On being wrong

I enjoyed listening to this conversation with Felicity Thow on the You Matter Podcast. She talks about how she missed an achilles tendon rupture in one of her patients, and the shame she felt when she found out she had been wrong. It's a good listen for any clinician who feels insecure and doubts themselves (so, everyone then?)

In writing our book on CES, Rob and I talked a lot about the fear of being wrong. As Felicity and the host Jo discussed in the podcast, this fear, and a sense of anxiety more generally, isn't separate from clinical reasoning, but feeds into it. This is especially so with CES, where the fear of being wrong seems to affect every clinical decision.  

Why are we afraid of being wrong about a CES decision? We want the best for our patient, of course. But, as Felicity discussed so well in the podcast, we're also afraid of being wrong for our own sake. Being wrong hurts our egos and undermines our confidence: “I felt sure that my patient had CES, but they didn't, is my clinical knowledge that bad?” We also worry that if we’re wrong, our colleagues will think less of us. “Did you hear, that junior referred someone else to A&E for CES last week. Turns out they didn’t have it of course…”

For me, the fear of being wrong grows as I get closer to making an actual CES decision. When I first begin to ask my patient some basic CES questions, I feel fine. I might even enjoy the conversation and the clinical reasoning puzzle. But as my thoughts start to crystallise into a decision on whether or not to refer my patient to A&E, the fear creeps into my mind.

If I’m beginning to think I should refer a patient to A&E, I'll picture the clinicians there rolling their eyes at another CES referral, and looking at one another knowingly when the MRI turns out to be clear. If I’m beginning to think I shouldn’t refer the patient to A&E, I'll picture my supervisor coming up to me in the office the next week: “Tom, do you remember a patient of yours from last week, a Mr. Smith? We just got a call from their GP…”

The fear of being wrong puts me into a state of analysis paralysis, messing up my clinical reasoning. I'll go back over my thought processes to triple and quadruple check everything (all while the clock is ticking...). I'll ask and re-ask my patient more and more questions, hoping they’ll answer with something that makes my decision so obvious that it must be right (“Ever since I got this bilateral radicular pain I feel like my bladder fills up until it overflows!”). If I’m not careful, then by the time I’m done, I’ve travelled down so many dead ends and followed so many tangents that I’m liable to make a worse decision than I was going to make in the first place. At best, it’ll take twice as long. 

Everyone’s different, but here’s how I get past the fear of being wrong, in this situation: I make sure to be very clear about what my responsibility is. And in fact my responsibility is not to be right, it’s to make a good decision.

To elaborate: my responsibility is not to be 'right' about whether or not that patient has CES, because that’s out of my control. It depends on information I couldn't possibly know, things my patient might not even have noticed, and things that haven't even happened yet (since CES unfolds over time).

Instead, my responsibility is simply to make a good decision, one that’s careful and reasonable, based on the information I have. That’s not easy, but it’s realistically in my control to do it well.

Besides, one thing to remember when it comes to CES in particular is that the decision to refer someone to A&E for suspected CES is in fact most likely to be ‘wrong’. As one review puts it, “We must expect high rates of negative MRI; a high true negative rating following MRI is necessary to achieve the lowest false positive rate based upon clinical assessment.” A low hit-rate is expected. And by the way, studies suggest that even experienced doctors can’t guess which referrals will turn out to have CES, and which won’t. All this just highlights the futility of judging CES decisions by their outcomes.

This ‘decision over outcome’ attitude also helps when it comes to the subject of Felicity's podcast, which is the shame one feels after making a decision that does have a bad outcome. For example, if I decide not to refer a patient to A&E but, later, I find out that they did indeed have CES, then that is certainly cause for reflection, but the fact that the outcome was bad does not in and of itself mean I have failed professionally, that I'm inadequate, that I'm incompetent, or anything like that. I shouldn't let any single bad outcome (or good outcome!) influence too much what I think of myself, because the outcome is partly, sometimes mostly, out of my control.

One annoying thing about working with Rob (my coauthor) is that he always, at length, relates everything back to Star Trek. I’ve watched maybe two episodes of Star Trek in my life, so I never know what he’s talking about and I just have to smile and nod. But when we last discussed the fear and shame of being wrong, I must admit he did bring up a nice quote from Cpt. Jean-Luc Picard: "It is possible to make no mistakes and still lose. That is not weakness, that is life."

So, whether we are reflecting on a past CES decision or worrying about a future one, we should judge that decision by its own merit, not by its outcome. That’s not to say we should ignore the outcome, especially if it’s part of a wider pattern, but that we should regard it as an outcome of the uncertainty of practice and of the complexity of the world as much as it’s an outcome of the decision in question. The key is to remind ourselves of our responsibility, which is merely to make a careful and reasonable decision, based on the information we have.

That’s what helps for me, anyway.