Make no mistake, ‘perfect’
  practice can be costly

October 2005
Recommended Reading

Anne Ford

Fifty-four years ago, a young intern in Montefiore Hospital, New York City, noticed that his patient, a teenage boy with kidney disease, had severely scarred elbows. The boy explained that he often absentmindedly leaned on the searing radiators in his family’s apartment because he couldn’t feel their heat burning his skin. The resident physician dismissed the intern’s suggestion that the boy might have Hansen’s disease. Six months later, the patient began developing the facial deformities associated with the disease, and a skin biopsy confirmed the diagnosis. The amazed hospital staff started referring to not “Hansen’s disease,” but “Hasson’s disease,” after the intern who had made the correct diagnosis so many months earlier—Jack Hasson, MD, retired associate professor of pathology, University of Connecticut Health Center, Farmington.

Now, decades later, Dr. Hasson has written Why Even Good Doctors Make Mistakes: An Anecdotal Introduction to Medicine.

Published in June, the book comprises dozens of anecdotes, each of which describes a medical error or conundrum Dr. Hasson encountered during his 50-plus years practicing pathology. “Why should I bother at 75 years of age to write a book like this?” Dr. Hasson told CAPTODAY. “It’s a very simple answer. I want to see an end to this firestorm of medical litigation that has paralyzed medical education. One of the basic misunderstandings that is fueling medical litigation is an expectation by everyone concerned, not only the public but doctors as well, that perfect practice is the expected standard, and you simply can’t make mistakes. I want to do what I can to banish that presumption.”

The pressure to be perfect, he adds, is in no one’s best interests—not the doctors’ and not the public’s. Whereas hospitals once routinely held “goof conferences” to review and learn from staff errors, nowadays “the doctors, if they make a mistake, will invariably conceal it,” Dr. Hasson says. “They don’t want it discussed, because they’re afraid of it becoming discoverable in court. We don’t have real peer-review conferences anymore. [And] when you don’t review your mistakes, you make them over and over again, and people are hurt.”

Dr. Hasson’s interest in this issue was sparked in the 1970s by the birth of the medical litigation boom and the subsequent dramatic drop-off in rates of autopsy. As he writes, “Requesting an autopsy [became] a first step in self-incrimination.” After he retired in 2000, the topic continued to preoccupy him. Decades earlier, he had completed a book-length manuscript on the history and importance of autopsies, but hadn’t been able to interest an agent. Now his own doctor—Michael Grey, MD, MPH, professor of medicine and acting division chief of occupational/environmental medicine at the University of Connecticut Health Center—suggested that Dr. Hasson compile in book form the anecdotes he had shared with medical students during his career. “I got a big bang out of remembering all those cases,” Dr. Hasson says. “It brought back a lot of memories.”

Because Dr. Hasson wanted laypeople as well as physicians to understand what fuels medical litigation, he attempted to write the book in an informal, accessible style—no easy task, as he discovered. “I’m a doctor, and I’m as much a stuffed shirt as every other doctor when it comes to writing,” he says. “It’s a handicap. I needed a sounding board, and I preferred that it weren’t a doctor.” He enlisted the help of his friend Razi Sharafieh (a video production specialist with whom he had previously worked on an aborted project to film autopsy dissection techniques). “I asked Razi if he would work with me to make [the book] read like plain English. Let me tell you, I could not have written that book without him,” he says, so much so that he named Sharafieh his co-author. The book can be ordered through iUniverse, a print-on-demand publishing house, by visiting www.iuniverse.com or calling 800-288-4677.

One question Dr. Hasson has often found himself fielding since the book’s publication: How on earth did he remember all the anecdotes’ details? “I do have a terrific memory,” he says. But “you have to understand that I’ve been telling these stories all my life. I would use these experiences spontaneously to illustrate whatever I was talking about to students. All my interesting, heartbreaking, exciting, upsetting, wonderful cases, all of those had a diagnostic teaching point to make. I’ve relived these experiences dozens of times.”

Dr. Hasson emphasizes throughout the book that while many medical mistakes are preventable, some are simply not. One illustration of unavoidable error took place during his tenure as attending pathologist at Montefiore Hospital from 1966 to 1973. It was there that he encountered an 82-year-old patient who had suffered a seemingly ordinary stroke. Rather than improving gradually over two to three weeks as expected, the patient died during the second week after developing pneumonia, which did not respond to antibiotics.

The autopsy revealed that the patient, having lost his cough reflex, had aspirated saliva into his lower right lung. However, another, more startling development was also brought to light: Despite suffering disorientation and a paralyzed left arm and leg, the patient hadn’t had a stroke at all. The lesion and edema in his brain were the result of a metastasized lung cancer, which had gone undiscovered because it wasn’t visible on X-rays. Without CAT scans—which would not become available for about five years—there had been no way to discern the tumor. Meanwhile, the autopsy revealed other metastases in the brain, lymph nodes, liver, kidneys, and adrenal glands.

“This case illustrates how an unavoidable error may make no difference in the outcome of a hopeless fatal disease,” Dr. Hasson writes.

Though the book is devoted to the topic of medical error, in its conclusion Dr. Hasson briefly addresses other problems he feels must be solved if the medical litigation crisis is to end. “All the money available for any injury is only from the doctor’s liability insurance,” he says. “One possibility is that some kind of accident compensation insurance be available to patients. It could be done through a private insurance company. The other possibility, of course, is that awful big word: government. I didn’t want to get into that in this book because it’s an extremely controversial subject.” He also proposes that in cases of malpractice, a panel of physicians, lawyers, clergy, and educated lay people be appointed in lieu of a jury: “Jurypeople are laypeople, and they’re as much victims of the presumption of medical infallibility as anybody else,” he says. “A good lawyer can convince a lay jury of anything.”

Though Dr. Hasson is retired, the myth of medical infallibility and its effects on medical education continue to disturb him. He did, after all, experience it personally for many years. “After being visited by professors of law from Harvard University in our hospital to lecture us on medical litigation, what I wound up with was an impression that a lot of doctors wound up with: ‘I’ve got to be perfect. If I’m not perfect, I’m dead,’” he says. Meanwhile, “I did make mistakes, and every time I did I went into an acute depression, as all doctors do.” Not for another two decades did he realize that, as he writes, “medical fallibility is unavoidable because the only way to end it is to end medical practice.” Or, in more emphatic terms: “It happens. You might as well learn from it.”