Ratio diagnostica.

    Richard S. Cranovsky

Personal experience: period 1974 - 1977 [1]

For this purpose ratio = relationship between risk and clinical benefit of invasive diagnostic procedures. E.g. delayed adverse reactions after intrathecal injection of dye "Amipaque" for mylography (confusion, transitory aphasia, troubles with memory) or transient aggravation of symptoms after cerebral angiography in cases of minor cerebrovascular disease.

Conclusions from registered cases in the 70's:
  • Respect the indications – establish rules for appropriateness;
  • Assess the risk/benefit in individual cases;
  • Always obtain informed consent;
  • Be prepared for adequate treatment of adverse events (AE);
  • Disclose the AE and offer support;
  • In the future: bet on less invasive methods!

Recall of some historical cases of errors
  • Inadequate X-ray treatment of a woman with syringomyelia, i.e. a cavity formed within the spinal cord.
    Treatment duration: 1946-1973.
    Outcome: No improvement, severe, late, deep skin lesions.
    Error: due to deficit of knowledge (application of X-rays badly understood).
  • Radiculography performed in a small regional hospital - exploration of the lower part of the dural sac with strongly irritating dye.
    Outcome: shock, paraplegia.
    Errors: wrong indication, wrong technique, inappropriate settings.

Epidemiology of health care associated AE at the beginning of the XXI century

Iceberg phenomenon?
  • Taxonomy - non homogenous;
  • Variety of sources;
  • Issues of disclosure: medical, legal, cultural;
  • Complexity of systems and procedures;
  • Human factors are frequently causing AE and contributing to concealment of truth.
Human Factors
  • Short half-life/life-time of acquired knowledge.
  • Discrepancy between growth of knowledge and doctors' time available for learning.
  • Increasing complexity of treatments and huge variety of therapeutic choices.
  • "Fog of uncertainty" related to emerging pathologies and to interpretation of new tests.
  • Errors in clinical reasoning and in decision making.
  • False attitudes toward clinical facts:
    - spurious analogies,
    - overestimation of own experience,
    - several sort of bias: selection, availability, recall bias,
    - lack of understanding of pre-test probability.
  • Narcissistic personality:
    - feels unique or special,
    - self-admiring, self-absorbed,
    - envious, arrogant/haughty,
    - perfectionist-compulsive, - authoritative,
    - interpersonally exploitative.
    "Muted or closeted narcissism of health professionals serves as a form of self-protection" [2].
  • Macho-type personality:
    - "I can intubate any patient in all situations";
    - "No complication happen to me – this is a routine procedure";
    - "Don't teach me here what I have to do – standards and guidelines are for other people".

Simple rules after an adverse event
  • Maintain essential vital functions.
  • Stop or immediately change current treatment.
  • Depending on the type and gravity of AE, file a report in an appropriate way.
  • It should be known:
    - who, when, how, about what must inform the patient, his family or representative.
Issues in disclosure of an AE
  • First learn, order and register the facts; preserve the materials and proof.
  • Start initial simplified analysis of direct causes.
  • Decide about the disclosure; tell what you believe is the truth!
  • Wrongdoings incl. concealment of the truth: cases of "near miss or close call" vs. "transitory damage" vs. "permanent lesion" or "death".

Issues in reporting of AE
    1. Various types and methods of reporting:
    Local (one organization or it‘s subdivision);
  • Regional or in a given network of providers;
  • National and international (pharmacovigilance, haemovigilance);
  • According to the type of presentation and of the kind of AE (medicinal therapy or vaccines, blood transfusion, laboratory tests, surgery).
  • 2. Reporting requires :
  • Motivation, responsibility, openness;
  • Culture of behaviour in case of error;
  • Reasonable and feasible system of reporting (from verbal to e-reporting);
  • Legal basis for protection of sensible data to be used to prevent similar AE;
  • Legally protected, "blame-free" environment
NOT REFLECTING protection of reporting with freedom from responsibility for errors.

Sad reality about AE
    (A) extreme attitudes:
  • Principle of "no disclosure";
  • Apply best available treatment;
  • Reduce maximally the sequelae.
  • (B) should vouch for all activities:
  • Disclose facts and circumstances, recognize an AE;
  • Present an apology;
  • Offer immediately assistance, repair and compensation.

Rationalize, explain, minimalize
  • Concealment of the truth is a psychologically well-known defence mechanism.
  • Rationalization and explanation when omitting relevant facts can be both: self-deception and lying to the victim.
  • "We admit that the wrong leg was amputated, but it should be amputated later anyway".

  • Explanation & rationalization without full disclosure is an attempt to avoid the responsibility, it is not the way to tell the truth, to admit an error and propose repair or compensation.
  • E.g. "The ER was exceptionally busy, but a delay in the start of thrombolysis was not relevant in this case of such a severe myocardial infarct".
  • Old dilemma: concealment of truth vs. lie (selected attitudes).
  • St. Augustine described 8 categories of lies: from harmless to intentionally damaging.
  • St.Thomas doubted whether every lie is a sin.
  • E. Kant categorically rejected any kind of lies.
  • D. Bohnhoefer (Tegel Essay, 1943) justified concealment of truth to protect life of people endangered by criminals.
  • S. Bok presented a comprehensive analysis of lying in public and private life in 1989.
  • Veracity in relationship with sick or dying people (S. Bok).
  • Original text of "Hippocratic Oath" doesn‘t mention the duty of veracity.
  • The principle "primum non nocere" is the most important quote.
  • Search for the truth and communication of the results is justified only if it is not endangering the patient.
  • Only the treating physician should be allowed to "manipulate" the truth in the best interest of patients.

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By-passing the truth, autodefensive rationalization
  • "Why have we to disclose the cause of this error? The status of the patient was hopeless anyway".
  • "To inform the family fully about this fatal event will only deepen their grief".
  • "The patient is also partially responsible for this event. Would he take better care of his hypertension, this mistake would not have caused such severe harm".

Defensive strategies (examples)
Euphemisms used to describe an evident error:
- complications;
- therapeutic mishappening;
- incident;
- "calamities of surgery" (E. A. Codman).

Malicious interpretation of an AE
  • "Valuable experience";
  • "Opportunity to improve the treatment";
  • "Important lesson";
  • "Blessing in disguise".

Avoiding responsibility
  • Accusing others.
  • Dilution of responsibility (indicating as guilty members of the team or people only indirectly involved in a given treatment procedure).
  • Example: inadequate administration of a medication as result of illegible handwritten doctor's order - the accused parties are: assistant/resident, nurse, pharmacist.
  • "Tactical split of personality": the GOOD I (caring, competent) can‘t take responsibility for the errors of the BAD ME (negligent).

Disclosure of truth is an ethical duty
  • Fiduciary doctor-patient relationship is build on trust.
  • Patient trusts that doctor is knowledgeable, skilled and good willed.
  • Frequently patient has no possibility to check the competence of doctors.
  • The patient is usually the weaker party.
  • Doctor's honesty after an AE must never be diminished because of fear of an investigation.

Legal protection of reporting AE
Different kinds & methods of reporting require:
- motivation and adequate behaviour of involved people;
- well-designed, purposeful and functioning system;
- legal framework for protection of reporting health professionals – blame-free system and data-protection.
NB! This needs not to be understood as protection from responsibility for committed errors!

  • When? Without delay, but it depends on the type and severity of an AE, damage, current clinical status of the patient.
  • How? Sincerely, with empathy, offering assistance and repair/compensation.
  • Who? It must be compatible with pre-established policy in a healthcare organization. It must be made by an experienced and responsible person. It should be the direct treating/caring physician. It is usually better when disclosure and apology are made by the same person.

Spurious apology
  • "I apologize for an event so disagreeable for you".
  • "I am sorry that something unexpected happened to you".
  • "I regret that your mother died shortly after the operation".
  • "I am troubled by the fact that wrong dosage of medicament resulted in prolongation of your hospitalization".

Recognition of an error and apology
  • "I am very sorry, that I have committed an error, causing massive bleeding that will delay your healing".
  • "I recognize that we have underestimated the symptoms of the MI your father presented with, and have delayed the adequate treatment. We are very sorry. How can we compensate for such a painful loss?"

Apology is not a self-accusation
    There are various ethical and legal situations possible.
  • "I am sorry…" as expression of empathy and recognition of error not protected by the law (Massachusetts 1986, Florida 2001).
  • "I apologize for causing this AE … I will do my best to repair the damage." Apology and statement of causation possibly protected by the law (Oregon, Colorado 2003). Example: "I apologize for the error in anaesthesia caused by myself and by my team. We will offer you assistance and fair compensation". Such statement can be in some countries recognized as an act of goodwill and as disclosure protected by law.

Apology and repair
The general principles of an alternative dispute resolution procedure may apply. Promise of repair or compensation is essential. Citing Bishop Desmond Tutu (RSA, Nobel Prize Winner): "If you have stolen my pen and are apologizing for that, but you don‘t give it back to me – nothing changes in the conflict between us."

Selected sources of data on AE
  • Malpractice claims
  • JCAHO data on "sentinel events"
  • OECD
  • WHO
  • World Alliance on Patient Safety
  • Regional and national statistics
  • Pharmacovigilance, Haemovigilance
  • Reporting systems: local, regional, national
  • Opinion research (e.g. Eurobarometer)


[1] Cranovsky RS. Ratio diagnostica. And Richard’s lifelong practice. Habilitation at University of Bern, Switzerland 1976.
[2] Banja J. Medical Errors and Medical Narcissism Illustrated Edition. Jones & Bartlett Learning 2004.

Conflict of interest: none declared

Authors’ affiliations:
Former Global Faculty Member of Fairleigh Dickinson University, NJ, USA
Former RC-Consulting Lausanne/Epalinges, Switzerland

Corresponding author:
The article was published posthumously.
Please see:
Gościński I. A tribute to Prof. Richard Cranovsky and Prof. Ryszard Gryglewski. World J Med Images Videos Cases 2023; 9:e31-35.

To cite this article: Cranovsky RS. Ratio diagnostica. World J Med Images Videos Cases 2023; 9:e39-43.

Submitted for publication: 8 June 2020
Accepted for publication: 11 November 2023
Published on: 31 December 2023

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