Skip to main content
Log in

The heart of darkness

The impact of perceived mistakes on physicians

  • Original Articles
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

Abstract

Objectives:To describe how physicians think and feel about their perceived mistakes, to examine how physicians’ prior beliefs and manners of coping with mistakes may influence their emotional responses, and to promote further discussion in the medical community about this sensitive issue.

Design:Audiotaped, in-depth interviews with physicians in which each physician discussed a previous mistake and its impact on his or her lift. Transcripts of the interviews were analyzed qualitatively and the data organized into five topic areas: the nature of the mistake, the physician’s beliefs about the mistake, the emotions experienced in the aftermath of the mistake, the physician’s way of coping with the mistake, and changes in the physician’s practice as a result of the mistake.

Participants and setting:Eleven general internists and medical subspecialists practicing at a community, university-affiliated hospital in Oregon.

Results:Themes emerging from analysis of the interviews were the ubiquity of mistakes in clinical practice; the infrequency of self-disclosure about mistakes to colleagues, family, and friends; the lack of support among colleagues; the degree of emotional impact on the physician, so that some mistakes were remembered in great detail even after several years; and the influence of the physician’s professional locus of control on subsequent emotions.

Conclusions:The perception of having made a mistake creates significant emotional distress for practicing physicians. The severity of this distress may be influenced by factors such as prior beliefs and perfectionism. The extent to which physicians share this distress with colleagues may be influenced by the degree of competitiveness engendered by medical training. Open discussion of mistakes should be more prominent in medical training and practice, and there should be continued research on this topic.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Paget MA. The unity of mistakes: a phenomenological interpretation of medical work. Philadelphia: Temple University Press, 1988.

    Google Scholar 

  2. DiMatteo MR. The psychology of health, illness, and medical care. Pacific Grove, CA: Brooks/Cole, 1991;276.

    Google Scholar 

  3. Voytovich AE, Rippey RM, Suffredini A. Premature conclusions in diagnostic reasoning. J Med Educ. 1985;60:302–7.

    PubMed  CAS  Google Scholar 

  4. Coggan PG, Macdonald SC, Camacho Z, Carline J, Taylor T. An analysis of the magnitude of clinical reasoning deficiencies in one class. J Med Educ. 1985;60:243–301.

    Google Scholar 

  5. Dawson NV, Arkes HR. Systematic errors in medical decision making: judgment limitations. J Gen Intern Med. 1987;2:183–7.

    Article  PubMed  CAS  Google Scholar 

  6. Eisenberg JM. Sociological influences on decision-making by clinicians. Ann Intern Med. 1979;90:957–64.

    PubMed  CAS  Google Scholar 

  7. Elstein AS. Clinical judgment: psychological research and medical practice. Science. 1976;194:696–700.

    Article  PubMed  CAS  Google Scholar 

  8. Carmichael DH. Learning medical fallibility. South Med J. 1985;78:1–3.

    Article  PubMed  CAS  Google Scholar 

  9. Hilfiker D. Facing our mistakes. N Engl J Med. 1984;310:118–22.

    Article  PubMed  CAS  Google Scholar 

  10. Krakowski AJ. Stress and the practice of medicine II. Stressors, stresses, and strains. Psychother Psychosom. 1982;38:11–23.

    Article  PubMed  CAS  Google Scholar 

  11. Levinson W, Dunn PM. Coping with fallibility. JAMA. 1989;261:2252.

    Article  PubMed  CAS  Google Scholar 

  12. Terry JS, Fricchione GL. Facing limitation and failure: four literary portraits. The Pharos. 1985;Fall:13–8.

    Google Scholar 

  13. Christensen JF. Assessment of stress: environmental, intrapersonal, and outcome issues. In: McReynolds P (ed.). Advances in psychological assessment. vol. 5. San Francisco: Jossey-Bass, 1981;62–123.

    Google Scholar 

  14. Lazarus RS. Psychological stress and the coping process. New York: McGraw-Hill, 1966.

    Google Scholar 

  15. Caplan RA, Posner KL, Cheney FW. Effect of outcome on physician judgments of appropriateness of care. JAMA. 1991;265:1957–60.

    Article  PubMed  CAS  Google Scholar 

  16. Folkman S, Lazarus R. An analysis of coping in a middle-aged community sample. J Health Soc Behav. 1980;21:219–39.

    Article  PubMed  CAS  Google Scholar 

  17. Light D. Uncertainty and control in professional training. J Health Soc Behav. 1979;20:310–22.

    Article  PubMed  Google Scholar 

  18. Fox RC. Training for uncertainty. In: Merton RK, Reader GG, Kendall P (eds.). The student physician. Cambridge, MA: Harvard University Press, 1957;207–41.

    Google Scholar 

  19. Rhoades JM. Overwork. JAMA. 1977;237:2615–8.

    Article  Google Scholar 

  20. Gabbard GO. The role of compulsiveness in the normal physician. JAMA. 1985;254:2926–9.

    Article  PubMed  CAS  Google Scholar 

  21. Festinger L. A theory of cognitive dissonance. Evanston, IL: Row, Peterson, 1957.

    Google Scholar 

  22. Breznitz S. Seven kinds of denial. In: Breznitz S (ed.). The denial of stress. New York: International Universities Press, 1983;257–80.

    Google Scholar 

  23. Lazarus RS. Costs and benefits of denial. In: Breznitz S (ed.). The denial of stress. New York: International Universities Press, 1983;1–30.

    Google Scholar 

  24. Peterson C, Seligman MEP. The learned helplessness model of depression: current status of theory and research. In: Beckham EE, Leber WR (eds.). Handbook of depression: treatment, assessment, and research. Homewood, IL: Dorsey, 1985;914–39.

    Google Scholar 

  25. Daniels M. Affect and its control in the intern. Am J Sociol. 1961;66:259–67.

    Article  Google Scholar 

  26. Millman M. The unkindest cut: life in the backrooms of medicine. New York: William Morrow & Co., 1977.

    Google Scholar 

  27. Hughes EC. Mistakes at work [1951]. In: The sociological eye: selected papers. Chicago: Aldine, 1971.

    Google Scholar 

  28. Adamson TE, Tschann JM, Gullion DS, Oppenberg AA. Physician communication skills and malpractice claims—a complex relationship. West J Med. 1989;150(3):356–60.

    PubMed  CAS  Google Scholar 

  29. Avery JK. Lawyers tell what turns some patients litigious. Med Malpract Prev. 1985;35–7.

  30. Shapiro RS, Simpson DE, Lawrence SL, Talsky AM, Sobocinski KA, Schiedermayer DL. A survey of sued and nonsued physicians and suing patients. Arch Intern Med. 1989;149:2190–6.

    Article  PubMed  CAS  Google Scholar 

  31. Gutheil TG, Bursztajn H, Brodsky A. Malpractice prevention through the sharing of uncertainty: informed consent and the therapeutic alliance. N Engl J Med. 1984;311:49–51.

    Article  PubMed  CAS  Google Scholar 

  32. Calnan M. Clinical uncertainty: is it a problem in the doctor—patient relationship? Sociol Health Illness. 1984;6:74–85.

    Article  Google Scholar 

  33. Sorensen JR. Biomedical innovation, uncertainty, and the doctor-patient interaction. J Health Soc Behav. 1974;15:366–74.

    Article  Google Scholar 

  34. Nazareth AM, Kanekar S. Effects of admitting or denying a mistake. J Soc Psychol. 1986;126:531–7.

    Article  Google Scholar 

  35. Sorotzkin B. The quest for perfection: avoiding guilt or avoiding shame? Psychotherapy. 1985;22:564–71.

    Google Scholar 

  36. Vaillant GE, Sobowale NC, McArthur C. Some psychological vulnerabilities of physicians. N Engl J Med. 1972;287:372–5.

    Article  PubMed  CAS  Google Scholar 

  37. Bosk CL. Forgive and remember: managing medical failure. Chicago: University of Chicago Press, 1979.

    Google Scholar 

  38. Katz J. Why doctors don’t disclose uncertainty. Hastings Cent Rep. 1984;February:25–44.

    Google Scholar 

  39. Mizrahi T. Managing medical mistakes: ideology, insecurity, and accountability among internists-in-training. Soc Sci Med. 1984;19(2):135–46.

    Article  PubMed  CAS  Google Scholar 

  40. Dubrowsky SL, Schrier RW. The mystique of medical training: is teaching perfection in medical housestaff training a reasonable goal or a precurser of low self-esteem? JAMA. 1983;250:3057–8.

    Article  Google Scholar 

  41. Walsh KW. Neuropsychology: a clinical approach. New York: Churchill Livingstone, 1978.

    Google Scholar 

  42. Wu AW, Folkman S, McPhee SJ, Lo B. Do house officers learn from their mistakes? JAMA. 1991;265:2089–94.

    Article  PubMed  CAS  Google Scholar 

  43. Pennebaker JW. Traumatic experience and psychosomatic disease: exploring the roles of behavioural inhibition, obsession, and confiding. Can Psychol. 1985;26:82–95.

    Google Scholar 

  44. Fox RC, Swazey JP. The courage to fail. Chicago: University of Chicago Press, 1974;109–21.

    Google Scholar 

  45. Light DW. Psychiatry and suicide: the management of a mistake. Am J Sociol. 1972;77:821–38.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Rights and permissions

Reprints and permissions

About this article

Cite this article

Christensen, J.F., Levinson, W. & Dunn, P.M. The heart of darkness. J Gen Intern Med 7, 424–431 (1992). https://doi.org/10.1007/BF02599161

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/BF02599161

Key words

Navigation