Past Book Review (November 16, 2008): "Medical Errors and Medical Narcissism"

Past book review (i.e. posted prior to starting this blog) for Medical Errors and Medical Narcissism, by John D. Banja, Jones & Bartlett Learning, 2005, reposted here:

Published almost four years ago at the time of this review, it is rather interesting that other readers have not yet shared their thoughts about this book. Quite simply, this is an extremely well written, well organized text, and the subject matter is relevant to a large segment of society. Health care touches almost everyone, and understanding the mind of the health care worker, especially the physician, is important when assessing medical errors. According to author Banja, Associate Professor in the Center for Ethics at Emory University, behavior that he refers to as "medical narcissism" can have a profound influence on how the physician reacts to occurrences of such errors. Before Banja discusses narcissism in health care, he first explains error and rationalization, and follows the discussion of narcissism with chapters on forgiveness, remedies, and empathic disclosure.

The author indicates that "it is important to note that the variance, departure, or straying from the standard of care that is presently being offered as a definition of error must be morally problematic, or uncomprehending, or unintended by the actor. Simply calling an error 'a failure to accommodate the standard of care' would imply that medicine could not have progressed since Hippocrates without its practitioners making 'errors', which seems intuitively wrong. The failure to follow the standard of care, then, must be unwarranted and, overwhelmingly, the errors discussed in this book are just so". And "it is grossly unfair to hold health professionals to a standard of competence that defines 'error' in a way that exceeds ordinary and reasonable levels of performance. Because imputing error can have onerous repercussions, health professionals and especially risk managers must insist on a coherent understanding of error and resist imprecise definitions that could confuse or compromise hospital policy on patient safety and managing adverse outcomes. Consequently, the definition of error that will be used throughout this book is: 'An error is an unwarranted failure of action or judgment to accommodate the standard of care'."

Following his discussion of medical errors, Banja then takes a look at how such errors are handled, providing many examples of such scenarios, which suggest "a temporally tight juxtaposition of immense anxiety and concern for the patient's welfare, followed closely or even simultaneously by the provider's intense anxiety about his or her own welfare. The lock-step nature of these dual anxieties is key". As the author continues with his presentation, he indicates that it is unfortunate that there is no national consensus (i.e. within the United States) that dictates how such errors need to be communicated to affected parties. According to cited studies, what is often the case is that information associated with such errors is withheld, and in one study where disclosure practices of over 200 hospitals were examined, the conclusion was that only 10% to 20% of serious, preventable, iatrogenic harms that occurred to patients were disclosed. What is often the case, according to surveys of physicians, is that harm-causing medical errors are often rationalized.

One of the most interesting portions of the text is the discussion on the origins of medical narcissist characteristics (emotional disengagement, ideological rigidity, and compulsiveness), which often start in childhood and are later reinforced during medical training. And the author's later secular discussion of forgiveness is superb. While Banja indicates that there is no consensual definition of forgiveness, a very compelling presentation is presented of what true forgiveness might look like from psychological and moral perspectives, beginning with a quote which reads as follows: "What is annulled in the act of forgiveness is not the crime itself but the distorting effect that this wrong has upon one's relations with the wrongdoer and perhaps with others". The cognitive-emotive-behavioral triad that the author presents is powerful. Forgiveness for the forgiver from each of these, respectively, might be: "I will stop thinking about the offense", "I will cease to feel anger and hatred toward the offender", and "I will not seek revenge"; forgiveness for the forgiven might be, respectively: "I will acknowledge and admit my wrongdoing", "I will feel and express sorrow for what I did", and "I will desist from committing that wrong again and make amends".

The stumbling block for the medical narcissist, however, is that forgiveness "requires a humbling of the self and a relinquishment (at least temporarily) of grandiosity". Considering the lengthy discussion on errors and how errors are handled, this book would not be complete without the chapter on remedies, which includes sections on tort reform, the blameless and nonpunitive environment, and mindfulness. And the following chapter discusses the empathic disclosure of medical error, how errors arguably should be handled. Within the closing pages, the author indicates that he "wrote this book with a particular kind of health professional in mind. He or she is one who believes it is immensely important to: (1) maintain a professional distance or guardedness with patients that largely precludes empathically reacting to their anxiety or suffering, (2) appear utterly competent always, (3) understand and ground that competence in scientific method and a densely clinical vocabulary, (4) never admit ignorance, hesitation, or error, (5) direct and control the conversation with patients always, and (6) use the power of his or her white coat to direct how the patient should behave and feel".