How Can I Be Wrong When It Feels So Right?
Nefthi Sandeep
Medical Director of Pediatric Cardiology - Mary Bridge Children's Hospital
In my world of pediatric cardiology, when we get things wrong, part of the process of moving forward involves a critical and thoughtful review of what happened so we can be better next time. Reflecting on the case of Maya Kowalski at All Children’s in St. Petersburg, it seems to me the critical error of Maya’s collective medical team was not their initial diagnosis of Munchausen-by-proxy at the hands of her parents, but their unwillingness to let go of their initial conclusions, and pivot as new information came in.
?In medicine, our process of arriving at the truth (i.e. correct diagnosis) involves making multiple educated guesses simultaneously knowing they all cannot be correct. This is why we order multiple tests at once instead of one at a time. It’s why we set finite windows of time (weeks, days, sometimes hours) after which we reevaluate and reassess for progress and improvement. Getting it wrong is actually part of the process of getting it right. Getting it wrong is expected. Staying wrong after you’ve been given multiple opportunities to become right is a problem.
This, in my view,? is where All Children’s went wrong with Maya, who was admittedly a patient with a challenging diagnosis. ?I don’t envy the medical team one bit. Maya had been previously diagnosed with complex regional pain syndrome (CRPS), which as the name implies, is complex. The underlying cause is unknown.?There’s no single blood test, x-ray, or MRI that says you definitely have it, and treatment recommendations vary widely.
The medical team was right to initially have concerns when her mother requested ketamine for Maya. Ketamine is an anesthetic predominantly used during in-hospital procedures, and a tightly controlled substance. And Maya’s mother didn’t just ask for ketamine, she demanded it. To make matters even more complicated, Florida law mandates that anyone who suspects child abuse must notify authorities or risk a third-degree felony conviction. It’s easy to see how Maya’s doctors’ early concerns quickly grew into a three-alarm blaze when actually, nothing was on fire but the hospital’s hair.?
?It would be asking a lot of Maya’s medical team to understand all the nuances of Maya’s diagnosis and how best to treat it in the heat of the moment. However, a simple Google search would have revealed within minutes that multiple studies have been published (that include pediatric patients) in peer-reviewed journals regarding the use of ketamine in treating CRPS---Maya’s own local anesthesiologist and pain specialist, who first gave Maya her diagnosis and treated her with ketamine, authored one such study.
?From this point forward, it becomes difficult to understand the medical team’s thought process. Separating Maya from the “danger” (in their initial assessment, Maya’s mother) did not result in improvement, as would be expected with Munchausen-by-proxy. Maya continued to report extreme pain. Further, while in hospital custody, there were new objective findings of bumps and lesions on Maya’s limbs and face. These would be more suggestive of CRPS, and yet, instead of reconsidering their initial diagnosis, they seemed to double down. If someone had stopped and thought, wait, maybe we were wrong about Munchausen, things might have proceeded very differently indeed.
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Being a doctor, or a leader, demands self-awareness, and an unwavering commitment to the truth, even if this means admitting that we’ve been wrong and reversing course. Here are the things we doctors keep in mind when we are tracking down an elusive diagnosis, that leaders might find useful when making their own difficult calls.
1.??? Respect your metrics: What does the evidence actually say to you, separate and aside from what you hope it says?
2.??? Measure your progress: Is the patient improving? Is the solution you’ve implemented producing the results you expected?
3.??? Be humble: Mistakes are a teaching moment. Be willing to learn and admit that you might have been wrong.
4.??? Listen objectively: Make an effort to listen to every member of the team and to give their perspective as much weight as you give your own.
5.??? Don’t get married to your first impressions. The truth is not personal, and the search for truth is not about you, but the patient.
Global Operations Performance Manager at bp
1 年Thanks for sharing Nefthi! These are the same pit falls that we go through as engineers. Knowing when to pivot when your initial assumptions are not right and following the data and the real insights from that data is key. Also, we often talk about group think and going along with the strongest voice in the room. I don't know this story, but there is usually someone, a quiet voice, or someone who didn't speak up for fear of sounding stupid, that thought, "this doesn't make sense". Building a culture where people can and will speak up is hard but it's needed. Again, thanks for sharing. I think we can learn a lot across industries.