It seems a cruel twist—how years of success in the classroom and the clinic can be banished from the mind by the memory of a single error. For Ronald Epstein, the haunting moment occurred nearly two decades ago, when he noticed a patient’s kidney turning purple during an operation. He told the attending physician, who barked at Epstein (a lowly intern) to shut up. Moments passed, the kidney darkened. Epstein finally summoned the nerve to tell the nurse, who told the resident, who informed the attending—too late. A surgeon had to be called in to remove the organ.
“A huge number of physicians carry these memories of errors around with them, and they’re very painful,” said Epstein, a professor of family medicine and psychiatry at the University of Rochester. He was speaking at a symposium, “The Mindful Brain,” sponsored by the HMS Academy Center for Teaching and Learning, on April 6.
Physicians have traditionally kept these errors—of omission and commission—to themselves, but that is changing. In books, articles, and conferences, medical mistakes are being outed. Drawing on a mix of psychology, neuroscience, and personal reflection, physicians are staring down their demons, asking: how and why do medical errors occur—and what can be done to stop them? An emerging consensus, revealed at the symposium and in recent books such as How Doctors Think, by HMS professor Jerome Groopman, is that medical errors, even those that take only a moment to commit, are often years in the making. Rather than the result of momentary lapses of medical judgment, they may be the direct result of a medical education system that encourages what some are calling a state of mindlessness in doctors—a tendency to regard learned facts as unchanging and absolute, to quickly commit patients to preconceived schema and categories, and to have little tolerance for doubt or uncertainty.
The good news, said participants at the symposium, which was supported by a grant from the Arthur P. Gold Foundation, is that the alternative—mindfulness—can be taught. The presentations had the feel of a contest, with mindlessness and mindfulness duking it out before an audience that included physicians, medical educators, and administrators, as well as a few students. It was said that mindfulness can win, though it was not always clear how exactly that might occur.
Indeed, mindlessness emerged as a weighty opponent, precisely because it is learned. “This thing called mindlessness is not stupidity,” said Ellen Langer, professor of psychology at Harvard University and author of the classic 1989 book Mindfulness and two other books on the subject. A key feature of mindlessness is a willingness, almost a drive, to view facts as absolute rather than determined by context. A playful, almost impish presence, Langer countered by pointing out that one plus one does not always equal two. It can equal one when two pieces of chewing gum are wadded together. If the outcome of a simple arithmetic problem can change depending on circumstance, the possibility for error is even greater when considering more complex and subtle problems such as how to accurately diagnose a patient. “We take complicated information that changes over time and circumstances, but is taught as absolute fact,” she said.
Part of the problem is not just how information is presented—as absolute and authoritative—but also when. Much learning, especially of basic principles, occurs long before students are actually called upon to try out those principles. As a result, students may get locked into a particular mindset, which can result in what Langer called premature cognitive commitments.
To offset such a mindset, and mindlessness itself, Langer prescribed the practice of mindfulness. Yet it appeared a vague antidote. She was careful to distinguish mindfulness from meditation, for example, and instead described mindfulness as a way of engaging the world—with attention to novelty and a tolerance for doubt. But it was not clear how exactly students can cultivate these powers. She did encourage teachers to adopt a new stance—to relinquish the mantle of authority and to encourage students, perhaps by example, to live with doubt. “If we’re to have just one mindset, let it be a healthy respect for uncertainty,” she said.
“Attention to novelty in what’s familiar opens the mind up to not being on automatic,” said Daniel Siegel, associate professor of psychiatry at the UCLA School of Medicine. Mindfulness does more, he said. He presented seven attributes, each an answer to the question, What is the outcome of mindfulness? They included attuned communication, better physiological regulation, emotional balance, resilience, insight, empathy, and the ability to modulate fear.
Siegel, author of The Mindful Brain, believes that all seven, and presumably mindfulness itself, have roots in a particular part of the brain, the middle prefrontal cortex. He described a patient with a lesion in this area who lost these seven abilities. “She told me, ‘I guess what’s happened to me is that I’ve lost my soul,’” he said.
Yet possession of an intact middle prefrontal cortex is no guarantee of mindfulness. To cultivate the state, he recommended meditation. “There’s a technology for developing the brain that has been developed over thousands of years that’s as accessible to us now, that could give us the kind of brain I wish I had when I was in medical school,” said Siegel, who with Epstein was a student at HMS in the mid-1980s.
A goal of some forms of meditation is to dispassionately watch the comings and goings of the mind. This could be especially useful for physicians whose minds, Epstein said, are packed with uninvited guests such as contradiction, conflict, and strong emotion. To that list, he added the scripts and heuristics that doctors use to diagnose—and sometimes misdiagnose—patients. “What happens when we have these uninvited guests,” he said, “is that it can lead us to slam the door shut” on uncertainty, which can render doctors immune to the normal self-questioning that should accompany every diagnosis.
“Good surgeons know how to question themselves,” he said, “sometimes with a great deal of pain.” Presumably, it is nothing compared to the pain of a mistake recollected.
