Observations Ethics Man

A passion for accuracy

BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e4977 (Published 23 July 2012) Cite this as: BMJ 2012;345:e4977
  1. Daniel K Sokol, honorary senior lecturer in medical ethics and barrister at the Inner Temple
  1. daniel.sokol{at}talk21.com

A cursory glance at doctors and others at the peak of their profession reveals that attention to detail binds them all

When I was called to the bar, my father gave me a beautiful wooden box, within which were inscribed the words of Hardy Cross Dillard, once dean of the University of Virginia Law School and later a judge at the International Court of Justice in the Hague. The text described the perfect lawyer, and one sentence read, “He is endowed alike with legal imagination and a passion for accuracy.”

Even a cursory glance at people at the peak of their discipline reveals that a passion for accuracy, or attention to detail, binds them all. Although not enough to achieve success, it is a necessary component of it. The chess legend Gary Kasparov spent so much time analysing the games of his opponents before tournaments that a rumour emerged that he had a team of grandmasters conducting research on his behalf. Michael Jordan was known in his pre-National Basketball Association days for spending more time practising on the basketball court than any of his peers. The elite group of three star Michelin chefs, though widely different in style, share an almost obsessive concern for perfection. Fyodor Uglov, a surgeon renowned for his flawless technique, sutured 400 rubber gloves to improve his skills in anastomosis. It is a safe bet that all the medallists at the forthcoming Olympic Games, from archery to wrestling, will owe their triumph in part to a phenomenal attention to detail.

A passion for accuracy goes hand in hand with patience and persistence. Albert Einstein once said, “It’s not that I’m so smart. It’s just that I stay with problems longer.” The challenge is staying focused for long periods when the task is dull. I can only imagine that studying the intricacies of the law of indirect tax is as soul sapping as studying the complex anatomy of the foot, but sadly there is no shortcut to mastering the subject. This is why William Osler considered the master word in medicine to be . . . “work.” Patience and persistence require time, and a key concern with the reduction in doctors’ working hours brought about by the European Working Time Directive is that they will no longer have the time to develop an eye for detail.

A passion for accuracy is also needed for the practice of medical ethics. In my teaching I tell students that good ethics starts with good facts. Although on occasion decisions cannot wait and must be made with limited information, most of the time there are opportunities to gather more facts and reduce the role of conjecture. In medicine, too, there are times when attention to detail is inappropriate. Harvey Cushing, the father of modern neurosurgery, was a slow and meticulous surgeon, but his precision was unhelpful when transposed to a busy military hospital in war torn France. The historian Michael Bliss compared Cushing at the casualty clearing station to a master chef working at McDonald’s. Nevertheless, in normal circumstances attention to detail is beneficial. This is why it is risky for professionals, including doctors and lawyers, to give advice in so called “kerbside” or corridor consultations. The account of the problem is likely to be one sided and incomplete. The spectre of negligence looms ominously behind such requests.

In the United Kingdom professional medical ethicists are rare birds who seldom make decisions that directly affect patients. In recent years an increasing number of clinical ethics committees have appeared in UK hospitals. This is a welcome development. Yet, looking back on my days sitting on these committees, I am concerned that, although well meaning and able, our advice to clinicians was based on partial information. With luck, we would receive a short summary of the case, drafted by the requesting clinician, hours before the meeting. Occasionally the clinician would attend and briefly present the case. We never had the other side of the story, at least no more than the clinician’s account of it; nor were we ever shown the patient’s medical notes.

In such cases the risk of a biased presentation is significant. Deliberately or otherwise, the presentation may be structured in a way that favours the answer sought. There is no such thing as a neutral description of the facts of an ethical problem. What is said, and left unsaid, how it is told, in what order, by whom, what is emphasised and downplayed—all these affect the listener, even if only subliminally.

This unstructured approach is in contrast to that of the research ethics committee on which I sit, where we receive detailed protocols days in advance, spend hours reading over them, and prepare questions for the researcher. There is an uncomfortable asymmetry between the rigour expected of research ethics committees and clinical ethics committees, yet the advice of the second type can also, if acted on, affect patients. What is the quality assurance of clinical ethics committees—or indeed of medical ethicists such as myself? Anyone reading this article could call him or herself a medical ethicist and set up a consultancy service.

If I were the chairman of a clinical ethics committee or a hospital manager, I would ask myself this question: if someone issued a claim of negligence against a recommendation of the committee, what would the forensic examination of the decision making process reveal? Could we show a thorough attention to detail?

A passion for accuracy is not only a necessary element of great clinicians and committees: in each case it confers the added advantage of legal protection.

Notes

Cite this as: BMJ 2012;345:e4977

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