The Undoing Project: A Friendship that Changed the World(61)

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* By the time they were finished with the project, they had dreamed up an array of hysterically bland characters for people to evaluate and judge to be more likely lawyers or engineers. Paul, for example. “Paul is 36 years old, married, with 2 children. He is relaxed and comfortable with himself and with others. An excellent member of a team, he is constructive and not opinionated. He enjoys all aspects of his work, and in particular, the satisfaction of finding clean solutions to complex problems.”

? In a brief memoir, Fischhoff later recalled how his idea had first come to him in Danny’s seminar: “We read Paul Meehl’s (1973) ‘Why I Do Not Attend Case Conferences.’ One of his many insights concerned clinicians’ exaggerated feeling of having known all along how cases were going to turn out.” The conversation about Meehl’s idea led Fischhoff to think about the way Israelis were always pretending to have foreseen essentially unforeseeable political events. Fischhoff thought, “If we’re so prescient, why aren’t we running the world?” Then he set out to see exactly how prescient people who thought themselves prescient actually were.





8



GOING VIRAL

The young woman they called him to examine that summer day was still in a state of shock. As Don Redelmeier understood it, her car had smashed head-on into another car a few hours earlier, and the ambulance had rushed her straight to Sunnybrook Hospital. She’d suffered broken bones everywhere—some of which they had detected and others, it later became clear, they had not. They’d found the multiple fractures in her ankles, feet, hips, and face. (They’d missed the fractures in her ribs.) But it was only after she arrived in the Sunnybrook operating room that they realized there was something wrong with her heart.

Sunnybrook was Canada’s first and largest regional trauma center, an eruption of red-brown bricks in a quiet Toronto suburb. It had started its life as a hospital for soldiers returning from the Second World War, but as the veterans died, its purpose shifted. In the 1960s the government finished building what would become at its widest a twenty-four-lane highway across Ontario. It would also become the most heavily used road in North America, and one of its busiest stretches passed close by the hospital. The carnage from Highway 401 gave the hospital a new life. Sunnybrook rapidly acquired a reputation for treating victims of automobile accidents; its ability to cope with one sort of medical trauma inevitably attracted other sorts of trauma. “Business begets business,” explained one of Sunnybrook’s administrators. By the turn of the twenty-first century, Sunnybrook was the go-to destination not only for victims of car crashes but for attempted suicides, wounded police officers, old people who had taken a fall, pregnant women with serious complications, construction workers who had been hurt on the job, and the survivors of gruesome snowmobile crashes—who were medevaced in with surprising frequency from the northern Canadian boondocks. Along with the trauma came complexity. A lot of the damaged people who turned up at Sunnybrook had more than one thing wrong with them.

That’s where Redelmeier entered. By nature a generalist, and by training an internist, his job in the trauma center was, in part, to check the understanding of the specialists for mental errors. “It isn’t explicit but it’s acknowledged that he will serve as a check on other people’s thinking,” said Rob Fowler, an epidemiologist at Sunnybrook. “About how people do their thinking. He keeps people honest. The first time people interact with him they’ll be taken aback: Who the hell is this guy, and why is he giving me feedback? But he’s lovable, at least the second time you meet him.” That Sunnybrook’s doctors had come to appreciate the need for a person to serve as a check on their thinking, Redelmeier thought, was a sign of how much the profession had changed since he entered it in the mid-1980s. When he’d started out, doctors set themselves up as infallible experts; now there was a place in Canada’s leading regional trauma center for a connoisseur of medical error. A hospital was now viewed not just as a place to treat the unwell but also as a machine for coping with uncertainty. “Wherever there is uncertainty there has got to be judgment,” said Redelmeier, “and wherever there is judgment there is an opportunity for human fallibility.”

Across North America, more people died every year as a result of preventable accidents in hospitals than died in car crashes—which was saying something. Bad things happened to patients, Redelmeier often pointed out, when they were moved without extreme care from one place in a hospital to another. Bad things happened when patients were treated by doctors and nurses who had forgotten to wash their hands. Bad things even happened to people when they pressed hospital elevator buttons. Redelmeier had actually co-written an article about that: “Elevator Buttons as Unrecognized Sources of Bacterial Colonization in Hospitals.” For one of his studies, he had swabbed 120 elevator buttons and 96 toilet seats at three big Toronto hospitals and produced evidence that the elevator buttons were far more likely to infect you with some disease.

But of all the bad things that happened to people in hospitals, the one that most preoccupied Redelmeier was clinical misjudgment. Doctors and nurses were human, too. They sometimes failed to see that the information patients offered them was unreliable—for instance, patients often said that they were feeling better, and might indeed believe themselves to be improving, when they had experienced no real change in their condition. Doctors tended to pay attention mainly to what they were asked to pay attention to, and to miss some bigger picture. They sometimes failed to notice what they were not directly assigned to notice. “One of the things Don taught me was the value of observing the room when the patient isn’t there,” says Jon Zipursky, chief of residents at Sunnybrook. “Look at their meal tray. Did they eat? Did they pack for a long stay or a short one? Is the room messy or neat? Once we walked into the room and the patient was sleeping. I was about to wake him up and Don stops me and says, There is a lot you can learn about people from just watching.”