EP145: Infallibility in Medicine: Insights from Dr. Victor Prieto

The Human Side of Dermatopathology: A Conversation with Dr. Victor Prieto

In this episode, Dr. Victor Prieto, a pathologist and dermatopathologist at MD Anderson Cancer Center, discusses the fallibility of experts, the importance of addressing mistakes in medicine, and the crucial balance of experience and humility in clinical practice. He shares insights into improving patient care by learning from errors, the significance of self-care, and the profound impact of a doctor's work on patients' lives. Dr. Prieto also offers advice on finding mentorship and reinforces the value of passion and dedication in the medical profession.

00:00 Introduction and Guest Welcome

00:45 The Fallibility of Experts

03:07 Addressing Mistakes in Medicine

05:46 Work-Life Balance in Medicine

07:44 The Rewards of a Medical Career

09:39 Final Thoughts and Advice

Transcript

Christine Ko: [00:00:00] Welcome to today's episode. I'm happy to be with Dr. Victor Prieto. Dr. Prieto is a pathologist and dermatopathologist with a special interest in malignant melanoma. He has been at MD Anderson Cancer Center since 1999, with a joint appointment in the Departments of Pathology and Dermatology. He is a well-respected clinician, researcher, and educator, co-directing the Melanoma Tissue Bank, studying primary and metastatic melanoma and predictors of behavior, and assessing new treatments of melanoma. He has served for 10 years as chair of the Department of Pathology at the University of Texas MD Anderson Cancer Center.

Welcome to Victor. 

Victor Prieto: Hello. Good to see you.

Christine Ko: Thank you so much for being willing to do this.

Victor Prieto: Of course, my pleasure. 

Christine Ko: So my goals for this podcast are to get to know people with slightly different questions than we sometimes talk about in academic conferences, but things that I think are very important to the practice of [00:01:00] dermatopathology and being a doctor. Recently at our American Society of Dermatopathology meeting, you had a really nice comment during one of the sessions. And it was because the speaker had been talking about, well, you can send a difficult case to MD Anderson and you, you get the right answer. And it was in slightly different words, but the speaker said something like that. And you stood up at the end and made a comment. You said, I just want people to note that no expert is infallible. Could you elaborate on that? 

Victor Prieto: We are humans, after all. If we weren't fallible, there wouldn't be any second opinions. One thing that we tend to forget is that there is nothing that is absolutely 100 percent correct or wrong. We see that very easily in laboratory medicine; if you receive a 120 result for glucose, that doesn't mean that you are diabetic or you [00:02:00] are not diabetic. If it is 121, it's basically the same as 119. Sometimes we have a similar thing in pathology. We tend to have an either/or so it's a hundred percent diagnostic one or the other. Sometimes it's not that. So this is a long answer, but that's what I meant. As an expert, you have seen more cases of that. Here in Anderson, everybody is a specialized physician. There is one surgeon that the only thing he does is treating penile cancer. He has more experience than other people. So if I had penile cancer, I would go to see him because everything is about your experience. 

Christine Ko: Yes. 

Victor Prieto: An expert may have more experience about a particular topic, but that doesn't mean that he or she will be always right. 

Christine Ko: There's no perfect doctor. 

Victor Prieto: We cannot see absolutely the whole truth or the future. 

Christine Ko: I definitely came through training with this idea that other doctors don't [00:03:00] make mistakes.

Victor Prieto: Everybody makes mistakes. The question is, how many and how frequent? 

Christine Ko: I think that I had that impression because we don't talk about mistakes.

Victor Prieto: it's difficult to talk about mistakes, but it's getting better. It's because it's uncomfortable to recognize mistakes. We have a long way to go to reach what the airline industry has done. For probably 20, 30 years, what they have been doing is that they have created a culture in which mistakes or errors are opportunities for improvement. If we classify errors into, I made a mistake because I'm evil, or I made a mistake because I made an honest mistake. So the evil one, that's not going to be a way for us to protect us. But for the others, yes, because if I make a mistake because I was tired, or the slides were dirty that means that it was not my intention to make that mistake.. Medicine changed that, as probably 30 years ago, with that famous case of Mr. Warhol[00:04:00] in New York in which a resident had been practicing for more than two days straight. And of course, he was not prepared to deal with a difficult situation. The only way for us to know how to improve is to find out what the problems are. You have to find out what the problems are and try to solve them before they occur.

Christine Ko: There's a term called near miss. We should try to learn a lot from our near misses because they are areas where there's probably some kind of challenge that should be fixed. Back to your comment about the honest mistake. If I'm making an error, hopefully it's an honest mistake, meaning that I'm not doing it deliberately. It's not because I'm an evil doctor and I'm like, let me deliberately put this wrong thing in the report, so it's an honest mistake. I don't know that I'm doing it because obviously if I did, I would do something differently. I don't know when I'm making errors. Oftentimes the way that they're caught, it's usually not me that catches them, but sometimes [00:05:00] the clinician will call and say, this didn't fit quite right. Or the case is reviewed in Grand Rounds or some other conference for some reason. And the error is caught. Every once in a while, a case didn't sit well with me. And I look back at it and maybe I change it in some way. Can you comment on that and how you deal with that?

Victor Prieto: It's very important to have processes that help prevent errors. As we were mentioning before, airline industry, they have reduced significantly the number of accidents. And it is much safer to travel by plane than going to the airport in your car. I think that we are reaching the same way in medicine. We still have a long way to go, but I think we have improved significantly.

Christine Ko: You mentioned resident work hours being reduced. Do you have a routine that you have for yourself to try to make sure that you're not overtired? 

Victor Prieto: Of course you have to sleep!

Christine Ko: Yeah. 

Victor Prieto: The older you get, the more you have to make sure that you're keeping alert. One of the methods that I [00:06:00] use is that, after hours, and I'm talking about anything between four or five o'clock, I do not give a diagnosis on a specimen if it is controversial or difficult. I will let it sit and then I will look at it the following day. Also, when it comes time to eat, I eat. Unless there's an emergency, I stop and I eat and I come back. Things like that are maybe silly, but they help me. Actually, they did a study, very interesting one, in Israel. They look at the number of parole awards that judges were giving. If it was before lunch, it was much lower than if it was after lunch. 

Christine Ko: Yes. Maybe it sounds silly. You stop and you eat when you're hungry, when it's time to eat and you sleep enough. We all need to sleep, but I think the culture of medicine is just work, and the more you can work, the better. The more that you say yes to things, that's just more opportunity. With life also coming at you.... I've [00:07:00] sacrificed meals for sure. I've sacrificed on my sleep. Especially when I had kids and they were babies, you have to be getting up in the middle of the night. And so, I think just sometimes it's really hard to do those very simple things like eat. It is actually really important and not a silly thing that we really prioritize those things. Eat and sleep and drink water, very important.

Victor Prieto: Now there are different stages in our life because when I was a resident first and a fellow, of course, I spent more time working because the more you see, the better you are. But then there is a point of no increasing return if you keep staring at the microscope.

Christine Ko: Thank you for all of those answers. I'm going to shift gears and ask you how you thrive in medicine, given all of the pressures that are on us today.

Victor Prieto: Because this is the greatest profession. I didn't go into medicine because I wanted to be rich. In medicine, even when I'm at home, I'm thinking about the cases that I saw. Because what we do, it has a direct impact on people. Particularly in pathology, anytime that I issue a report, it has direct impact. If I make a diagnosis of benignity, the patient is going to be happy. I make the diagnosis of [00:09:00] malignancy, there's going to be an impact on how the patient feels and what is going to happen the rest of his or her life. Just to give an example, I remember a case that I was shown in consultation. And when I looked at the slides, I said this patient is at risk of malignancy of the GI tract, or the gastrointestinal tract, particularly of the colon., I put that in a note, and three weeks later, the surgeon called me and told me Victor, the patient had very early colon carcinoma. We were able to cure him. So that's a type of impact that our work has on our patients. And that's why that is so rewarding.

Christine Ko: I agree. Do you have, is there any advice that you wish you had known earlier?

Victor Prieto: The most difficult thing about the future is to predict it. I'm just paraphrasing. There's not much that you can foresee because you don't know where things are going to go. I've been blessed because I've had the advice of people that were ahead of me, and they had experience. The [00:10:00] most important thing is to be working with somebody who is an expert, not necessarily that is the person who knows the most about diagnosis, but the person who knows about how to deal with difficult situations. That's the main thing. Now, had I known, of all the people I met afterwards, who was the best mentor, yes, that would be great. I don't think somebody can tell you, oh, this person is going to be the best mentor, because it has to work both ways. So I don't know, is that too wishy washy answer? 

Christine Ko: No, I think it's helpful. I think it's true that the world changes and we're not going to necessarily know how it's going to change. Your mentor comment ties into that as well. It's really hard to know who is really going to have a large impact on you until the past is the past. So I think to keep an open mind and I think like one of the key things there is you knew yourself and you did know what you wanted. You wanted to have work be more [00:11:00] a part of your life rather than just, Oh, work is just to create a life and to make a certain amount of money. And, you're right. I think that when we're doctors and we really care about what we do, it does spill into the rest of our life. 

Victor Prieto: One thing that that I wanted to say is that in any profession, you can make it a job to make money or you can make it a profession. I know pathologists who they just want to work from eight to five. Or eight to three, and then go and play golf, which I have nothing against that. But to me, that's not a profession. It's just only a job.

Christine Ko: I appreciate that. Do you have any final thoughts?

Victor Prieto: Medicine in general, as I said before, is the greatest profession because what [00:12:00] we do has an impact directly on the lives of many people. Neil deGrasse Tyson, I don't know if you know him, he is the director of the Museum of Natural History in New York. He came to give the commencement speech at the University of Houston. He said, if you're doing what you love, and they pay you, that's fantastic. But if you're doing a job that you don't like, simply because they pay you, you're likely going to be miserable. That really resonated with me. So as I said before, I didn't do medicine because I wanted to be rich. And every day I feel very grateful because they pay me to do it. 

Christine Ko: They pay you to do something you love. There's nothing better than that. Thank you so much for spending some time with me. I really appreciate it. 

Victor Prieto: Absolutely. Looking forward to talk to you again.