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Join us for an insightful exploration of the complexities of managing mistakes in health care with our guest, Josh Schwarzbaum, an emergency physician. Together, we’ll discuss the importance of embracing errors as opportunities for growth, fostering a culture of humility and learning, and navigating the delicate balance between self-reflection and the demands of fast-paced medical environments.

Josh Schwarzbaum is an emergency physician.

He discusses the KevinMD article, “We all make mistakes. Don’t let them define you.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Josh Schwarzbaum. He’s an emergency physician, and today’s KevinMD article is “We all make mistakes. Don’t let them define you.” Josh, welcome back to the show.

Josh Schwarzbaum: Thanks, thanks for having me here.

Kevin Pho: Josh has been on in the past. Go to KevinMD.com/podcast to search for his name and hear his story and prior episode. But today let’s jump right into your most recent KevinMD article. It’s titled “We all make mistakes. Don’t let them define you.” What’s this one about?

Josh Schwarzbaum: Yeah, this article I wrote, I don’t remember exactly what inspired me to write it at the time, I wrote it a little bit ago. But in medicine and in life we all make mistakes. It’s something that always happens. None of us are perfect in any realm. We’re always learning, we’re always growing, we’re always trying to see new things, figure out new things.

And what I’ve seen in my life, working in emergency rooms, working in addiction centers, especially in addiction centers, people make a lot of mistakes to end up being a patient in an addiction center, theoretically a mistake. But even training doctors, and in my coaching practice as well, and dealing with the residents and medical students, there’s a fear of making mistakes, messing up, looking bad in front of other people, looking bad in front of yourself. But it’s something that we all do, and it’s something that happens to all of us all the time.

So the question that I ask is, well, is this something that we need to run away from, or is this something that we can come to terms with and then utilize it to help us grow and become better physicians, become better parents, become better partners, become better in relationships, whatever realm it may be in?

Kevin Pho: Yeah. So in the medical field, and in emergency medicine, how are mistakes in the medical profession, how are they normally handled, that you’ve seen?

Josh Schwarzbaum: I mean, I think it depends on the type of mistake and the severity of mistake. There could be a small mistake, for example, I could be getting a presentation of a case and there could be a mistake in the sense of, well, maybe you’re not giving me the best differential diagnosis or something like that. That could be theoretically a mistake.

So in that sense, if I have a resident or medical student, let’s say, presenting to me, maybe they’re going to think that they’re stupid, or they don’t know enough or whatever, and then that theoretical mistake could be something that really harms their self-confidence or prevents them from moving ahead in the field. So that could be theoretically defined as a mistake.

And then there’s obviously much, much bigger mistakes that happen, which fortunately we don’t see very much, but surgical mistakes, or giving the patient a wrong medication, or not giving the proper treatment or something like that. And that can be a much bigger mistake as well. And in medicine especially, some of these mistakes, if it’s a big enough mistake, can obviously cost someone their life, and we need to be very, very careful about those types of mistakes especially.

So I think within medicine and within life there’s obviously a variety of different types of mistakes, and the severity of the mistakes and how big of an impact that they have. But I do think that having a framework to address these, if we’re able to take mistakes as a category and as a whole, we can take them back and then learn an effective way and have an effective approach to deal with them.

And then also, I think by not letting our mistakes eat us up, we are less prone to making mistakes in the future. Because think about when you’ve done something and you feel very tense, how well does that come out? If I’m scared all the time about what could happen, or the bad things, I’m just not going to perform well. And if I feel more relaxed, if I feel more calm, then I’m going to be able to perform better inherently.

So I think part of it is dealing with our mistakes after the fact, but then having an approach to proactively come into a place and be somewhere where we are in our best selves and in our best state of mind, so that we are preemptively trying to minimize the mistakes, and especially the severity of mistakes, that we may make.

Kevin Pho: Now, from your experience, from what you’ve seen in the emergency department, or what you’ve seen through coaching, in general how do physicians deal with the aftermath of potential mistakes? What’s the spectrum of their responses that you’ve seen?

Josh Schwarzbaum: I think it goes from apathy to complete meltdown. Some people just say, I don’t care, it’s not my fault, it’s the system, it’s this, find some external thing to blame it on. Other people, they eat themselves up, and, I can’t go back to work because I made this huge mistake and it cost somebody their life. And then you have everything in between.

And I think everybody approaches these things very, very differently, based on whatever their own personal experience was, whatever the mistake may have been. And it’s interesting to see how two people could also make the same mistake and then come out of it very differently and have very different feelings about the same mistake. So you get people really across the entire spectrum.

And it is interesting to see, and then working through those things as well with the different physicians, it’s a process. And if we’re able to get this understanding, essentially, and if we’re able to see mistakes in a slightly different way, something that is potentially learning and growth, and use it to propel us forward, no matter where we are on that spectrum.

And it comes with introspection too. Mistakes don’t necessarily happen in a vacuum, so it could be easy to deflect them and blame something outside of ourselves for it. It’s also easy to blame something within ourselves. And then there’s some sort of a combination that it’s probably going to be.

But then what I found, at least, is that if each one of us is able to bring our best self to the table, like I said before, if I can approach a situation as best as I possibly can, then I at least know that I’m doing what I can do. I can’t change the whole hospital system, I can’t change the amount of staff, I can’t change the computer system, all this stuff that I could blame mistakes on theoretically. I can’t change a lot of that stuff, but I can do the best I can. And if I can do that, then that’s the best I can do.

Kevin Pho: All right. So you talked about a framework that physicians can use whenever they encounter a mistake, or when they make a mistake. So take us through that framework.

Josh Schwarzbaum: Part of it is, I think it’s looking at it in different stages. So you have events that lead up to the mistake, you have the mistake, and then you have events after the mistake.

Now, what leads up to a mistake? Could I have looked at something differently, could I personally have done something differently, is this a system problem, is this a combination problem? So it comes with some introspection, looking inward and saying, what could I potentially have done differently?

But again, in that stage I think it’s important to recognize not to put blame on myself. Because once I start judging myself for being an idiot, or being stupid, or, I could have done something differently, well, no, I probably couldn’t have done something differently, because if I could have done something differently, I would have done something differently. Maybe next time I can do something differently. So I think that stage is key.

And then it’s also depending on how we’re working. If we’re working on a systems level, obviously we have hospital systems that will respond to a mistake, that then do root cause analyses and make these big process changes and all that sort of stuff, which I think is a little bit different than dealing with it on a personal level.

But on a personal level, looking at what potentially led up to this mistake, what could I have done differently, and without blaming myself, and then, what was my part in leading up to this, and then for the next time saying, OK, I’ve learned something from here without blame.

I’ve made mistakes in my career. There have been things that I’ve missed, or I wish I would have caught on earlier, or things I could have done differently. And I look at these cases as learning cases, and I hope and I pray that for every case that I deal with that it’s not going to be a bad outcome.

Because we also have to recognize that we’re all human. Each one of us is a human being, and the amount of medical information and medical knowledge that’s out there, it’s just exponentially growing every single day. It’s impossible to keep up with everything. So it’s like, what standard are we going to hold ourselves to?

And that’s another thing, I think a lot of this comes with, what sort of pressures we put on ourselves, what sort of pressures we take on from other people and stuff like that. We have a lot more control, and I fundamentally believe this, that we have a lot more control over ourselves than our profession gives us credit for, and our societies give us credit for, than the world gives us credit for.

I mean, we hear all the time how everybody’s burned out, or everybody’s going to experience terrible times in medicine. And some of us may, some of us may not. But we have so much power in this regard. And if we’re able to harness that power and recognize the goodness that we have within ourselves, and the ability that we have to approach these situations with calm and ease and learning and really doing good for another person, then we could.

And despite all of that, medicine is inherently risky, and that’s another thing I think that’s important as part of the framework too, because we’re dealing with unknowns. We’re not God, none of us are God. So we’re dealing with different things that we can use our best judgment about. But even if you have the same problem and you go to two different doctors, you may get two complete opposite opinions with the same subjective facts. So how does something like that happen? So who’s making the mistake, one doctor or the other doctor?

So when we start to look at this stuff in a little bit of a bigger picture, and I think part of the framework is building this kind of support structure essentially around, and understanding our role vis-a-vis the patient, vis-a-vis life, vis-a-vis everything that’s going on around us, and the way in which we look at things and how we think and how we process and all that sort of stuff. And when we build that framework, then we start to recognize that our mistakes truly don’t define who we are.

We have a piece inside of ourselves that’s untouchable. Nothing can touch that, if we’re willing to make sure we see it, and we’re willing to hold on to it and make sure that we’re cultivating that. And we’re the only ones that can do that for ourselves. And the more that any of us are able to do that, the more that our mistakes are not going to define us, and the more that we’re going to approach these situations from a place of good-heartedness.

And I don’t want to go into a patient not feeling good inside, because then I’m going to be more prone to making a mistake, I’m not going to care about that mistake. But if it’s my job to go take care of another person when their life is in danger, I’ve got to do that. And how do I do that for myself? And I think it’s really building up that whole framework, and then still recognizing the uncertainty.

And then after it happens, that’s another stage. And it’s again, like we said before, not beating ourselves up about it, recognizing that we are human, that people do make mistakes, and that we can learn from it and it doesn’t have to define us. And if we keep on making the same mistakes over and over and over again, at that point we really need to take a hard look in the mirror and say, what’s going on here? Because how many times can I blame it on something else?

Kevin Pho: Sure. Give us an example, tell us a story of a mistake you’ve made, and I’ve made plenty of mistakes as well, where you could apply some of those lessons from your framework to turn that mistake into a more constructive situation.

Josh Schwarzbaum: Currently I work in St. Barnabas Hospital in the Bronx, it’s a very busy emergency room, and I trained at Jacobi and Montefiore, all city kind of emergency.

And I think the mistakes that I tend to remember, I guess, are, a lot of times when you’re relating to people there are little words or phrases or something that we take for granted in medicine that we may say, or talk about a patient in a certain way, that can really tick people off in like half a second.

And all of a sudden you say something like, you know, the guy over there with the, or the drunk guy over there, or whatever, just using that as an example, or the guy who’s high on whatever. And then all of a sudden they wake up and they feel this sort of judgment coming from us, and then that takes a very calm situation and turns it around.

So I saw this happening a lot in the beginning of my career. I’ve essentially always been dealing with the same type of patient population, but in the beginning of my career, the first two years of residency I would say, I would be going to the hospital and being like, what am I doing here? Makes no sense. I’m trying to help people, nobody cares, they come back with the same issues.

And I realized all along, afterwards, that I was making a mistake in the way that I’m approaching every one of these. Because the truth is, now I’ve changed my approach to it, because I’ve seen something new, I’ve gained a deeper knowledge having practiced for so much longer. So now when I go to talk to somebody, I’m more cognizant of it.

I remember actually on rounds one time, this was during my residency, I made some stupid joke or whatever, and the program director, it sticks with me to this day, but I was one of the senior residents, I don’t remember if it was during my third year or fourth year, whatever. But the program director said, you have younger residents that are watching you and learning from you. Like, you make this stupid joke, it has a big impact.

And it hit me at that point, like, what we say really makes a difference, not only for the patients but for the doctors. And the more I become cognizant of that, and the more in which we’re able to present ourselves with respect. And I do think it’s important to joke in medicine and to have humor in medicine, don’t get me wrong. I still to this day, things are funny and we laugh at them and whatever. There’s a time and there’s a place and there’s a way to do it, and a respectful way to do it, and all that sort of stuff.

And I think utilizing these experiences that I’ve had, I could look at them as mistakes and say, I pissed off this guy, pissed off that guy, I did whatever. Or I could say, look, I’ve come from point A to point B to C, and I’ve been learning and I’m refining these skills. And that’s where I think it’s very helpful to have this type of approach. Because even today I may still say something that upsets somebody or whatever, and then I can learn from it for the next time, and then for the next time, and hopefully continuously improve.

And that’s what life is about, it’s continuous improvement, it’s continuous moving forward. So don’t get stuck in the past, don’t get stuck in what was, because you have a new opportunity coming up.

Kevin Pho: How about hospitals and medical institutions in general? Do you think that they foster an environment where physicians can turn these mistakes into constructive learning experiences? And if not, what can they do to transform that experience?

Josh Schwarzbaum: Yeah, it’s a good question. I like it, because I think there’s a lot of room that could be worked on in that realm.

I would probably say that overall it’s probably not the, let’s all walk around and talk about our mistakes and feel good about them and have learning experiences from them. I think there is a way to do it, and I do think it would be very important, and especially for people in training, because the more we’re able to talk about these things, the more we’re able to show the humanity that we all share. And it’s by coming together and by recognizing that these things will happen. They will. But by virtue of understanding that they will happen, hopefully we can minimize their effect.

So as hospital systems, they design processes to do this sort of stuff. I think bringing people together is always a good option, whether that be through writing or stories or just casual conversations. But having some sort of framework, and bringing in people or leaders, or even developing this within a hospital or within a department, where people can kind of come and talk over cases, talk over things about what they’ve been dealing with and what they’ve been going through.

And it’s something I’ve actually done with a couple of the hospitals I’ve worked in, for the residents, and it’s been successful and it’s been very effective, because it gives people the time and the place to hear each other out, to know that they’re not alone.

And that’s the other thing with mistakes too. You don’t know what mistakes anybody else has made, you only know what mistakes you’ve made. So all of a sudden I make a big mistake, I think I’m the only idiot who’s ever made this mistake in my life, and I feel terrible about it. But then sure enough I go talk to some of my attendings who are 20 years ahead of me, or I speak to other colleagues or whatever, and sure enough they’ve made a similar mistake, or a worse mistake, or something else that maybe I haven’t done. And all of a sudden I’m not alone in this anymore, and I’m not the only idiot in town.

So those types of things I think are definitely beneficial. And there’s a barrier to pass, because I think in medicine it potentially is somewhat embarrassing. Nobody wants to be known as the guy who messed up. So I think inherently we don’t want to talk about it so much because of some embarrassment for ourselves. But if we’re able to get past that, I do think we’re able to.

And it doesn’t even need to be necessarily me talking about my mistakes, but it could be me telling somebody who’s then presenting a case and going over it, and then that way at least maybe takes away some of the embarrassment. Or not, but some people can and do have the ability to get up there and talk about it.

But I think it just goes to show how we all can learn from each other. And it’s definitely, I think, beneficial, and something that if we as a profession and hospital systems and corporations really started to implement more, I think we would see a lot more improvement than some of the corrective actions that we typically do, that, while designed to be helpful, don’t really address the root of what’s going on.

Kevin Pho: We’re talking to Josh Schwarzbaum. He’s an emergency physician. Today’s KevinMD article is “We all make mistakes. Don’t let them define you.” Josh, we’ll end with some of your take-home messages to the KevinMD audience.

Josh Schwarzbaum: Yeah, thanks. The messages I guess I would say is that, believe in yourself, trust in yourself, find the good within yourself, develop that, bring it out. The more you’re able to do that, the more you’re going to be able to heal other people, the better you’re going to feel for yourself first of all, and then by virtue of that you’re going to be able to heal other people.

And then recognize that we’re all human, and don’t beat yourself up for being human. So when stuff happens, if stuff happens, learn from it, utilize it, talk to people about it, share it with others, because they can transform you, but you can also utilize them to transform others. And also learn from other people, and learn from other people’s mistakes. And then by virtue of doing that, you’re going to propel yourself much, much, much faster than you would just by keeping your head down, doing your own thing, not having any interaction with anybody else.

Because you utilize the people around you. There’s a lot of good people out there, and people want to hear from you too. So don’t be shy, and do what you can to help support the profession, help support each other, and really help yourself.

Kevin Pho: Josh, thank you so much for sharing your perspective and insight, and thanks again for coming back on the show.

Josh Schwarzbaum: Yeah, thank you very much. Thanks for having me.