistakes means that we should welcome peer review and timely intervention. The usefulness of peer review is beyond question. I recently read a study about the use of AI in medical diagnosis. It pitted individual human physicians against an AI “panel” made up of multiple AI “personalities” that were very different, and even antagonistic each other. The panel outperformed the individuals by a huge margin. I don’t think it was all that convincing an argument for AI, since the way they provided information to the human physicians was very formalized and unlike real practice. But it’s a nice demonstration of the value of bringing different viewpoints to a case. Peer review has been invaluable to me. At the office where I do locum tenens, they have a weekly peer review session for difficult cases. It’s always fascinating, and the discussions often provide approaches that I did not consider. Almost every study I’ve seen indicates that diagnoses made with the help of a team ends up with lower error rates. Plus, peer review means on an ongoing basis means that you will catch errors and weaknesses before they end up happening on a high profile case, or, even better, before the case is signed out at all. It’s invaluable.
Most of the above is oriented for casework in an office, e.g. full time ME work or locum tenens. What about consultation work? The same principles apply, First, in consultation work, we often don’t get all the data. Every report I write has a disclaimer that I might change my diagnosis with new data. I have not suffered from this, but I have seen colleagues who were completely sandbagged by counsel, being given only biased and selected records to review. I recently testified in a trial where the question was one of abuse. I was given 15 years of medical records in which there was an obvious pattern of recurring injuries, etc. characteristic of abusive injury. Counsel for the opposing side gave their expert only the records from the terminal admission, and thus the expert knew nothing of the years leading up to this. If something comes up, I am quick to respond if I need to change something. This is particularly true in torts where there may be a series of reports and rebuttals from experts. If an expert from an opposing side brings up a valid point, don’t ignore or dismiss it just because they are on the opposite side. If they are right, they are right.
If you are on the stand, it’s even more important to be straight up about uncertainty and error. In my personal experience, juries are fairly forgiving of honest mistakes, but they hate it when you try to bullshit your way through and cover up an error. Plus, if opposing counsel is good, they will rip you apart.
A couple of years ago, I testified on a case I did in my regular job. The defense decided to make a big deal about a single hair fiber that was stuck in dried blood on the hand of the decedent. They were making the assertion that the “real” assailant was someone else, and that he would have been discovered if only I had saved that hair as trace evidence. Of course at autopsy, I didn’t even see the thing. It was obvious in the close up photos of the hand (that we take in all cases), but I just didn’t see it at the time. And, frankly, even if I had, I probably wouldn’t have saved it. There’s a lot of little bits of debris on a body found laying on a rug, and I almost never collect all of it. We do fingernail clippings, etc., but we don’t save all the flakes of blood that come off the skin.
So, at trial, it came up. “What is this?”
“This is a picture of the decedent’s hand before being washed.”
“And what is this on the thumb?”
“It’s a hair in the dried blood.”
“Did you submit this hair as trace evidence?”
“No.”
“Why not?”
“I didn’t notice it.”
“You didn’t look?”
“I looked, I just didn’t see it.”
And that’s it. From that point on, counsel didn’t have anywhere to go without looking like a jerk. If I had tried to come up with some BS thing to pretend that I had seen it but there was some important reason not to collect it, I would have sounded foolish. Instead, I sounded human. Many years ago, I had a trial in which counsel spent an hour attacking my competence, integrity, etc. After my cross examination, the judge called a break. One of the paralegals heard the jurors talking as they waited for the elevator. They thought the lawyer had been such as ass and treated me so badly that they were considering voting for conviction just to teach the lawyer a lesson. I can tell you that had I responded to his attacks with dissimulation or anger their attitude would have been different.
Errors are not good. We should try to minimize them as much as possible. But we shouldn’t be afraid of them. No pain, no gain.