Illusions of excellence and idiocy

June 8, 2020

The effect of inadvertent errors and oversights in the eye of the beholder.

A friend of mine made use of her recent COVID-lockdown time by going through old photos and organizing them into albums. Along the way, she used social media to share pics of friends and family she encountered. I, thus, recently had occasion to see some snapshots of myself from high school and college.

Aside from the usual “gosh, how much younger I looked” reaction, I was struck by how the pics contrasted with my self-image…both current and past. For instance, the younger me looked a helluva lot more assured and comfortable in his own skin than I felt at the time.

Cameras are far from the only tool for obtaining “snapshots” of a moment in time that mislead as to the characteristics of their subjects. Pretty much anything you do that leaves a physical record can accomplish the same thing. Even your actions, if witnesses remember them.

For instance, during this past week as I was churning through my worklist, images from an X-ray popped onto my screens to show a nice, big fishhook sticking out of the end of an index finger. Not exactly a head-scratcher of a case. The provided clinical history probably stimulated more mental activity for me: “R/O FB.” Such activity was not in terms of puzzling about the case…instead, musings on the referrer.

As a rad who’s been in the medical game for more than 20 years, I’m pretty sure even the most inattentive, careless, and/or clueless healthcare provider, seeing part of a fishhook sticking out of somebody’s flesh, would have no doubt whatsoever that there was, indeed, a foreign body. No amount of imaging would, thus, rule one out.

My oft-cynical mind recognized that the referrer wanted to expend the barest minimum of time and effort to order the study, and “R/O FB” was his miserly best. A true minimalist, I might add, would have omitted even the “R/O,” and, thus, come across in a better light.

And yet, even in the fraction of a second it takes for my mind to run through that cycle of thought, the referrer and/or his department gets colored in my mind as being less-than attentive, conscientious, clueful, whatever). That snapshot of his input to the healthcare scenario does not flatter him. Further, anybody else who might subsequently review the case is going to see the same snapshot.

Maybe those other witnesses won’t have been in the healthcare game as long as I have, and will conclude that the referrer somehow didn’t notice the fishhook sticking out of his patient. Perhaps he didn’t bother to ask the patient why he came to the ER (since, we can hope, the patient would say “I have a fishhook stuck in my finger”). Or, maybe he didn’t even see the patient before ordering imaging.

The referrer could be the most brilliant ER-doc in the world, saving countless lives and limbs year after year…but you’d never know it from this snapshot he created of himself, which will indefinitely serve as an illusion of his carelessness, incompetence, or even idiocy.

We see other illusions of idiocy on a regular basis: Referrers ordering imaging on the wrong body part (right vs. left, for instance). Or, telling us a chest X-ray is for chest-pain…but then, fortunately, the tech asks the patient what’s going on and is able to provide us with a note that, no, the patient states he has never had chest pain. Instead, he is rather here for a positive PPD.

Lest we stone-throwers forget about our own glass houses, we’ve got plenty of opportunities to go on the record as being careless and/or idiotic ourselves…and, unfortunately, make use of them.

Not thoroughly proofreading dictated reports before signing is probably our most fertile ground. Just like referrers, we’re quite capable of flubbing right-versus-left, even of referring to metatarsals in the hand or metacarpals in the foot. Describing an 11-mm nodule as being an 11-cm one. Omitting little-but-important negative words, like “no” or “not,” thereby reversing the entire meaning of a statement.

Such things come out in the wash (we hope) when someone seeing the illusion of idiocy reaches out to directly communicate with the seeming-idiot. Maybe after the not-idiot experiences painful embarrassment, he can correct the error, and look better in the eyes of that particular beholder. But, most medical records don’t let us go back and remove the original sin. Only place an addendum, which paradoxically calls attention to the gaffe for future viewers.

“But, wait,” some readers might protest. “You also mentioned illusions of ‘excellence’ in your title. How can we do that?”
The good news is that this can happen just as accidentally (or carelessly). If errors and oversights are essentially happening randomly, there should be a chance that some things we inadvertently say or do will make us look better, more capable, than we actually are. And, there are habits we can cultivate to give a better impression of ourselves than we probably deserve (without being overtly fraudulent). I’ve talked about some of those in other columns.

I wouldn’t count on the haphazard stuff rebounding to our advantage all that much, though. It’s entropy at work-the natural trend is for things to break down and disorganize. Our profession is pretty high up on the metaphorical mountain of complexity and sophistication. As our errors and oversights accumulate, their net effect has a much better chance of making us fall and lose altitude than accidentally climb higher.