The PAPERs Podcast

Episode host: Lara Varpio

 

In today’s episode, the hosts discuss a paper about the medical errors committed by physicians—their triggers, the topics they reflect in relation to those errors, and what lessons they take away from those error experiences. While that is the topic of the paper, the hosts debate several points in the paper—not the least of which being: What can you do when your research data are actually chapters in a published book?  

Episode article

Raghoebar-Krieger, H. M. J., Barnhoorn, P. C., & Verhoeven, A. A. H. (2023). Reflection on medical errors: A thematic analysis. Medical teacher, 1–7. Advance online publication. https://doi-org.proxy.kib.ki.se/10.1080/0142159X.2023.2221809

Episode notes 

Background 

I’ve studied medical errors for many years now—not how errors happened, nor how to prevent them. Instead, I’m interested in what it means for the physician when they do the very human thing of not being perfect, of making a mistake. I worry that we spend a lot of time trying to create ways of avoiding errors, but we spend much less on dealing with the reality that we do make mistakes. Errors happen. Humans make mistakes. Systems have weaknesses. We can do everything in our power to prevent errors, but we will never be 100% successful. Errors happen because we are imperfect humans, working in imperfect systems. 

My paper selection examines errors and the impact they have on individual physicians. The paper is entitled Reflection on medical errors: A thematic analysis, published in Medical Teacher in 2023.  

I’ve renamed this paper My Best Mistake 

This paper suggests that we can use reflection to learn from errors and to prevent them. They define reflection as the systematic and critical analysis of past behaviors and underlying assumptions. In this study, the authors want to understand the reflection that doctors engage in when they make errors in hopes of being able to better train physicians to use reflection to learn from errors and to minimize future errors. The authors ask a 3 part question:  

• What triggers doctors to become aware of their errors? 
• What topics do doctors reflect upon to explain the error? 
• What lessons to doctors learn after reflection on their errors, visible in their behavior change? 

Method 

The authors conducted a thematic analysis of pre-existing data from a book that was published entitled “When Healthcare Hurts: Doctors share their darkest hours”. The book consists of “transcribed verbatims from interviews between the book’s author and medical doctors”. Publicly well known, respected doctors working in patient care had an interview with the book’s author. And that interview was then presented in the book in 3 pages, following a specific outline. 

1. The doctor’s name, a photo, their specialty and a quote about the error. An introduction is given with the doctor’s description of some core aspects of the error. 

2. A summary of the doctor’s academic and work history. 

3.  “An extensive reflection is given about the analysis of what happened and the changes the doctor made after making the error.” 

They used these 3 page descriptions as their data. 

In terms of analysis, two authors read the reports in the book and coded them independently. They did line by line coding and “using a constant comparative approach, they developed codes and themes.” They explain that to code, they identified triggers, topics and lessons learned (note: they used their research question to structure their coding). They turned codes into themes by “selecting verbs that identified expressions of action and selected nouns and key terms that identified the action’s domain.” Then they used Barnhoorn’s multi-level professionalism framework to characterize behaviors as either outer world (aka environment) or inner world (eg personal features, beliefs, values) 

Results/Findings 

The authors identified 3 trigger themes that made the doctors aware they had made a mistake: death, complication to an intervention, or nothing / no trigger 

They identified 20 themes of error explanation topics: 17% of those related to the outer world (ie context); and 83% related to the inner world (eg a personal feature). They identified 16 lessons learned. Of which 29% related to the outer world and 71% concerned the inner world.  

For discussion, the authors draw 2 main conclusions. First, the authors state that the trigger that made the physicians aware that something had gone wrong come too late. Timing is a problem. They drew the conclusion that “doctors should be trained to be mindful. When a doctor is able to be mindful and is, at the same time, consciously applying reflection, then s/he might have a timely moment of reflection. By doing this, s/he might be creating a change from reflecting ON action to reflecting IN action.” 

Second, the authors posit that “the majority of topics that explained their errors and the majority of lessons they had learnt were related to the doctors’ inner world.” They then go on to say: “we hypothesize that when doctors learn more about handling their inner world, they might be able to discover the dynamic modulation in themselves.” They go on to suggest that physicians should pay attention to feelings of discomfort that could be serving as warning bells. 

Comments

As researchers, we need to be very thoughtful about the kind of data we use in our research. Yes, published books CAN BE used as research data. HOWEVER, then the researchers have to treat those as what they are: books. They aren’t research interviews. They are data of a different illk. In this book, the chapters are summaries and distillations of conversations held with the book author. Those conversations were conducted and curated and edited for publication in a book. Presumably, the author wanted people to buy the book. There is a LOT of context SHAPING what is being called data in this study. 

References and suggested reading

The article Jonathan refers to:

Kandasamy, S., Vanstone, M., Colvin, E., Chan, T., Sherbino, J., & Monteiro, S. (2021). “I made a mistake!”: A narrative analysis of experienced physicians’ stories of preventable error. Journal of evaluation in clinical practice, 27(2), 236–245. https://doi-org.proxy.kib.ki.se/10.1111/jep.13531

Article about document analysis to help those of you interested in that method:

Bowen, G. A. (2009). Document Analysis as a Qualitative Research Method. Qualitative Research Journal, 9(2), 27–40. https://doi.org/10.3316/QRJ0902027

A good example of discourse analysis can be found in this article:

Coret, M., & Martimianakis, M. A. (Tina). (2023). Conceptualizations of “good death” and their relationship to technology: A scoping review and discourse analysis. Health Science Reports, 6(7), e1374. https://doi.org/10.1002/hsr2.1374