Intimacy versus Isolation: The Struggle Continues

As I’ve thought about Brexit over the last few days (Britain’s exit from the European Union), it reminds me of the struggle that I see in our country and in many of my patients.  There are numerous opinions out there about why the British made this choice. One of the common themes that I’ve heard is “They wanted to take back their country.” The theory is that they were tired of feeling out of control of their borders, and that they did not want their fate to be so tied to the political fortunes of the other members of the union. Of course, as all of the ramifications of the exit became clear, there was some regret. It seems that perhaps the average citizen did not realize how significant the withdrawal effects would be and how interconnected they already were.

Isn’t this really the core issue for all of us whether on a national or personal level?  Erik Erikson, a well-known psychologist active during the 1950’s and 60’s, proposed 8 stages of personality development. The 6th stage was intimacy vs. isolation. Erikson felt that this phase of personality development took place between ages 18 and 40, the time when young adults were beginning intimate relationships beyond the family of origin that could lead to long-term commitment, and a sense of trust, safety, security, and connection within a relationship. Failure to master this phase of personality development could lead to isolation and loneliness both in personal relationships and with the world in general.

How many times have we as individuals and as a country danced between intimacy and isolationism? When an intimate relationship goes bad, the natural tendency is to isolate. “I’ll never date again” is a refrain that I often hear. But rarely do people really stay isolated forever, because deep down, most of us do have a drive to connect and to avoid loneliness and despair.

The same dance seems to occur on a national level. After the devastating effects of World War I, the US moved to a much more isolationist stance. We refused to join the League of Nations because there was concern that we could be drawn into growing conflicts in Europe. Our absence in the League of Nations possibly resulted in that body being much less effective in dealing with the rising conflict in Europe. Finally, we were forced out of this stance by the surprise attack on Pearl Harbor in 1941.  Did we pay a price for our refusal to be more involved in world politics, the equivalent of intimacy vs. isolation in Erikson’s stages of personality development?

As we watch Europe being flooded with refugees, dealing with the uncertainty of who is a terrorist and who isn’t, it is not surprising that we would choose to isolate. We have the advantage of geographical distance from Europe. However, as we have seen, those conflicts can easily move to our country, and they already have. Isolationism doesn’t prevent that. In the same way, avoiding intimate personal relationships doesn’t guarantee happiness. It’s a trade-off; less short-term acute hurt but more long-term depression and despair.

Isolationism, at least in its extreme form, seems to me to be a temporary withdrawal to re-fuel and repair. That may be necessary in some cases. But as we saw pre-World War II, that stance did not keep us from being involved in outside conflicts. Connection with others, whether on a personal or national level, can eventually result in increased communication and understanding of each other’s values. It seems to me that a more connected world is a more tolerant world. If we are more dependent on each other, will that result in more tolerance out of necessity? Being more dependent on others is a scary concept. But is also increases the need to get along. How do we get there? I don’t know exactly. I believe it will take generations to achieve.

Perhaps we can start with thinking about the issue of intimacy vs. isolation in our own lives. Though Erikson was thinking primarily of intimate relationships, I think it applies to our connection with community as well.   It seems to me that trying to connect with people who seem different, people from another culture, or race, or sexual orientation, can only increase understanding of one another.  When people make disparaging remarks about gays or Muslims or another other groups, I wonder if they’ve actually talked to one. I would be willing to bet that the answer is no.  Though it is not a quick fix, I do believe that people who communicate and try to understand one another are less likely to kill each other.

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Should You Be Concerned About Medical Error?

On May 3, the British Medical Journal published a study titled “Medical error- the 3rd leading cause of death in the US.” The authors, Dr. Daniel Makary and Dr. Michael Daniel of Johns Hopkins Department of Surgery, analyzed 4 studies done between 2000 and 2008 looking at rates of death due to medical error in hospitalizations. They then used those death rates and calculated how many deaths due to medical error occurred in 2013 based on 35,416,020 hospitalizations. They concluded that 251,454 deaths occurred in 2013 due to medical error during hospitalization. That’s 9.5% of all deaths each year in the US which would make it the 3rd largest cause of death.  As you can imagine, this has created outrage in the medical world. Most physicians don’t believe it; hospitals are denying it, and patients are upset and anxious.  There are a few medical practitioners who agree with it and suspect that the estimate is actually on the low side.

I admit to some bias here. I’m a doctor. I don’t like to think that there are that many medical errors contributing to so many deaths. Already, I’m seeing various versions of this story splashed over the internet, in newspapers and magazines. I’m not surprised. We aren’t a trusting society anymore, and this is one more piece of evidence that what we thought could be trusted really can’t.

If this study is going to be this widely quoted, I think it is important to really understand the study.   If we are going to make sweeping conclusions about the medical profession, let’s make sure the study really says what we think it does.  Here are some issues that have been raised regarding the study.

  • It’s one study. In any scientific field, one study is not considered proof of anything until it is replicated.   Also, they based their conclusions on data from 4 studies done between 2000 and 2008 looking at medical error in the United States. So you have to look at these studies and really assess whether their methodology was accurate.  This is key.
  • Many doctors take issue with the definition of medical error used by the researchers. They defined medical error as “an unintended act (either of omission or commission) or one that does not achieve its intended outcome, the failure of a planned action to be completed as intended (an error of execution), the use of a wrong plan to achieve an aim (an error of planning), or a deviation from the process of care that may or may not cause harm to the patient.” That’s a very broad definition of medical error. Can you really say that a procedure that doesn’t achieve its intended outcome is a medical error?
  • The study is only looking at medical error in the hospital. Remember that people would not be in the hospital unless they had some serious medical problems. They aren’t just healthy people living their lives who are suddenly struck down by medical error.  If you are really going to define medical error as an unintended act of either omission or commission or an act that does not achieve it’s intended outcome, is that more likely to happen with people who are undergoing high-risk medical procedures and who may be more prone to complications due to the seriousness of their illness?  It may still be medical error by definition, but certainly unintended consequences are more likely to occur in very sick, debilitated people undergoing complicated procedures. Does that mean that we should not do those procedures?

There is risk inherent in any procedure, any treatment, any medication. There is risk in taking Tylenol.  How much risk are we willing to accept?  Are we clearly informed of the risk? Informed consent is another controversial issue in the medical field.  Theoretically, patients need to be fully informed. However, the true risk of a treatment may not be that easy to determine. It depends on the underlying general health of the patient, the circumstances (is it an emergency or a planned procedure) and to some extent the facilities of the hospital and experience of the physician. It’s always fair to ask “How many of these procedures have you done?” or “How many times have you used this medication?”

The study is important and deserves recognition. Certainly, there are medical errors.  Ignoring evidence suggesting one course of action in order to follow another without solid reasons, not adequately monitoring effects of a procedure or medication, performing a procedure or using a medication without having proper training, failing to clearly communicate with another professional, team, or facility involved in the patient’s care would all constitute medical errors in my opinion. The study needs to be replicated with a clearer definition of medical error.  As physicians, even with reservations about the article, we can’t ignore the fact that there are more medical errors than there should be.

The field of medicine is not as certain and exact as most people think. There often isn’t one way to do things.  Decision-making in medicine combines what is known based on basic science research with the physician’s assessment of what is best for the patient taking into account many factors particular to that patient. That is where the art of medicine comes in.  Maybe in another 50 years when we practice medicine like Bones did in Star Trek, all medical decision-making will be based on pure science with little input from the physician.  We will simply do what the computer tells us to do.  I’m not looking forward to that day. But until then, we must accept some degree of risk, some degree of uncertainty when it comes to medical decision-making.