The Pleasure of Being Wrong

With rates of misdiagnosis as high as 15%,1 the practice of medicine is fraught with error. Despite this statistic, medical culture promotes a façade of authority and expertise. In 1998, Pilpel et al. described the “hidden curriculum” of medicine, which “denies uncertainty, de-legitimizes error and conveys magical notions of absolute knowledge.”2 Medical training encourages confidence in the face of uncertainty. However, physicians are often unaware of their own limitations, and data show that confidence is not always correlated with accuracy of diagnosis.1 Despite the Accreditation Council for Graduate Medical Education–mandated implementation of morbidity and mortality conferences in 1983 to educate the community about errors in medicine,3 there is a pervasive culture of reluctance or, in some cases, unwillingness to acknowledge or admit mistakes.4 This is often attributed to external motivations; physicians who make mistakes face punitive consequences such as job loss, denial of promotion or advancement, decreased compensation, litigation, damage to their reputation, and loss of patient trust. However, one must not discount the internal motivations for a physician’s reluctance to acknowledge personal mistakes. There is an emotional cost to admitting we were wrong—not only does it damage our ego, but it forces us to confront cognitive dissonance. COGNITIVE DISSONANCE IN MEDICINE Klein and McColl define cognitive dissonance as the “uncomfortable tension we experience when we hold two or more inconsistent beliefs, or when our behavior is inconsistent with our beliefs.”5 Acknowledging a mistake is inconsistent with the belief that a physician is careful, knowledgeable, and competent. To avoid the discomfort of cognitive dissonance in these situations, physicians often engage in maladaptive practices. Confirmation bias encourages physicians to seek out information that vindicates them and justifies their past decisions and actions in the face of a negative patient outcome. Instead of accepting responsibility for an error, they blame external factors—other members of the health care team, the institution, the overall health care system, or the patient’s noncompliance. Alternatively, they declare that the outcome was inevitable—the patient’s overall health was so poor that a successful outcome was impossible (Fig. 1).Fig. 1.: Maladaptive response to cognitive dissonance.Cognitive dissonance leads to not only reluctance to admit mistakes but also unwillingness to implement changes in practice when confronted with new data. Perhaps the most well-known example of this in medicine is the hygiene hypothesis. Despite the observation by Semmelweis that handwashing led to decreased incidence of puerperal fever, hand hygiene practices were initially rejected by the medical community in the nineteenth century. Even Semmelweis’s mentor refused to accept that his failure to wash his hands after morning autopsies was causing his patients’ disease.5 WHAT DO WE MEAN BY “WRONG?” In its simplest definition, being “wrong” implies that one has said or done something incorrectly. In medicine, this takes 2 different forms: acute and chronic. A physician who is “acutely wrong” has made a mistake. This frequently results from inexperience or lack of knowledge. For example, a trainee might fail to diagnose superior orbital fissure syndrome because he or she has never encountered it outside of a test question and does not know how to identify the superior orbital fissure on computed tomography. However, experienced physicians are not immune to being acutely wrong. A surgeon who otherwise has an adequate knowledge base might also err through forgetfulness, poor judgment, or failure of observation. For example, the surgeon might miss a chin laceration after neglecting to look under the patient’s cervical collar. Experienced surgeons are more likely to experience cognitive dissonance than their trainees because their mistakes are inconsistent with what they know is right. Meanwhile, a physician who is “chronically wrong” has just learned that his or her routine practices are no longer standard of care. Medical knowledge is constantly evolving; accepted melanoma margins have decreased in size,6 lidocaine with epinephrine is now routinely used in hand surgery,7 and dextran has fallen out of use as an anticoagulant.8 However, there are several widespread practices that are strongly disputed by the literature. Abdominal binders are frequently used after abdominoplasty and hernia repairs because of an unsubstantiated belief that these prevent wound dehiscence—despite emerging concern that these garments increase the risk of venous stasis.9,10 The literature also does not support the use of postoperative antibiotics in the setting of mandible fractures, although these are still commonly prescribed.11 Although it is perhaps too early to conclude that these practices are “wrong,” the slow adoption of change in the plastic surgery world shows how easily surgeons accept their default practices as “right.” THE PLEASURE OF BEING WRONG …The advancement of knowledge depends on current theories collapsing in the face of new insights and discoveries. In this model of progress, errors do not lead us away from the truth. Instead, they edge us incrementally toward it. —Kathryn Schulz, Adventures in the Margin of Error12 In non–safety-sensitive fields, mistakes and experimentation are encouraged. The animation studio Pixar encourages its employees to “be wrong as fast as you can.”13 People form strong memories associated with mistakes, and accepting that we were wrong results in great personal and intellectual growth. Although no physician should derive “pleasure” from a patient’s adverse outcome, we owe it to our patients to rise above cognitive dissonance and accept our errors (Fig. 2). Mistakes are not isolated shameful moments, and we must view them in a more global context. Each patient deserves the highest level of care possible, but our ability to deliver that care is limited by our current knowledge. It is important that we use what we learn from today’s patient to inform our decisions about the patient who walks into our office tomorrow. The errors we identify today become the data that guide future clinical practice.Fig. 2.: Healthy response to cognitive dissonance.LEARNING TO BE WRONG The authors propose the following solutions for reducing cognitive dissonance and fostering openness to acknowledging errors to learn how to be wrong in the most productive way possible (Fig. 3):Fig. 3.: How to be productively wrong.Increase Opportunities for Identification of Errors Continuity of care is often inadequate at the trainee level, creating potential for missing errors. To improve this, residency programs could implement a system where the follow-up visit note and relevant photographs are sent to the resident who initially managed the patient. In addition, health care facilities should introduce diagnostic instruments and technology resources into the patient-evaluation process. These are not vulnerable to the same emotional biases and provide increased opportunities to identify errors—or impending errors—early. Create a Safe Reporting Culture versus a Culture of Shame Trainees and employees working in an environment of shame and abuse are less likely to admit mistakes or question the appropriateness of current management practices. Instead, employers should cultivate a culture of psychological safety. One way to do this is to lead by example. If senior members of a team are willing to admit mistakes, others will do so as well. There should also be an avenue for anonymous reporting of errors.14,15 Create a Culture of Learning and Inquiry Good medical practice is dynamic rather than static, and all members of the team should be reminded of this. Rather than commending trainees for their intelligence or accuracy, mentors should praise their commitment to learning and improvement.5 Language is another way to frame how mistakes are viewed. It is important to teach open-minded language for accepting new or conflicting information: “I was not aware of that.” “I have not thought of it that way before.” “Thank you for bringing that to my attention.” Marshall et al. describe a system in which they reframed errors as “diagnostic learning opportunities.” They also created an anonymous reporting system with monthly updates to clinicians and biweekly “diagnostic reflection time.”15 Both acute and chronic “wrongs” should be shared nonjudgmentally with the medical community so that others learn and grow without having to repeat the same mistakes. Finally, institutions should encourage opportunities for data gathering and research to identify ways to prevent complications and optimize care. The practice of medicine evolves through discovery. To define best practices, we must identify and acknowledge incorrect or harmful practices. This cannot occur unless surgeons are willing to confront cognitive dissonance and embrace being wrong. DISCLOSURE Dr. Heiman is supported by an institutional surgeon scientist training award from the National Institutes of Health (5T32GM008616-25). Dr. Chung receives funding from the National Institutes of Health and book royalties from Wolters Kluwer and Elsevier. He received research funding from Sonex to study outcomes of carpal tunnel surgery.