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More Creative Conflict on the Care Team Might Cut Medical Errors

Jeff Cleary Tarayn Fairlie

A favorite medical urban legend—perpetuated by TV medical dramas and repeated frequently by housestaff—is that most doctors kill at least three patients before completing residency training. Prior to internship, I think I would have laughed nervously, but not really agreed. In med school, I saw a couple of flagrant errors, but never anything that I could directly attribute to a trainee. Most of the more obvious errors I did see were overall system failures: a transcription error, a misread lab value, or an order that wasn’t checked by appropriate personnel. Still, for the most part, I trusted that the system tended to prevent such mistakes. Wasn’t it the same system that had finally limited resident work hours and mandated more direct attending supervision of resident clinical care?

Now finishing the end of my intern year, I think I may have placed a little too much confidence in the system and, in turn, underestimated what may be one of the biggest factors in medical errors: the desire on almost everyone’s part to avoid conflict.

I can’t blame myself or anyone else for not wanting to rock the boat. After a year of routinely questioning things that appeared to fall short of the standard of care, I am frankly ready for smooth relations on the care team. I know that I occasionally may have to ignore what seem like less than optimal decisions made by peers, senior residents, and even attendings. Rather than speaking out, I might resort to micromanaging one of my patients if I think her care is heading in the wrong direction.

Avoiding conflict is a tendency that I apparently share with other health care providers; a report sponsored, in part, by the American Association of Critical-Care Nurses titled “Silence Kills: The Seven Crucial Conversations in Healthcare” reveals that errors, questionable skills and judgment, and other problems rarely go addressed for fear of repercussions or simply to preserve a decent working environment.

At the end of my internship, I can’t help but think that inexperienced housestaff who compromise safety aren’t necessarily doing so because they lack clinical skills but because they’ve run up against barriers to asking questions, presenting alternatives, or discussing concerns. If nothing else, most interns and residents are overly cautious about potentially harming patients; we rarely take a step without checking ourselves against the current literature (well, OK, Uptodate.com) or a trusted senior physician. The choice to advocate for one’s patients against the orders of a superior is often frowned upon at best; there’s simply little precedent for it in most hospitals, as the report “Silence Kills” illustrates so well.

I fear that after three or more years of learning not to protest, I too might become an attending whose orders are better left unquestioned or whose care plans are accepted and performed by staffers who may have concerns, but simply won’t voice them. Perhaps the best I can hope for is that the next wave of advocates for patient safety will recognize the risk posed by a system that often discourages open communication about the issues that patient care inevitably presents.

—Tarayn Fairlie, HMS ’06, began training as a family medicine resident at Middlesex Hospital in Middletown, Conn., and has switched to pediatrics at Baystate Medical Center in Springfield, Mass..

The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.

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Copyright 2007 by the President and Fellows of Harvard College