When asked about their single worst mistake as doctors, 90 percent of medical residents responding to a national survey said that the error had an adverse impact on their patient's health, and almost one-third said that the error contributed to the patient's death.
Moreover, only about half of the residents -- 54 percent -- said they admitted their most serious error to their supervising doctor, and less than a quarter said they confessed the error to the patient or family.
The authors of the study at the University of California San Francisco recommended that teaching hospitals create an atmosphere in which doctors can discuss and learn from their mistakes without fear of being ostracized. Easing the grueling work schedules of residents might also help cut down on errors, they said.
The anonymous survey, described in today's Journal of the American Medical Association, asked each resident to disclose details of the worst mistake he or she had made. Questionnaires were sent to 254 residents in internal medicine, and 114 responded.
Identities of the hospitals and of the doctors themselves were kept secret in order to encourage truthful responses.
Dr. Alfred Wu, an assistant professor of medical policy at the Johns Hopkins School of Medicine, said yesterday that the study did not attempt to find out how often residents make serious errors. Instead, he wanted to learn the causes and consequences of the worst errors and recommend ways to avoid them.
"Uncertainty and the possibility of making mistakes is a constant part of practicing medicine," said Dr. Wu, who conducted the study in 1989 while working at the University of California. "When mistakes occur, and they inevitably will, residents should learn from them so they can become better doctors and benefit future patients."
Responding to the article, Dr. M.Roy Schwarz of the American Medical Association noted that the study offered no proof that the errors in fact contributed to the patients' deaths in 31 percent of the cases -- as the residents reported. Young doctors facing the extreme pressures of their apprenticeship, he suggested, may have blamed themselves too severely for deaths that could have occurred whether or not they had erred in treatment.
"I remember it well," said Dr. Schwarz, the AMA's vice president for medical education and science. "You felt if you didn't know the diagnosis immediately and didn't know what to do, you were a failure. The first . . . deaths -- you felt as if it was your fault. It's very human."
In the survey, the young doctors often attributed their mistakes to overlapping causes: Fifty-four percent said they didn't have enough information to treat the patient correctly, 51 percent said they were burdened by too many tasks, and 41 percent said they were too tired to concentrate.
Most of the residents reported feeling remorseful about their mistakes and willing to discuss them with other doctors -- if not the family or the supervising physician. "After a fatal mistake involving a young patient, one [resident] wrote: 'This event has been the greatest challenge to me in my training.' "
Residents felt that the highly charged and competitive atmosphere of medical training inhibited them from talking about their mistakes in 27 percent of the cases "and that the administration was judgmental about the mistakes in 20 percent."
"Training programs do not sympathize or help one learn from one's mistakes," one resident wrote. "Instead, the administration is usually critical and often ostracizes the individual."
Dr. Wu said the residents who admitted and took responsibility for their mistakes were more likely to make constructive changes toward avoiding future mishaps than were doctors who concealed their errors.