Safety in Numbers

To the Editor: Ginsburg and colleagues1 touch the tip of the iceberg in their recent article examining physicians’ responses to professional challenges. The authors analyzed physicians’ explanations of why they would make “wrong” decisions in response to dilemmas likely to occur in medical practice and found that participants’ desire to be helpful was a frequent rationale. If being seen as helpful requires decisions that are inconsistent with standard of care guidelines, perhaps we should question the usefulness of such guidelines. Of equal importance, yet not emphasized by Ginsburg and colleagues (because it was not as prominent as other factors they identified), is the role of social pressure as an influence on physicians’ decision making. The physicians in this study referred to the actions of other doctors when making decisions about dilemmas—as Ginsburg and colleagues note, “Participants often made reference to ‘what the other doctors’ would do, even while admitting that they do not always know what other doctors would actually do.” To use other doctors as reasons for less-than-professional practice seems, well, unprofessional. These subtle social pressures occur far more often in everyday practice. For example, we recently attended a medical grand rounds session, during which a respected faculty member shared a patient history with an unequivocal diagnosis and management plan. However, in the interest of seeing how the audience would respond, he gave a “wrong” diagnosis. This was followed by a series of three questions posed to the audience and an invitation to respond by using polling clickers for anonymity. The polling percentages showed the audience’s alignment with the incorrect diagnosis, with 48% choosing a diagnostic step, 30% choosing a first line of therapy, and 62% choosing a disposition and consultation that would be consistent with the incorrect diagnosis. Are physicians using one another as a safety net or as a means of absolving personal responsibility? There are many similar anecdotes, and empirical studies are emerging too.2 With the goal of evolving into a high-reliability organization driven by a focus on patient safety and high-quality decision making, findings such as those reported by Ginsburg and colleagues demonstrate that justifying and rationalizing a mind-set for conforming to the need to be seen as helpful to our patients, friends, colleagues, and the general public is not helpful at all. Ghazwan Altabbaa, MD, MSc Clinical associate professor and associate program director, Internal Medicine Residency Program, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; [email protected] Tanya Beran, PhD Professor of medical education, Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada. Alyshah Kaba, MSc PhD candidate, medical education and research, Department of Community Health Sciences, Cumming School of Medicine, W21C Research and Innovation Centre, University of Calgary, Calgary, Alberta, Canada.

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