The Best Rx: Facing Up to Mistakes

A study from Johns Hopkins reveals that the father of successful neurosurgery, Harvey Cushing, a driven, egotistical figure, was nonetheless also routinely frank about admitting his mistakes.  I profiled Cushing recently (see below) and was also struck that, apart from being meticulously careful in his work, he also relied on methodical record-keeping and self-criticism to improve his results.  In the new study, medical student Katherine Latimer and her co-authors

… were surprised by Cushing’s frank and copious documentation of his own shortcomings. His notes acknowledged mistakes that may have resulted in patients’ deaths, as well as those that didn’t seem to harm patients’ outcomes. They said the documentation took place in an era in which malpractice litigation was becoming a growing concern for doctors. Though malpractice penalties were substantially smaller in Cushing’s day, lawsuits presented a serious risk for physicians’ reputations, the authors noted.

The authors also emphasized that Cushing practiced in a time of enormous surgical innovation. For example, patient mortality from surgical treatment of brain tumors fell from 50 percent to 13 percent during his career. While some of this jump ahead was due to improving technology, the authors propose that part of the reason was open documentation of errors, which helped Cushing and other surgeons develop fixes to avoid them.

The Brain Cutter

Here’s my profile of Harvey Cushing, published recently in the Yale Alumni Magazine:

Deep beneath the stacks of the Yale medical school library, a kind of grotto venerates the human brain. It’s a memorial to an era when surgery on “the closed box” of the human skull was far more mysterious, even macabre, than it seems today. It’s also a celebration of one man who made it less so, essentially inventing modern brain surgery by his odd blend of audacity and painstaking care with scalpel, drill, saw, and clamp.

You get a hint of what lies beneath on the stairway down, where a large photograph from 1930 shows a 24-year-old surgical candidate in hospital pajama bottoms, facing the camera and displaying symptoms of the form of gigantism called acromegaly. Surgeon Harvey Cushing, Class of 1891, stands at his side. He is an older and much smaller man, facing the patient, one knee canted forward, one hand in the jacket pocket of a carefully tailored glen-check suit. With his other hand, he holds the giant delicately by two fingers, as if to lead him to his fate. (The patient, a farm laborer, had been told by another doctor that he would “die if anyone operated on his pituitary.” In fact,