Safe Assumptions

Sometime in the past six years after moving into my current house, I discovered that there was a recurring issue with pinhole-leaks in the copper piping. After one too many watery messes in the basement, I contacted the local utility to test our tap water for culprits.

The guy who came by and did the tests found nothing out of line, but commented to me that I was far from the only one in the region with this issue…and, whatever might be in the water to gradually degrade people’s pipes, the utility evidently wasn’t testing for it, because he never found anything. Intentional? Depends on how cynical you want to be.

Fast-forward to this past month: I’d come to detect a suspicious flavor in the water and got a testing kit of my own. I have no idea whether this related to the taste I was detecting, but our mercury and zinc levels were way too high.

Had they been too high when the guy from the utility had been here? Did his tests actually screen for these metals? It seemed a safe assumption that they would have…but it would also seem safe to assume the utility routinely screened for this stuff without customers like myself having to ask.

Safe assumptions often turn out to be less safe than we’d like. I’ve subsequently had a whole-house water filtration system installed, predominantly for the metals but also including softening, chlorine removal, etc. Is it safe to assume that’s getting the job done? The taste is improved, but what does that really mean? How about if I get another water-testing kit, and it says the mercury/zinc levels are no longer elevated? Safe to assume the problem is solved? Or might the testing kit be defective? Maybe the kit which originally tested positive for mercury was wrong.

People don’t like it when their “safe” assumptions turn out to be less than. Not uncommonly, the inclination is to cling to preconceptions: The assumptions were safe, and unwelcome events poking holes in those assumptions were unreasonable, even unfair. Especially – other fallible people were involved.

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Some folks have higher expectations, and thus stronger reactions, regarding such proven unsafe assumptions. I’ve noticed that this is especially the case with people who, themselves, are the subjects of high expectations—from others or self-directed. Not too surprising, really: If one gets accustomed to being reliable and trustworthy, one gets that much more vexed when others, or circumstances in general, fail to comparably measure up. In other words, “I’m doing my job properly; why isn’t anybody else?”

Physicians are a case in point. To become a doc (and remain a practicing one), a measure of perfectionism is helpful, if not necessary. After surmounting the competitive hurdles of pre-medical and medical education, then postgrad training, a doc is liable to feel like others can safely assume he’s earned his station. It’s a “safe assumption” that he knows what he’s doing…or will recognize when he’s in over his head and respond by learning more or calling in help from colleagues, consultants, etc.

Even if a physician hasn’t embraced the notion of being a safe assumption, other docs—and, indeed, much of society—will assume he deserves his credentials. And, thus, react negatively if it seems like he’s turning out to be undeserving. Fairly or not, there are plenty of unreasonably high expectations and unavoidable bad outcomes out there. Disappointed patients and their family and friends can easily blame a doc. Even if they don’t, plenty of medical malpractice attorneys and media will nudge them in the direction of doing so.

One of the problems we face in trying to be worthy of safe assumptions is that we’re given plenty of unsafe assumptions to work with. Defective, broken, or just low-quality tools. Drugs with side effects and adverse reactions. Colleagues and subordinates who turn out to be unsafe assumptions themselves—holes in their knowledge bases, incompletely-honed skills, poor work ethics, etc. Then there’s the patients themselves…or did you think it was a safe assumption they were always telling you the truth and following your instructions?

Firing up my workstation for a day of reading radiology studies, I enter a virtual minefield of assumptions that are supposed to be safe. Here’s an X-ray for chest pain: I have to assume that it’s the right patient, that he actually has chest pain (have I mentioned how frequently the histories we get are incomplete or dead wrong?), and that any priors I’m given are correct (same patient, relevant reports attached). If I’m given no priors, I have to take it on faith that there are none in the system visible to the tech who uploaded the case or in the great wide world out there (did anybody ask the patient if he’d been imaged elsewhere? Made some sort of effort to retrieve such relevant studies?).

We also have a bunch of assumptions about whether our reports will get the attention of the right people. Will the referrer read our stuff attentively, understand what needs action, and make the appropriate next moves? Or will important stuff fall through the cracks?

In recognition of the importance of all this stuff, safety nets have been put into place. “Critical results” protocols where referrers are immediately contacted and verbally told what we’ve seen. BI-RADS letters to patients so they will have some idea of what’s going on even if their docs don’t tell them. But, again, sooner or later, we’re left with the questionably safe assumption that, having done everything the “standard-of-care” said we should, others will proceed to play their parts, and there will be no fumbling of the medical ball.

I think most rads are semi-conscious of the steady stream of “safe” assumptions they’re making in order to get through a typical day. And, as the number mounts, it’s a statistical given that wrong assumptions have drifted by undetected. We find out about some of them when we get calls to make addenda to our reports because, no, the patient didn’t have chest pain. Or yes, there was a relevant prior: Here’s a CD, and now we get to re-read everything.

Each instance is another unpleasant reminder of the minefield we’ve been weaving through and another jab at the “I’m doing my job properly…” emotion. Is it any wonder that some rads seem to overreact when one of these moments turns out to be the last straw for the day?

Follow Eric Postal, M.D., on Twitter, @EricPostal_MD.