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The Seventh Rule

By Issam Makhoul, MD

The day was drawing to an end and Charlie – my third year medical student – and I were struggling to see the last patients when my pager went off.

Being involved in examining a patient I asked Charlie to get it for me. He came back saying that Mrs. Smith had potassium at 7.5 and she needed to go to the emergency room immediately.

I asked him to hold off and inquired, “Have you applied the seventh?” He looked at me intrigued, not understanding what I meant.

This incident took me back to my years of training when I was the fellow on the oncology consult  team. The team was made up of a faculty oncologist, a resident and myself – the fellow. One day, as we had received many consults we decided to divide and concur.

At the time of rounds, I presented my cases and the resident presented the case of a 54-year-old pancreatic cancer patient who had undergone a Whipple procedure. He went on to recommend adjuvant chemo and radiation therapy. After he finished his presentation, the attending turned to me and asked for my opinion.

As the resident had rehearsed with me and I was the one who gave him the plan, I expressed my agreement. He then asked, “Have you seen the pathology report?” At that moment my brain came to
a halt and my heart began pounding as if I had burned a red light while another car was passing the intersection. I said “No.”

After we reviewed the pathology report it turned out that the patient had a low-grade neuroendocrine tumor of the pancreas that was completely resected with no lymph node involvement. And neither chemo nor radiation therapy were indicated in this case.

No harm was done other than a transient confusion for which we had to apologize, on our attending’s recommendation, to the patient and her family. That was when my seventh rule was born.

In 1999, the Institute of Medicine (IOM) issued its first report on medical errors, “To Err Is Human.” Medical errors are unintended acts of omission, commission or planning. They span the continuum of care from prevention (failure to provide prophylactic treatment or inadequate follow up); to diagnosis (delay in diagnosis, failure to employ indicated tests, use of outmoded tests or therapy and the failure to act on results of monitoring or testing; to treatment (wrong surgery or medical treatment, wrong dose and delay in treatment or in responding to an abnormal test; and failure of communication.

A recent study published in 2016 estimated the number of medical error-related deaths in the U.S. at more than 250,000 per year, ranking third after cardiovascular disease and cancer. Other than the loss of lives
or function, medical errors lead to financial losses estimated in tens of billions of dollars and, more importantly, loss of trust of the patients in the medical system. The major issue about medical errors is that it is very difficult to accurately estimate their prevalence, which is a must since we cannot improve what we
cannot measure.

Furthermore, this is the starting point to assess the role of a defective system vs. the role of the individuals
and their culture. The need for members of different professional groups to provide care for the same patient creates an opportunity for excellence but also a risk for fragmentation of care. It is only when every member of the team takes personal ownership in the patient’s case and when the different members are fully integrated on the basis of shared principles that the risk of medical errors will be minimized.
The seventh rule is “Do not assume, check it for yourself.”

Mrs. Smith was a vibrant 67-year-old woman with a history of breast cancer diagnosed five years earlier and was enjoying complete remission status with nothing to explain a high potassium. Indeed, further investigation revealed that the test belonged to another “Mrs. Smith” from the adjacent surgical clinic. Charlie stopped and asked, “How many rules do you have?” – “Ten rules,” I responded.

Rule # 1 is “Every patient is unique;” rule # 2 is “Consider every encounter with a patient as your first and last one before meeting your creator;” rule # 3 is “Listen to your patients’ stories and accept them with their families as partners.” As Steven Covey says “To touch the soul of another human being is to walk on holy ground.”

You have to believe that every patient is unique and every encounter is a special opportunity to learn about him or her and to walk on holy ground. Because you care you will apply the seventh to make sure that every time you interact with them you’re giving them accurate information and appropriate care.

“How about the other rules?” he asked. “That is enough for today. It is time to go home.”

Commentary originally featured in the December issue of The Journal of the Arkansas Medical Society. Dr. Makhoul has been an AMS member since 2003 and is an Associate Professor and Director of the Division of Hematology Oncology in the Department of Internal Medicine at the University of Arkansas for Medical Sciences (UAMS). 

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