Medicine Mistakes and the Reptilian Brain

A book by: Dr. John Mary Meagher

 


 


Table of Contents

Preface

Introduction: My Error, My Post-Mortem

 
Part I: REDUCING ERROR

Chapter 1 Nineteen Doctors’ Errors and the Theorem of Attribution of Error to
the Reptilian Brain

Chapter 2 Contending against the Reptilian Attachments

Chapter 3 Theorem of Attachments and the NewMind Response™

Chapter 4 Striving towards The NewMind Response™

Chapter 5 An Example of The NewMind Response™ from Dr. A. J. Cronin

 
Part II: BARRIERS TO GOOD WORK

Introduction: Relating the Swiss Cheese Model to Medical Performance

Chapter 6 Acute Sleep Loss and the Graveyard Shift

Chapter 7 Haste: When the Consultation is Inconvenient A Physician’s Parable
about Time

Chapter 8 Egoism

Chapter 9 Acute Stress, Chronic Stress, and Burnout

 
Part III: FOUR VARIATIONS ON THE THEME OF DIAGNOSIS

Chapter 10 Diagnosis for Data: a Dangerous Trade

A Distant View of Climbing the Devil’s Ladder toward the Diagnosis

When is a Diagnosis a No-Brainer?

A Taoist Space for Diagnosing: What is in your centre?

 
Part IV: LISTENING

Chapter 11 The Difficult Art of Listening to What One Doesn’t Want to Hear

Chapter 12 Listening for the Whisper of Doubt Within

 
Sun Tzu’s Introduction to Part V
Part V THE NEWMIND RESPOSE™

Chapter 13 Calisthenics to improve recognition of reptilian attachment and
vigilance to the task at hand. Chapter 14 The Physician Prepares for Work

Chapter 15 THE NEWMIND RESPOSE™

 

 


 

 

Preface

  • Betsy Lehman … died from an overdose during chemotherapy.
  • Willie King … had the wrong leg amputated.
  • Ben Kold … was eight years old when he died during “minor” surgery due to a drug mixup.

 

This is the stark opening of the Institute of Medicine’s “Report on the Quality of Health Care” from their 2001 “Crossing the Quality Chasm: A New Health System for the 21st Century” study which called for fundamental change in quality of care within all points of care, across the medical industry.

 

 

Introduction

“…One of my mistakes jolted me to research the nature of error. I searched for the causes of my errors in the system, the staff, and the patients. But I found that the cause was myself. I also found that non-ownership of error only leads through a desert of aimlessness, where one can find no bearing from which to improve. Error admitted, on the other hand, can bring one to an oasis of meaning and self-knowledge, a starting point from which to improve one’s work.”

 


 

 

RECOMMENDATIONS

  1. “Medicine, Mistakes and the Reptilian Brain is more important than any lecture; more critical than any diagnostic test. Recognize the tell-tale signs that you’re in an error-prone state. Learn how to readjust your mindset.”

    Dr. Louis Crowe, Physician

  2. “Our residency at Indiana University developed a Patient Safety Committee about 5 years ago – unique in that the leadership stems from residents, not faculty (we serve as advisors). This year the group selected your text to serve as our book club reading.”

    Carey D. Chisholm, M.D., Director, IU-Methodist Emergency Medicine Residency Program, Professor of Emergency Medicine

  3. “Because the medical profession affects our overall well-being and life and death itself, its impact is particularly critical. This said, the same thought processes do indeed apply to other fields and situations, something that cannot be overstated. We can’t help but recognize those elements that define the reptilian mind. At the very least, upon completion of the book one cannot help but be moved to attempt to neutralize some of the more primitive thinking processes that have molded us into acting and functioning in the way we do.”

    Andrew Boghen, Ph.D., Professeur titulaire, Département de biologie, Université de Moncton

  4. “The practice of medicine is primarily a mental one. How a doctor thinks as he or she goes about their work with patients will largely determine how successful the interaction becomes. John Meagher’s book addresses this issue from the perspective of medical error. While most literature on medical error focuses upon either contributing systemic factors or on descriptions of psychological shortcuts that we utilize (at our patients’ peril), Dr. Meagher’s approach considers the attitudes that we employ as we do our jobs. Some of his insights are adapted from the “culture of safety” which has been developed over decades within the airline industry. It’s a fresh and fascinating approach with practical recommendations that can be useful to any physician. The quality of my own work, and my enjoyment of it, have been enhanced by Dr. Meagher’s teachings. I highly recommend this book.”

    Allison Dysart M.D., Physician

  5. “In Medicine, Mistakes and the Reptilian Brain Dr. John Meagher has accomplished what others in the behavioral sciences field have failed to achieve using his experience and considerable skill in telling how the recognition of and admitting our errors can, in his words, “…become an oasis of meaning and self-knowledge, a starting point from which to improve one’s work.” Analyzing our brain’s two control centres, the evolutionary reptilian brain which “typically screens and reacts to signs of threat, food needs, mating and fatigue,” and the new brain which “discerns, ponders, postpones, tests and responds to problems,” has led Dr. Meagher to his theorem of “New Mind Response” a detailed explanation of which is included in his book.
    An enlightening review of the nature of error and how the reptilian control and the new brain control centres react is supported by numerous examples drawn from Dr. Meagher’s wide experience and those of other medical professionals. Further evidence is provided in the Crew Resource Management model developed for the commercial aviation industry.
    Although many of the examples, anecdotes and recommendations refer to the medical profession, Medicine, Mistakes and the Reptilian Brain is really a guidebook and manual for everyone to follow. It provides a clear understanding of the barriers to good work and performance in all walks of life and how to realistically overcome them.
    Altogether Medicine, Mistakes and the Reptilian Brain is a well-crafted and insightful work of research and analysis with a no-nonsense easy to follow road map for all of us to have, it is a constant reminder on how to help improve our work and lives.”

      — Peter Sawyer, President of the Moncton Regional Learning Council

  6. “His (Dr. Meagher’s) focus on callisthenics, or daily practice, makes a lot of sense, and is what I try to develop in my personal knowledge mastery workshops… I will give this book to my son, who intends on going into medicine.”

    Harold Jarche, Workplace Training & Learning Consultant

 


 

 

Seminar Topics:

  1. Introduction to the Theorem of Attribution: to err is human, the reptilian part. (Two clinical accounts evaluated).

  2. The 4 major barriers to good work and judgement.

  3. Why and how to create you own Irritability Barometer.

  4. The algorithm to monitoring and countering heightened attachment to the reptilian brain.

  5. The art of listening to what you don’t want to hear. How to appreciate the whisper of doubt within.

  6. Mindfulness: attention to the task at hand.

  7. Speak Truth to Power.

  8. Why there is no one way ticket to serenity- the Stoics’ attempt to reach serenity and remain there.

  9. Calisthenics for improving attention to the task at hand and monitoring attachment to the reptilian brain to improve decisions.

  10. The influence of the stoics on Sir William Osler.

 


 

 

Outline of the of Medicine, Mistakes and the Reptilian Brain

Chapter-by-Chapter

Introduction

This emergency room physician confesses to a clinical mistake which proved
lethal for his patient. The writer contends that non-ownership of error is a
desert of aimlessness, where there is no milestone from which to improve. Error
admitted, on the other hand, is an oasis of meaning and self-knowledge, a
starting point from which to improve one’s work. Also one can’t separate the
diagnostician from the diagnosis: the quality of the diagnosis can reflect on
the poise of the diagnostician at the time of diagnosis. The introduction
finally invites readers to learn more about that inner fault-line that inclines
to err.

Part I – REDUCING ERROR

Part 1 shows the development of the hypothesis and how it can improve one’s
work. It is a summary of the book.
Chapter 1 – Nineteen Physicians’ Errors and the Reptilian
Brain

Overview of the chapter: Human factors that cause errors in
medicine and aviation originate from the reptilian brain. See Figure 1 below.

The verbatim accounts of nineteen physicians’ most memorable mistakes highlight
ten attitudes, which are then grouped under three attitudes: namely, Egoism,
Haste and Apathy. During his research, the author was so impressed with the
safety record of the commercial aviation industry that he attended Crew Resource
Management Courses at a flight college. There he discovered that the aviation
industry describes six hazardous attitudes of pilots which cause mishaps and
errors. These six hazardous attitudes are also grouped under the same three
attitudes: Egoism, Haste and Apathy.

By linking these three attitudes to the reptilian part of the human brain, the
author presents an original, unifying, practical theory of error: the reptilian
part of the human brain is the source of error. The brain has two control
centers: a “lower” evolutionary older, embedded reptilian brain and a “higher,”
evolutionary newer, outer brain.

The reptile reacts in nanoseconds to friend, foe, food and the possibility of a
mate. The reptile defends its territory for food and offspring, and becomes
apathetic when overwhelmed or fatigued. Similarly, the physician’s reptilian
brain (the reptile within) is hard-wired: to react to data, to assume, to defend
its intellectual territory against challenging data, and to be apathetic when
overwhelmed or fatigued.

Chapter 2 – Contending against the Reptilian Attachments

Overview of the chapter: When the reptile within bares its
fangs and hisses, error is afoot.

Dr. Viktor Frankl showed how prisoners responded selfishly or altruistically to
the same system, the same profound stresses of Nazi Labor Camps. He claimed this
freedom to respond was inalienable. By inference, we have the potential to
reduce our attachment to our reptilian brain.

Two signs can alert us when the reptile within is bearing its fangs and hissing.
These signs are: derogatory labeling of the patient, and heightened irritability
by the physician.

The last part of the chapter reviews a physician-patient consultation under the
following headings:

Reptilian Expressions: Labeling, Irritability, Egoism and Haste.

New Brain Initiatives: Humility, Doing the inconvenient.

Chapter 3 – The Constant of Brain Attachments

Overview of the chapter: Good work requires reduced attachment
to the reptilian brain and increased attachment to the new brain.

The chapter presents the second and third theorems of cerebral dynamics which
are based on two assumptions ( See Figure 2 below, the Theorem of Attachments
and the NewMind Response™ Theorem. This provides both direction and traction for
the readers to improve. The chapter then concludes with an extensive list of the
opposing activities and characteristics of the reptilian brain and the new
brain.

Chapter 4 – Striving towards The NewMind Response™

Overview of the chapter: We require three skills to reduce
attachment to the reptilian brain and enhance attachment to the new brain.

These three skills are:

1. Self-monitoring one’s attachment to the reptilian brain, (4 steps to creating
and using one’s Irritability Barometer, an innovation of the author).

2. There are two steps to curb attachment to the reptilian brain (from the
aviation industry).

3. Vigilance to the task at hand (an adaptation by the author of meditation at
work and other activities).

First Skill – Monitoring the Irritability Barometer

There are four steps to create and use the Irritability Barometer:

1. Make a list of frequent irritants encountered at home, while commuting, and
at work.

2. Categorize one’s different levels of response to irritants.

3. Match one’s usual responses to the frequent irritants listed in step one.

4. Monitor one’s levels of responses to common irritants.

Should one’s response to a common irritant be increased, heightened reptilian
attachment is present and needs to be curbed by the second skill.

Second Skill – There are two steps to curb one’s heightened
attachment to the reptilian brain.

Step one identifies which of the four sources for heightened attachment to the
reptilian brain is lurking? Ask:

• Am I rushing?

• Am I tired?

• Am I concerned about my self-image?

• Am I doubting?

Step two counters the source of the heightened reptilian attachment.

The Crew Resource Management Manual for Pilots recommends positive responses to
the hazardous attitudes. They call these responses, antidotes. By repeating to
oneself the appropriate antidote, one can counter the prevailing reptilian
attitude. (Note that doubting does not require an antidote, because it is a new
brain activity). A table of these specific antidotes accentuates them for easy
reference.

Third Skill – The Third skill is “Vigilance to the Task at
Hand.”

Maintaining attention is also a skill. Like hitting a tennis ball or playing the
guitar, the more one practices, the more adept one becomes. Therefore, to
improve one’s vigilance to the task at hand, one must practice this throughout
the day: in the morning, driving to work, at work and in the evening.

Chapter 5 – An Example of the NewMind Response™ from Dr.
A. J. Cronin

The chapter offers an example of a physician’s NewMind Response™ from the
“Citadel” by Dr. A.J. Cronin. Analysis of this celebrated clinical case follows
under the same headings:

Reptilian Activity: Haste

New Brain Activity: Doubt, Doing the Inconvenient, Vigilance to the task at
hand.

Also the approaches of the two doctors in Cronin’s account are contrasted
employing the reptilian and the new brain attachments.

Part II – BARRIERS TO GOOD WORK

Contrasting Swiss Cheese Models to Performance

The introduction to the section presents Professor James Reason’s Swiss Cheese
Model for safety in The Aviation and Nuclear Industries. There are few
regulations in medicine when compared to these industries. Therefore, to more
accurately represent the medical arena, the Swiss Cheese Model is inverted. My
illustration of impediments to good judgement follows. It is one of my three
inversions of Professor Reason’s model.

The four chapters of Part II delve into four major impediments to good work,
beginning with Sleep Loss.

Chapter 6 – Acute Sleep Loss and the Graveyard Shift

Overview of the chapter: Acute sleep loss is a cheap drunk for the physician but
expensive for the patient.
When the author worked on an oil rig in the North Sea, the urge to sleep aced
his will to survive. Medical studies (appropriately referenced) demonstrate the
increase in serious diagnostic errors by sleep-deprived physicians and interns.
Other studies resolve that moderate levels of fatigue impair performance to an
extent equivalent to or greater than is currently acceptable for alcohol
intoxication.

Recent experiments demonstrate that acute sleep deprivation reduces prefrontal
and parietal lobe activities, compromising judgment, mental arithmetic and
duties.

The chapter then addresses:

• Effects of sleep deprivation

• Sleep deprivation countermeasures

• Myths about Sleep Deprivation.

The next section of the chapter focuses on the graveyard shift. Studies reveal
that between the hours of 4 A.M. and 8 A.M. on the first night of a night shift,
performance is equivalent to having a blood alcohol equal to or greater than
0.05%, a level illegal to drive or operate a machine. The author provides
personal anecdotes of my impaired performance when toiling the graveyard shift.

Chapter 7 – Haste

Overview of the chapter: Haste is a polite form of fleeing which is a reptilian
reflex.

The chapter has three sections:

• Haste

• When the Consultation is Inconvenient

• A Physician’s Parable about Time

Haste: The Chapter opens with the verbatim accounts of three physicians who
blamed haste for their errors. About 75% of Canadian physicians feel hurried.
When we look at the time, we do not experience a few impartial numbers. Rather
we experience a prod to hurry up, to bolt the present, to escape doubting or to
end the day’s heavy list. And escape is a reptilian reflex.

Our past-times prove that we can forget about time. The author recommends
exercises to become free of time’s nagging. He claims that only by ignoring time
can one have time for the patient.

When the Consultation is Inconvenient: I recount the death of my Labrador bitch,
which died because her vet did not wish to tend her at midnight. Because the
time was inconvenient for the pilot, his judgement was impaired and resulted in
the crash of the KLM 707 at Tenerife Airport.

Inconvenience is also a critique of the present, which the reptile within wishes
to flee. Therefore, when seeing a patient at an inconvenient time, it behoves
one to monitor one’s irritability barometer, and employ the appropriate
antidote.

A Physician’s Parable about Time: A thoracic surgeon communicates with a deaf
mute patient who had not communicated with anyone for many years. He finished
his account, “It was my reward for spending time.”

Chapter 8 – Egoism

Overview of the chapter: Nothing is too good for my patient providing it
involves no shame for me.

The reptile vigorously defends its territory for its food, progeny, and social
hierarchy. Likewise the physician can emphatically defend three territories:

• Assumptions

• Diagnoses and

• Self esteem among peers and patients.

Emphatic expression often is a form of vigorous defense of unacknowledged doubt.
It can also be a sign of heightened attachment to the reptilian brain.

The next part of the chapter relates verbatim accounts of physicians whose
advocacy for their self-image trumped advocacy for their patients. A reliable
compass in this reptilian fog is the question, “Would I like to be tended as I
am tending the patient?”

The antidote to egoism is humility which empowers one to speak truth to power,
to the bully without and to the tyrant within.

Chapter 9 – Acute Stress, Chronic Stress and Burnout

Overview of the chapter: Recent scientific research shows how chronic stress
impairs the new brain more than the reptilian brain.

Acute Stress: The short section shows how acute stress impairs judgement
sometimes with serious consequences. Examples range from pharmacist and pilot to
physician. Following a heart-felt loss or worry, like the illness or the death
of a dear one, one needs time to recover the potential to be vigilant to the
task at hand.

Chronic Stress: Like acute stress, chronic stress also can impair good judgment.
The findings of the 2003 Professional Stress and Burnout Study reflect the
prevalence of burnout among physicians. The effects of chronic stress are cited:
drug addiction, alcoholism, depression, suicide and impaired performance at
work. A nurse expressed her inability to work as, “One can’t give from an empty
basket.”

The burnout syndrome with its early warning signs are described. Recent
neurophysiology discoveries demonstrate that areas of the new brain are more
impaired by burnout than the reptilian part.

The next part of the chapter reviews three approaches to preventing, treating
and managing stresses:

• The advice of Dr. Gautam, an expert in treating burnout among physicians

• Dr. Viktor Frnakl’s approach

• Recently published Mindfulness-Based Stress Reduction Program for Nurses and
Physicians.

Part III – FOUR VARIATIONS ON THE THEME OF DIAGNOSIS.

Chapter 10 – Four Variations on the Theme of Diagnosis

Overview of the chapter: The author devotes a full section to diagnosis because
misdiagnosis is accompanied by more frequent serious consequences than other
errors in medicine.

First Variation – Diagnosis for Data, a Dangerous Trade:

In the first “variation,” Nobel Laureate, Henri Bregson cautions that concept
(or naming) for data can be a dangerous trade. The physician also trades the
patient’s data for a diagnosis, also a concept. Bergson’s warnings regarding
thinking mirror expressions of the Reptilian Brain.
Second Variation – A Distant View of Climbing the Devil’s
Ladder towards the Diagnosis:

The ladder image is used to describe how progress upward in science has been
retreats from blind alleys. Similarly the physician has to undo diagnosis in the
light of challenging data.

The ladder image is also used to describe my experience in climbing The Devil’s
Ladder, a thousand foot steep part of a route on Carrauntoohil, Ireland. My
brother-in-law said that retracing to get a better approach seemed to us a big
inconvenience. To an observer, a mile or two away, he said, it does not seem
inconvenient. With this distant perspective, subsequent retreats on the assent
of the Devil’s Ladder were less inconvenient to me. Similarly, if a physician
can view present inconvenience from three month’s in the future, he or she can
gain a more objective (less reptilian) view. The distant temporal view reflects
Dr. Viktor Frankl’s use of “Distance Transposition for Objectivity” to ease his
hardships in the labor camps.

Third Variation – When is a Diagnosis a No-Brainer?

A clinical case of a simple corneal abrasion from “The Lancet” is reproduced.
This corneal abrasion was a sign of a brain tumor. The author proposes that a
medical question is rarely a no-brainer, because most symptoms take time to
discover whether the diagnosis is a symptom or sign of something else. For
another example, a fractured humerus in a toddler might be sign of child abuse.
Fourth Variation

A Taoist Space for Diagnosing:

(What is in your centre?)

The author rolls out the wheel from the Tao Te Ching. Lao Tzu claims that the
wheel will not work if the hub is not clear to rotate around the axle. Similarly
the physician’s centre should be clear of reptilian influences such as agenda,
fatigue, egoism, and imperatives or prompts of time. The empty hub helps the
readers visualize the necessity of clearing space for the new brain to search
for challenging data, to welcome them, to be vigilant to the task at hand, to
ask what else could the be, what else could complicate this, and would I like to
be tended as I am tending now?

 
Part IV – LISTENING

Chapter 11 – The Difficult Art of Listening to what we
Don’t want to Hear

Overview of the chapter: Heightened reptilian attachment deafens us to
challenging data.

In one study, 20% of physicians did not take an adequate history. Another study
concluded that, “physicians at all levels who had previously been thought quite
competent appeared defective in their interactions with patients.” Examples of
poor listening are reproduced.

The difference between active listening and hearing is explained. The obstacles
to active listening are Haste, Egoism and Apathy, expressions of the Reptilian
Brain. An example of good listening follows. The signs of not listening are
listed. The author provides calisthenics to improve one’s listening.

Chapter 12 – Listening for the Whisper of Doubt Within

Overview of the chapter: Heightened attachment to the reptilian chokes fragile
doubt.

The chapter affirms the value of doubting. Again the barriers to doubting are:
Haste, Egoism and Apathy. Using an observation of Simone Weil, I classify doubt
according to the strength of one’s attachment to the reptilian brain.

The next part instructs how we can become more open to doubt. (4 steps)

Step one: Lists many signs of doubting.

Step two: Decide how receptive are we to doubt’s presence?

Step three: Free space within for doubting employing the antidotes we have
learned to curb heightened attachment to the reptilian brain.

Step four: Pursue the lines of investigations triggered by doubt.

Then I give calisthenics to better appreciate doubt’s presence and to initiate
doubt. The chapter ends: “…we tend to shun doubt like a creditor, but doubt is a
true friend. Only a true friend will tell you that you’ve got dirt on your
face.”

(The chapter contains two figures and one table).

Part V – A PHYSICIAN PREPARES TO MEET THE PATIENT

Chapter 13 – Know the Enemy- the Reptilian Brain

Overview of the chapter: A comprehensive user-friendly algorithm summarizes how
to reduce heightened attachment to the reptilian brain thereby improving work.

The final chapter introduces the similarities between Sun Tzu’s “The Art of War”
and the physician’s work. The general knows that the enemy gets to vote on the
outcome. And for the physician, the enemy is the reptilian brain. Sun Tzu
maintained that every battle is won before it is fought. Similarly, the
physician needs to prepare for the day’s work by freeing space within.

The simple flow chart (below) instructs how to monitor heightened reptilian
attachment from moment to moment.
Figure 3. Algorithm for Heightened Attachment to the Reptilian Brain.

There are three steps:

Step 1 identifies heightened reptilian attachment: there are five questions
available.

Step 2. If heightened reptilian attachment is identified, we ask ourselves four
questions to know why?

Step 3. We employ appropriate antidote (+ or – generic antidotes) to counter
heightened reptilian attachment.

A life-time practice of twelve calisthenics can improve our recognition of
heightened reptilian attachment and our vigilance to the task at hand.
The book concludes:

“Throughout the book, I have neglected the patient, because by now we should
realize that the patient we are working on is the patient called ourselves,
whose symptoms are haste, egoism, and apathy and whose diagnosis is a
space-occupying lesion, called the reptilian brain. While the lesion is
inoperable and the prognosis for the condition is guarded, we can take hope:
that in a leaning tower, we can stand erect; that amid the profound depravities
of labor camps, we can be altruistic; and that in the face of danger, we can
command grace. Surely then, amid the uncertainties and demands of our medical
practice, we can without any irritability reach after fact and reason.”
End of Outline

 


 

 

Errata

Earlier printings of Medicine, Mistakes and the Reptilian Brain contain three mistakes which have come to my attention. Corrections to earlier printings of “Medicine Mistakes and the Reptilian Brain” version 1.0 and lower are as follows:
  1. Page 57 read: ” In the Ely group, 57% of the physicians felt hurried.”
    Should have read:  “In the Ely group, 91% of the physicians felt hurried.
  2. Page 90, read: “We speak approximately 125-160 words a minute but we have the capacity to listen to 900 words per minute ”
    Should have read: “We speak approximately 125-160 words a minute but we have the capacity to listen to 400 words per minute.”
  3. Finally, figure 17, page 116, has  wrong directives to two of the five reptilian revealing questions, namely, “Am I open to challenging data?” and “Would I like to be tended as I am tended now?”
    The earlier directions to these two questions were,  “If the answer is yes, then heightened reptilian activity is present.”
    clearly the directives should have asked, “If the answer is no, then heightened reptilian activity is present.”

 

 

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