Richard Smith, a former editor of the British Medical Journal, wrote a thoughtful essay offering guidance for new medical students. (Full text here.) Although it was published in 2003, someone just brought it to my attention via Twitter.

Dr. Smith lists many pearls of wisdom in a scholarly and lightly humorous way. I disagree with only one of his statements:

“Do not be afraid to be wrong.”

It is not that this is bad advice. To me, a timid doctor is prone to failure. Sometimes you have to take your best shot based on the information at hand. The problem is that in today’s medical world, we are expected to be perfect. If you make a wrong diagnosis and the patient suffers a poor outcome, you have a good chance of being sued and a better chance of experiencing an inquisition by emissaries from the quality improvement and/or risk management departments, AKA the “thought police.”

I once did some expert witness work for a malpractice insurance company. There is rarely a case that does not have many opportunities for second-guessing. When you know the outcome, you can always find something in the medical record that could have been done differently.

The current medicolegal and patient safety climate creates a feeling among physicians that any error is going to be extensively scrutinized. This results in a situation analogous to an athlete trying not to lose a game instead of trying to win. For those of you not familiar with sports, that strategy usually fails. Fear of being wrong can lead to excessive testing too.

Many say that medicine should have a blame-free or “just culture” like the airline industry, where reporting of near-miss and other events does not result in sanctions to pilots or air traffic controllers. It would be nice, but I know of no hospital that has achieved that state of nirvana in this country. (For more on the pitfalls of just culture, see a recent blog I wrote.)

This reminds me of the comic strip where the pointy-haired boss says to Dilbert: “According to the anonymous online survey, you don’t trust management. What’s up with that?”

Skeptical Scalpel is a practicing surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For almost 2 years, he has been blogging at and tweeting as @SkepticScalpel. His blog has had more than 185,000 page views, and he has over 2600 followers on Twitter.