A call for intellectual humility

Dr Danielle Ofri’s new book does not necessarily play to her undoubted writing skills

When Dr Danielle Ofri opened her talk at the dotMD 2018 conference, she did so with the story from one of her books about a French woman with Stage 3 lung cancer. The patient, doctor and wider team were in the intensive care unit discussing whether to intubate the woman or not. Ofri reads the dialogue-rich story, so we can feel the dilemma facing everyone. Eventually the patient agrees to seven days of intubation, during which an infection will hopefully be overcome. But just in case it’s the cancer that’s making breathing exceedingly difficult, she gives a clear instruction to her medical team: “Take it out if I don’t get better.”

I suspect it’s reminiscent of scenes throughout our acute hospitals in the weeks since Covid-19 took us in its grip. To ventilate or not, that is the question. With relatively low survival rates for those who are ventilated, it must be heart-rending for physicians, nurses, patients, and relatives. If you would like a taste of what that situation feels like, then Ofri’s talk is available at www.dotMD.ie.

It’s a rather long-winded way of introducing her new book, I admit. But it’s also a fine reminder that Ofri writes the way she speaks – gently and empathetically.

With When We Do Harm, her just published seventh book, one might reasonably assume from its title that it is less empathetic than some of her previous tomes. While medical science has made enormous strides over recent years there’s no doubt that treatment can also cause harm.

Ofri begins her book with a clear introduction: “Patient safety and avoidance of medical error is a complex mix of how individual medical professionals interact and communicate with one another, how they do so with patients and family members and how state-of-the-art medical systems can nevertheless allow small things to fall through the cracks.”

In When We Do Harm Ofri places the issues of medical error and patient safety front and centre of the healthcare conversation. Drawing on her professional experience and extensive interviews with nurses, physicians, administrators, researchers, patients, and families, Ofri explores the diagnostic, systemic, and cognitive causes of medical error. She advocates for strategic use of concrete safety interventions, such as checklists and improvements to the electronic medical record. So far so Atwul Gawandi, you might say. However, Ofri gives plenty of airtime to the cultural and cognitive shifts required to make a meaningful dent in medical error. And woven throughout the book are the powerfully human stories that Ofri is renowned for.

Ofri is a clinical professor at NYU School of Medicine, who has also treated patients at Bellevue Hospital for more than 20 years. It is the stories of patients who have been harmed that form the spine of her new book. What makes the book different from others in the well-trodden ‘medical mistakes’ genre is the author’s perceptive nature and her willingness to be upfront with readers about her concerns and vulnerabilities.

Her narrative focuses on the cases of two patients who died in hospital – one with leukaemia and one with severe burns. The wife of the patient with severe leukaemia attempts, in vain, to get her husband the care he needs, while in the second case a wife and daughter try for years to understand exactly why their husband and father died from his severe burns.

Doctors jumping to a diagnosis is a major issue, she believes. Ongoing diagnostic thinking, in which doctors continually question themselves, needs to move to the centre of patient care.

In the case of the leukemia patient, was the problem ineffective treatment? Or delayed treatment? Were there other complicating medical conditions? Was there an over reliance on computerised diagnosis algorithms?

Ofri argues for greater humility and less heroism on the part of health professionals. “There are few diagnoses more rare in the medical species than intellectual humility. There are few allergies more common than that of doctors to uncertainty,” she writes.

Reviewing this book not so long after reading Samuel Shem’s prescription for a new way of health caring (Man’s 4th Best Hospital), and with Atul Gawande’s  books still making an impression on me, I wonder if the topic Ofri has chosen to tackle is one that plays to her strengths?  No matter what way you look at medical error, there will always be an emphasis on numbers and statistics, with an equally dry dollop of system failures in the mix. For someone with the narrative strengths of Ofri, I’m just not sure it is a topic worthy of her undoubted writing skill.