Thursday April 20, 2017

April 20, 2017 full episode transcript

Note: Transcripts may contain errors. If you wish to re-use all, or part of, a transcript, please contact CBC for permission. Please check the corresponding audio before quoting in print. Copyright © CBC 2016

The Current Transcript for April 20, 2017

Host: Anna Maria Tremonti

STORIES FROM THIS EPISODE

Listen to the full episode

Prologue

[Music: Theme]

SOUNDCLIP

He sounded so racist about Aboriginal people. He mentioned that maybe she killed herself. I don’t think she would do that to herself.

ANNA MARIA TREMONTI: There was outrage last fall when a veteran Ottawa police officer was exposed as the person behind racist judgmental remarks posted on social media about the sudden and unexplained death of the Inuk artist Annie Pootoogook. What began as a personal tragedy turned into a national scandal. The police officer was temporarily demoted and the headlines went quiet. But behind the scenes, there was a great deal going on and it led to an encounter that no one could have predicted. In a moment, Kristin Nelson brings us a story that will take your breath away. Also today, tragic misdiagnoses in emergency rooms have been in the news over the last few months.

SOUNDCLIP

The truth of the matter is nobody knows in all of medicine, what a good surgeon or a physician or a paramedic is supposed to bat. What we do though is we send each one of them, including myself, out into the world with the admonition to be perfect.

AMT: The CBC's Brian Goldman, a practicing ER doctor, feels so strongly about the need to acknowledge doctors make mistakes, that he's given a TED Talk on the issue. Another ER doctor has gone further, creating the only program in Canada and perhaps the world to train doctors to avoid diagnostic errors. We'll hear from him in an hour and some of that TED Talk as well. And we're staying with medicine and the story of a woman who says it is her physique—not fat—that is debilitating. I am overweight but I still am pretty healthy. I can do a flight of stairs. I'm certainly not debilitated by my weight.

AMT: But Melody Harding’s body mass index is deemed too high to get the surgery she says would change her life. The BMI determines the weight of health care plans, medical insurance, eligibility for surgery while a growing number of health professionals say it is bogus. Hear the concerns in half an hour. I'm Anna Maria Tremonti. This is The Current.

Back To Top »

'I want to understand': Ottawa police sergeant openly apologizes for racist comments

Guests: Kristin Nelson, Chris Hrnchiar, Veldon Coburn

SOUNDCLIP

Our life is going up and down, up and down. Happy, not happy. Happy, not happy. That's what I drew, like that. Sometime I drew about my life. I'm not even shy about that drawing I did because it was me. It was my life.

AMT: Well, last September, the body of renowned Inuk artist Annie Pootoogook was discovered in downtown Ottawa on the banks of the Rideau River. She had been living at a nearby shelter and struggling with addiction. Ms. Pootoogook was born into a family of artists in Cape Dorset, Nunavut—more than two thousand kilometres away from Ottawa. Her ink, charcoal and crayon drawings were critically acclaimed—portraying everything from mundane scenes of life in the north to raw, arresting images about domestic abuse. Annie Pootoogook's death shook her family, the art world, and the Inuit communities across Canada. But it also profoundly changed the lives of two men in Canada's capital region: one who made a racist remark online about her death and the other who exposed that comment for very personal reasons. As part of our year-long project, The Disruptors, Kristin Nelson brings us their story.

SOUNDCLIP

Ottawa police have identified the body discovered earlier this week in the Rideau River.

KRISTIN NELSON: It was late on a Friday afternoon last September that Gatineau resident Veldon Coburn learned that celebrated Inuk artist Annie Pootoogook was dead.

SOUNDCLIP

The public’s help in retracing her steps.

KRISTIN NELSON: The story made local and national headlines.

SOUNDCLIP

International recognition for her drawings.

KRISTIN NELSON: And the following day, Coburn was reading an article online about Pootoogook's death when he came across troubling remarks in the comments section.

SOUNDCLIP

In one of those, the comment characterized Canada's Indigenous community as “just satisfied being alcohol or drug abusers." And in another comment it reads like this: "It's not a murder case.”

KRISTIN NELSON: Of course, controversial comments under online news stories are not uncommon, but Veldon Coburn says he was shocked when he figured out who wrote these ones.

VELDON COBURN: So I just clicked on the name and it took me to a sergeant of the Ottawa Police Service, his personal Facebook page.

KRISTIN NELSON: That Facebook page belonged to Staff Sergeant Chris Hrnchiar—a 30-year veteran of the Ottawa Police Service. In fact, he was the supervisor in charge of the forensic identification detective who processed the scene where Pootoogook's body was found.

VELDON COBURN: I took some screen captures and I sent an email to the mayor and Chief Bordeleau.

KRISTIN NELSON: He's referring to Ottawa Police Chief Charles Bordeleau.

VELDON COBURN: It's just simply unbecoming of an officer who wears a uniform to post such comments.

KRISTIN NELSON: The screen capture documented comments such as: "Much of the Aboriginal population in Canada is just satisfied being alcohol or drug abusers." He speculated publicly that Pootoogook's death was not suspicious, that it: "could be a suicide, accidental. She got drunk and fell in the river and drowned, who knows." He also wrote that: “This has nothing to do with missing or murdered Aboriginal women." But at the time, police were just acknowledging that elements of her death were in fact suspicious and did warrant further investigation.

VELDON COBURN: It's particularly problematic when an officer is commenting on an ongoing investigation and making derogatory comments and leading us to believe that it's not worth pursuing in the way that we would hope that the Ottawa Police Service has been, putting the full efforts behind, arriving at the truth of the untimely and sad circumstances of Annie Pootoogook's death.

KRISTIN NELSON: The story was personal for Veldon Coburn for many reasons. He's a member of the Algonquins of Pikwakanagan and father to four Indigenous kids. One of those children is the biological daughter of Annie Pootoogook—four-year-old Napachie. The Coburns adopted her in 2014. Annie wasn't in a position to care for a baby at the time. Without revealing his connection to Pootoogook, Coburn alerted the media about the author of the online comments.

SOUNDCLIP

There is more reaction tonight to a police investigation into a complaint alleging that an Ottawa police officer posted racist comments.

KRISTIN NELSON: The two men found themselves together at the centre of a media story.

SOUNDCLIP

VOICE 1: Ottawa police officer was caught posting racist and degrading comments…

VOICE 2: Ottawa police are looking into a complaint that a police officer may have posted derogatory comments speculating…

VOICE 3: Racist comments about the death of Annie Pootoogook on social media.

KRISTIN NELSON: That was over six months ago. From the public's perspective, the story has been dormant. But out of the public eye, Chris Hrnchiar has been trying to make amends for what he said. He started showing up at Inuit events in town, meeting with elders, writing letters of apology. And then last week, Veldon Coburn and Chris Hrnchiar met each other face-to-face for the first time.

[Sound: Restaurant ambiance]

KRISTIN NELSON: Veldon Coburn arrives at a restaurant in Gatineau, Quebec across the river from Ottawa.

SOUNDCLIP

I have a reservation for Coburn.

KRISTIN NELSON: The restaurant is located inside the Museum of History. Coburn tells me he chose this venue in part because the museum is home to the imposing "Spirit of the Haida Gwaii" sculpture by Haida artist Bill Reid. It's a six-metre-long white plaster-cast canoe crammed with mythical creatures paddling along the river. He likes the symbolism of it—diverse characters working together to move forward. This is also the place where the inquiry into missing and murdered Indigenous women was launched.

SOUNDCLIP

KRISTIN NELSON: How are you feeling?

VELDON COBURN: I'm at ease. I've had one or two exchanges with Chris over email in the past couple months. I'd imagine that Chris is probably a little bit maybe more on edge, but maybe not. I don't know. We'll find out.

KRISTIN NELSON: After Veldon Coburn complained about the sergeant's online comments, Chris Hrnchiar was charged with two counts of discreditable conduct under the Police Services Act. He pleaded guilty, was demoted for three months and ordered to undergo sensitivity training. But Hrnchiar has done much more than that.

VELDON COBURN: I'd seen the efforts of what Chris had been doing and I'd been hearing through the Inuit community, because my daughters are Inuit, and stories would get back to me and they would say, you know Chris Hrnchiar showed up at this event. Chris Hrnchiar was at a feast. Chris Hrnchiar, I saw him out with elders and whatnot. And I thought really? This is amazing. Because I thought he would just take a slap on his wrist, get his pay cut, go back to his job and nothing would become of it. But the exact opposite has occurred, so I guess that's why I'm here today.

KRISTIN NELSON: Coburn has his back to the entrance when Hrnchiar arrives. I end up being his look out.

SOUNDCLIP

VELDON COBURN: Two guys? One black guy?

KRISTIN NELSON: Hrnchiar enters the restaurant with the Dave Zackrias, head of the Ottawa Police's diversity and race relations unit. Hrnchiar looks like a cop in a movie from the eighties. He has short-cropped, greying hair and perfect posture. Veldon stands up to shake Chris Hrnchiar's hand.

SOUNDCLIP

VELDON COBURN: How you doing? You alright?

KRISTIN NELSON: But that quickly turns into an embrace. Hrnchiar buries his face into Veldon Coburn's shoulder.

SOUNDCLIP

CHRIS HRNCHIAR: [Muffled] Pleasure to meet you.

VELDON COBURN: I'm glad to meet you too. You okay?

CHRIS HRNCHIAR: Well, I got a little emotional this morning. But it was long overdue.

VELDON COBURN: I'm glad you're here.

CHRIS HRNCHIAR: Yeah, so am I. Absolutely. Nice to see you. Hi.

KRISTIN NELSON: As the two men sit down across from each other, emotions are running high.

CHRIS HRNCHIAR: Pardon me. I'm Slovak, so I wear my emotions on my sleeve there sometimes.

VELDON COBURN: Jeez, it's been six months eh?

CHRIS HRNCHIAR: My feeling was that I'm blessed to be able to see you to apologize to your face because I know how much it's hurt your community and the people you love. And I'm blessed to be able to get this opportunity to say I'm sorry to your face. And I've expressed that a lot and I've said I'm sorry to a lot of people. But with that, what I said, I realized that I didn't know as much as I should have known and I wasn't as sensitive to things as I should've. And I’m realizing more of that for a lot of the hurt that I was commenting inappropriately about—it's all our problems. And it’s actually shocking me a lot as to how much hurt there was and why some of the problems exist the way they do. And I was not as versed in that as I should have been. That causes me some shame as a Canadian and as a person. Sorry, I'm going to cry a lot. That's okay though. That's okay.

VELDON COBURN: I always thought about the myth of Sisyphus, of him with the boulder and constantly pushing it up the hill by himself. And I thought well, this isn't Chris' problem. And when Justice Murray Sinclair said this isn't an Indian problem, this is a Canadian problem. And I always thought let me stand next to him. This isn't for him to bear on his own.

KRISTIN NELSON: The tenderness between the two men is surprising, given the events that put their lives on a collision course.

CHRIS HRNCHIAR: I don't feel any animosity towards you and a lot of people would say well, that’s kind of unusual because someone who complained about you and stuff like that. But I never felt that because, as I said, if I did something wrong and it hurt somebody—and that was pointed out—why is that a bad thing?

VELDON COBURN: I said to others I can't fault him as a person because we used to read CBC comments on Indigenous articles. When I worked in Indigenous and northern affairs just around the corner from here, we used to sit in the office and when an Indigenous article would come up, we would read all the comments. And within an hour, there would be about 400 and we'd say, isn't this where the more high-minded and open-minded come to comment on stories? So it wasn't out of the norm, like this is a common sentiment. And if it had come from Bob the Accountant, I would have shrugged it off, but police officers, lawyers, judges, legislators, politicians—we place so much more trust in them so I think it was a conversation to have. So it's not a personal fault.

KRISTIN NELSON: In the five months since pleading guilty to discreditable conduct under the Police Services Act, Chris Hrnchiar took part in police diversity training course, attended a full-day forum about human biases and completed two days of training through the Department of Indigenous and Northern Affairs.

CHRIS HRNCHIAR: The government training we did was unbelievable. In a perfect world, I think every police officer should have that, really. I mean it was really shocking to realize the history that a lot of it I had no idea. Even reading Truth and Reconciliation and some of the residential school stories, I mean it brings you to tears. If that doesn't hit you, it's horrific.

VELDON COBURN: Most of Canada's only starting to recognize it in the last year or two.

KRISTIN NELSON: Chris Hrnchiar has also learned more about Annie Pootoogook.

CHRIS HRNCHIAR: I had no idea how accomplished she was. I had no idea. Amazing.

VELDON COBURN: Yeah.

CHRIS HRNCHIAR: And weren't both her parents acclaimed artists too?

VELDON COBURN: Napachie's grandmother was also Napachie Pootoogook. Her namesake is internationally renowned.

KRISTIN NELSON: The mention of his adopted daughter is a reminder of Veldon Coburn's personal connection to all of this—Napachie, the biological daughter of Annie Pootoogook.

VELDON COBURN: She never got the chance to meet Annie. Those are the things we took for granted. We knew that Annie was troubled. She was in no shape to care for a child. We didn't want to go visit her down at the shelter at the Shepherds of Good Hope because we didn't know if she'd be under the influence because she was still quite heavily abusing substances that we’d known of. So we took it for granted that 10 years from now, five years, we would just go down and see Annie. We would bring Napachie down.

KRISTIN NELSON: In spite of the hurt, Veldon Coburn has been moved by Hrnchiar's efforts to make amends.

VELDON COBURN: I didn't know that you weren't a cold person because I'd come from places—Thunder Bay, Regina—where police officers willingly say this and unapologetically. But after your apology, I was broken-hearted once again because I thought jeez, this is somebody who actually cares. There were other things too because the stories that circled back to me through the Inuit community and they said well, Chris has been here and Chris has seen the elders. And I think everyone in the Inuit community embraced you. I don't know if they’ve said that to you.

CHRIS HRNCHIAR: I've certainly felt—what's amazed me is I've felt a lot of forgiveness.

KRISTIN NELSON: To get a perspective from Ottawa's Inuit community, I went to the Ottawa Inuit Children's Centre—one of the places that Hrnchiar visited in the months since making the comments about Pootoogook. He told me when he went there, at least one person told them how angry some people were with him. And one parent decided to pull their kid out of class the day he was visiting. But others were more forgiving, including this woman.

REEPA EVIC-CARLETON: I'm Reepa Evic-Carleton. I'm originally from Penantang, Nunavut and I've been in the south for over 20 years.

KRISTIN NELSON: Miniature Inuit boot earrings made from ivory dangle from her ears as she recalls that meeting with Chris Hrnchiar.

REEPA EVIC-CARLETON: So I saw that Chris was reaching out. He really wanted to make it right. I saw that and I could tell that he was genuinely remorseful about what he had said about Annie Pootoogook. And that made it very easy for me to have this meeting and conversation around the whole thing. This man was very serious about wanting to make a difference and wanting to do it right. And he asked for forgiveness. So there's a lot of talk going on about reconciliation. To take it even to a higher level of reconciliation, forgiveness has to happen.

SOUNDCLIP

VELDON COBURN: Did you guys want to order something? Did you guys eat?

KRISTIN NELSON: Back at the restaurant, the two men begin to relax in each other's presence.

SOUNDCLIP

CHRIS HRNCHIAR: It's amazing to get to meet Veldon. It's long overdue. And just to hug him. I felt your energy and I hope you felt mine too

VELDON COBURN: I took great notice of the character of how Chris went through it. And believe it or not, it's something I would point to my kids as a model. Yep, I would. And say like growing up, never run away from things. Pick yourself up, dust yourself off and be the strongest person because far too often, you see people just put their head back down and they won't face the day. That's what I find so profound about Chris.

KRISTIN NELSON: How does it feel to hear that?

CHRIS HRNCHIAR: Oh, I appreciate that. You know mistakes don’t eliminate everything you are. I mean you can still be lacking in something, have a bias of something. It didn’t negate everything I’ve done. I volunteer and I look after my parents and I’ve looked after my sisters. I support different things. I’m engaged in my community. I love my community. It means something to me. All that stuff doesn’t get eliminated, you hope, because of one mistake and you hope people see a positive in correcting that. So just go forward and hold your head up and make it a new day. Make the best of a new day.

KRISTIN NELSON: After the plates are cleared away, Chris Hrnchiar gives Veldon Coburn a gift.

SOUNDCLIP

CHRIS HRNCHIAR: Now it’s not formally wrapped there. I’m sorry.

KRISTIN NELSON: It’s a picture he’d taken last summer in Newfoundland of an albino caribou—sacred for Indigenous people.

SOUNDCLIP

VELDON COBURN: I’m not a fancy guy.

[Sound: Tearing tissue paper]

VELDON COBURN: Oh wow.

KRISTIN NELSON: The conversation turns to reconciliation.

CHRIS HRNCHIAR: It's not one person's burden. It's a lot of people collectively that I think have to. And I think recognizing a lot of things that happened in the past, injustices, that's a first step, but that has to go with action. And it has to go with action not just of legislators, but of citizens.

VELDON COBURN: And that's why I can be here today with you because I think the story should be of one police officer who has said that it's not okay. I'm going to mend the relationship and I'm going to try my best to make it better than it was before. There's so much behind us, can I help heal? Because I think Canadians are looking for somebody who can bridge the gap. And that's why I can be here today.

AMT: We've been listening to a documentary produced by The Current’s Kristin Nelson and Josh Bloch. Stay with us. The CBC News is next and then—

SOUNDCLIP

VOICE 1: Like I'm pretty lean, but if someone else is my height and 175 pounds of mostly fat, we have the same body mass index.

VOICE 2: Mhm. Correct.

AMT: So we're going to size up the value of the body mass index. I’m Anna Maria Tremonti and you are listening to The Current on CBC Radio One, Sirius XM, online on www.cbc.ca/thecurrent and on your radio app.

[Music: Sting]

Back To Top »

BMI 'obsolete' and doesn't measure health, says doctor

Guests: Melody Harding, Dr. Arya Sharma, Dr. Scott Kahan

AMT: Hello. I'm Anna Maria Tremonti and you're listening to The Current.

[Music: Theme]

AMT: Still to come, diagnosing why there's so much misdiagnosis in hospital emergency rooms and what to do about it. But first, weighing in on the debate over the body mass index.

SOUNDCLIP

VOICE 1: In the nicest way possible, I would like you guys to arrange yourselves from lowest BMI to highest BMI.

MANY VOICES: Oh god. No.

VOICE 2: I can do this real fast.

MANY VOICES: No.

VOICE 1: Would you like to know the results?

VOICE 3: Let’s see it. Yeah.

VOICE 4: You are all the same.

VOICE 5: What?

VOICE 3: Our BMI is?

VOICE 6: That's crazy.

VOICE 7: So say I am 175 pounds, like I'm pretty lean. But if someone else is my height and 175 pounds of mostly fat, we have the same body mass index.

VOICE 1: Mhm. Correct.

VOICE 5: It doesn't know what's fat and what's muscle.

VOICE 1: Do you guys think that BMI is an accurate way of determining health?

VOICE 8: Definitely not.

VOICE 9: These numbers are a good beginning point because if you really are very far off the scale, there is a chance that you should consider something else in your life. But down to the minutae, it really is just how do you feel in your body.

AMT: Well, the results of a BuzzFeed body mass index experiment. Body mass index—or BMI—is a measure that is often used by doctors, insurance companies and governments to determine how fit you are. But the simple standardized test measuring weight relative to height may not be the best way to assess body weight. This week, a 29-year-old woman in Nova Scotia put a spotlight on the issue by calling on the government to stop using BMI to determine who qualifies for provincially funded breast reduction surgery. For more on this, Melody Harding joins us from our Halifax studio. Hello.

MELODY HARDING: Good morning.

AMT: What happened when you looked into getting a breast reduction covered by your provincial health care system?

MELODY HARDING: Well, first when I was in high school and first looked into it, I was told I was a candidate because I hadn't stopped growing. So that made sense to me. I kind of put it on the backburner. Years later when I looked into it, I was told no because my BMI was over the 27 BMI line, which is still the current criteria for breast reductions in Nova Scotia.

AMT: Okay. What is your BMI?

MELODY HARDING: I am considered obese on the BMI scale. My current BMI is about 46 and that is part of the stickler point for me because I am overweight but I still am pretty healthy. I can do a flight of stairs. I can go for walks and things like that. I'm certainly not debilitated by my weight but I am a bit debilitated by my chest unfortunately.

AMT: Why do you want a breast reduction?

MELODY HARDING: It's a long story, but to be brief, I'm suffering from incredible back and neck pain due to the weight on my ribcage. I suffer from self-esteem issues and psychological issues. I have broken into near hysterics because of my chest more times than I can count. It affects every aspect of my life, even down to my social life and I'm honestly sick and tired of having to deal with this and I'm also sick and tired of the government refusing to help me with this situation.

AMT: Can you tell me how large your chest is, Melody?

MELODY HARDING: Well, the bra I'm currently wearing today is a 38N—as in Nancy—cup. I can go, depending on the bra, anywhere from a 36JJ to 36O. Sometimes depending on the make of the bra I do have to wear 38 however.

AMT: So your ribcage is not very big.

MELODY HARDING: No. For years I was actually a 34. It's only been probably the last two years that I've had to up to about 36 band size and because my rib cage is so small and my chest is so big, I have permanent marks around my ribcage due to my band digging in. And with my auto immune disorder that I developed about 10 years ago, that also gives me hives in those places as well. So I'm an itchy mess at any time.

AMT: You make the point that it's physically difficult on your back. What about exercising? Is it difficult to exercise?

MELODY HARDING: It's very difficult and I contribute that a lot to the weight gain that I've had in the past 10 years. I can't bicycle for instance because gravity is not my friend. Leaning over a bicycle is painful, the strain on my back and my neck. I can do some recumbent biking thankfully, so that's an option for me. I love to swim and I would like to be doing more of that because it is a low impact exercise. However, finding a bathing suit that fits my body at this point pretty much impossible.

AMT: And so when you've gone to doctors to talk about this, what have they told you?

MELODY HARDING: I've been given the option of considering gastric sleeve surgery here in Nova Scotia which to me sounds extreme.

AMT: So they're telling you that you'd have to have gastric bypass surgery in order to get breast reduction surgery. You have to lose weight before they’ll do anything.

MELODY HARDING: Exactly. Currently I'd have to lose like 140 pounds. I'd have to be the weight I was in grade 11.

AMT: What are they saying, that your breasts will also reduce just with weight loss?

MELODY HARDING: Yeah. There's a certain amount that your breasts will reduce. However, I do have genetics working against me so no matter how much weight I lose, I'm destined to have a larger than average chest.

AMT: You know we asked for an interview with Nova Scotia's Ministry of Health and Wellness and no one was available. A spokesperson did give us a statement and I'll read it to you. They say the criteria that—I'm quoting here—“the criteria have been based on the best available evidence regarding medical necessity, surgical and post-surgery risks. This is to ensure when a patient requires this or any other surgery they have the best potential for surgical success. There are currently no plans to make changes in our criteria.” Essentially not saying that they're going to change what the BMI requirement is. What do you say to that argument that the BMI criteria is meant to protect you?

MELODY HARDING: Well, I currently feel like my life is going to fall apart in this situation I’m in. I’m trying really hard not to get emotional. I can't move my body effectively. I've got a bulged disc in my back. I've got a curvature in my back. My neck is also out of alignment. My shoulders are sloped. I'm starting to get numbness in my left hand at the end of the day from carrying the weight around. My mother who is only 52 years old has had two back surgeries and a third that involved a fusion and she's unable to get her BMI down to 27 or less at this point. So she's opted to pay nine to $11,000 to have it done privately—something I am unable to do at this time due to debt accrued during the recession.

AMT: You're in Nova Scotia. Do you know if other provinces have the same restrictions?

MELODY HARDING: New Brunswick is fairly similar. However, they do it by case-by-case basis. So me with my autoimmune disorder, my weight, my back and neck problems—

AMT: Might be okay in another province.

MELODY HARDING: Yeah.

AMT: But you live in Nova Scotia so in terms of getting provincially funded care, you have to get it there.

MELODY HARDING: Yeah. Essentially at this point, I would have to either wait or move to another province.

AMT: Right or pay the money.

MELODY HARDING: Yeah.

AMT: Okay. Well, Melody, thank you for sharing your story with us.

MELODY HARDING: Thanks so much. It was great to have the opportunity.

AMT: Melody Harding joined us from our studio in Halifax. A growing number of experts is saying it's time to retire the BMI is a way of measuring obesity and health. Dr. Arya Sharma is professor of medicine and chair in obesity research and management at the University of Alberta. He's also the scientific director of the Canadian Obesity Network. He's in Edmonton. Hello.

ARYA SHARMA: Hi. Good morning.

AMT: What did you think listening to what Melody had to say?

ARYA SHARMA: Well, it's a heartbreaking story because the evidence supporting the use of BMI in medical practice I think is largely obsolete and is largely opinion based and has very little to do with actual data showing that BMI makes any real difference to outcomes of surgeries in general. As was mentioned in the intro, when you look at body mass index, it’s really a measure of size. It tells you how big someone is. It does not tell you whether that person has health problems. It doesn't tell you whether that person is physically fit. In fact, it doesn't even tell you whether that person has excess body fat. So you know it is a number that needs to be recovered from medical practice. It does have a role in population surveillance which means that if you want to know where the people in Canada in general are getting larger, BMI is great for that. So for statistical purposes, it's great. But when you're talking about an individual patient like in this case Melody, BMI is simply not helpful and is not going to help you make a proper decision.

AMT: Why do they use BMI to decide whether someone should be allowed a surgery?

ARYA SHARMA: Well, I think the fear is—and really this is just a fear—is that as people's BMIs goes up and they have more body fat, the chances that they might have metabolic or other health problems which mean the chances that someone gets diabetes or you know gets heart disease, does go up on average with an increase in body mass index. But those are averages. Those don't apply to a given individual. You simply cannot step on a scale and decide whether you're healthy or not. That's not how the body works and that's not what the evidence shows.

AMT: And how many doctors you think use BMI as a measure of obesity?

ARYA SHARMA: Well, unfortunately that is the standard in most doctors’ practices and in fact even one of the recent guidelines on obesity management that came out a couple of years ago recommended that BMI can be used as a criteria. When there's a lot of evidence now showing that body mass index is simply not a very good predictor and especially when we look at this case, we are talking BMIs of 27. So let me tell you—for someone who has a BMI of 46 with all of the problems that Melody spoke about— even if she went tomorrow and had bariatric surgery, she would not end up with a BMI below 27. So there is virtually saying you know we are not going to do the surgery till you get a BMI of 27 basically means you'll never get the surgery. So even having a gastric bypass is not going to get her down there because gastric bypass on average will get you about you know 20 to 30 per cent weight loss which means that she's still going to have a BMI of 35. That would be considered you know a fantastic outcome for bariatric surgery but it will get her nowhere even remotely close to the BMI of 27 that they're asking for.

AMT: And if we're talking about cost and what to cover, then they're actually going to have to cover the costs of two surgeries anyway.

ARYA SHARMA: Well, bariatric surgery should be covered because bariatric surgery is now the recognized evidence-based treatment. In fact, the treatments we have for obesity are so poor that unfortunately bariatric surgery continues to be the only really effective treatment for someone of her size and is covered. But there is an access problem because the access to surgery is very, very different from one province to the next. Now let me tell you—we're talking here about breast reduction surgery but the BMI criteria is also used for a whole bunch of other medical procedures. It's been used for joint replacements. It's been used for fertility treatments. It's been used for organ transplants. And so the BMI criteria are so pervasive that they continue popping up and we have people who are being denied access to necessary medical treatments just based on BMI for all kinds of indications. That certainly needs to stop.

AMT: What are the consequences of that, Dr. Sharma?

ARYA SHARMA: Well, the consequence of that is here, that Melody is probably never going to get breast reduction surgery until Nova Scotia comes out and changes the criteria because even bariatric surgery is not going to get her to a BMI of 27 which means that she is going to have to live with all of the problems that you just heard about, which is a disaster, which is actually embarrassing and shameful for the medical system because it's not based on good evidence. And I'm quite aware of the evidence about BMI and risk of infections and post-operative recovery and all of that. That evidence is simply so weak that you could say it's not even evidence. It's an opinion that somebody has somewhere based on I have no idea what.

AMT: So if BMI is such a blunt tool, why do governments and doctors and insurance companies use this to measure, to determine if someone is obese?

ARYA SHARMA: Well, there's really only one reason for that and that it's a very convenient measure. It's something that I can ask you over the phone. If you telling me your height and weight over the phone, I can calculate your BMI, look it up in a chart and I can say yay or nay. It's purely the simplicity of this that has always been used as an argument to say well, we can’t make the diagnosis of obesity more complicated because then doctors want to know what it does. That’s nonsense. This really brings up this issue of do we consider obesity to be a medical disease or not? If it's a medical disease then we need to have criteria to diagnose a disease that actually ensures that the people that you say have obesity are actually sick.

AMT: Do you consider it to be a medical disease?

ARYA SHARMA: Absolutely. I mean there is no question that once your body fat starts affecting your health, you have obesity. That's the World Health definition of obesity, says that the presence of abnormal or excess body fat that impairs health is what obesity is. But what that means is that if you have excess body fat that's not impairing your health, then you don't have a disease and you don't have obesity. And you know even in my own practice, I have people walking through the door, perhaps even similar to Melody. You know they have a BMI of 46. They walk through the door. They're perfectly healthy. They're generally happy with themselves and they don't have a disease. They're not sick. You can run whatever test you want. They're pretty healthy. It doesn't mean that they're not at risk of maybe one day getting problems which is when they then have the disease. But right now, they're just large people and they’re perfectly healthy otherwise.

AMT: Is there an attitude problem still within the assumption that someone is heavier, ergo they are more susceptible to health problems than someone who is thinner, who has other health issues that you can't see walking in the door.

ARYA SHARMA: There's no question that excess body fat—it depends on the kind of body fat, which is really what makes this so difficult. When you have body fat that's located inside your abdomen, that body fat can really affect your metabolism and it can lead to diabetes. It can lead to increase in blood pressure, risk for heart disease and all of that. But then you have the fat that's located on your thighs and your arms and your buttocks, you know subcutaneous fat—that's fat that sits under your skin—that is pretty harmless fat. That fat does almost—metabolically it does almost nothing which is why you can have people who have pretty large amounts of body fat but are pretty healthy. So it's not the quantity of body fat that you have that impairs health. It's the kind of fat and the location of the fat and the biological function of that body fat. And so when you look at certain populations like people from South Asia, they can gain four pounds and have diabetes because of the kind of body fat that they accumulate. Worse is if you look at someone who’s a Caucasian who can gain 20 pounds and not get diabetes because their body fat is of a different type of body fat. So you know the general attitude is that health is something that you can measure on your scale and there's also this belief that people should be able to be whatever weight they want if they only tried hard enough. And I think and I fear that that's part of what the issue is here, that people say well, you know your BMI of 46, Melody, you've done this to yourself and if you don't make the effort to try to bring this down to what we consider normal which is 27, well then really you are not deserving of medical care. I mean that's basically what underlying tenor of this is because there isn't strong evidence showing that it's okay to do breast reduction on someone with BMI of 27, but when your BMI is above 30, then suddenly the risk goes through the roof.

AMT: Right. Okay. Well, Dr. Sharma, thank you for your thoughts on this.

ARYA SHARMA: You're welcome.

AMT: Dr. Arya Sharma, professor of medicine, chair in obesity research and management at the University of Alberta, also the scientific director of the Canadian Obesity Network. He's in Edmonton. Well, body mass index may be imperfect. Some doctors still see it as a valuable tool. Dr. Scott Kahan is a physician on the faculty at Johns Hopkins Bloomberg School of Public Health, also the director of the Washington-based National Center for Weight and Wellness and he is in Washington. Hello, Dr. Kahan.

SCOTT KAHAN: Hi there.

AMT: What is BMI good for?

SCOTT KAHAN: Well, as Dr. Sharma said, it is a quick, easy convenient tool to get a surrogate measure for one's body fat. And in that, it's far from perfect. You mentioned it's a blunt tool. It's only a rough estimate of people's body fat and even then, body fat is only a rough estimate of their body fat distribution and ultimately their unhealthy body fat and even that body fat distribution is only a surrogate or a rough estimate of what someone's health is or what their body fat’s effect on health is. So there's lots of assumptions upon assumptions upon assumptions here and that can lead to some wrong conclusions, as Dr. Sharma said, such as thinking that heavier people as a whole are always less healthy than thinner people. That's not true because it's a blunt tool. But still, it's quick, it's easy, it's convenient and therefore it can be a useful screening tool.

AMT: Do you use BMI on your own patients?

SCOTT KAHAN: I certainly use BMI on my patients but I always then further that basic screening with more in-depth evaluation and assessment and testing when appropriate to best understand what that patient's weight and health status is. But still using the BMI first and foremost, it's very easy to do and offers some input. So I don't think we should retire it by any means but I do think as Dr. Sharma said and as we see in this unfortunate case with Melody, there are some unintended consequences of just simply using that one tool without having context to understand what the data gives us.

AMT: Why might a health care provider have a BMI cut off in determining treatments for patients?

SCOTT KAHAN: Well, it's really a policy issue. So there are BMI cut offs in quite a number of policy areas because that's what we do in policy. It’s very challenging making policy. We have to use some generalities and heuristics or rules of thumb which are useful and reasonable to a point, but rules of thumb aren't perfect. So then there should be a mechanism to evaluate on a case-by-case basis in order to minimize errors that these generalities can lead to occasionally, as in the case of Melody.

AMT: So you really need your doctor then to be advocating for you on that front.

SCOTT KAHAN: You know it's always helpful when you have your doctor or other advocates in your corner or when you can advocate for yourself and I applaud Melody for—I know it's a tough situation for her but I'm glad that she's not just sitting down and taking it but rather trying to be an advocate for her and ultimately for other people down the line that may run into the same issue.

AMT: Does a BMI cut off make sense for breast reduction surgery?

SCOTT KAHAN: So there's two reasons that I can think of and I know I'm not a plastic surgeon. I'm not a surgeon at all. But there's two reasons I can think of where they may come up with this BMI cut off. The first is that there is an assumption of increased risks from the surgery with increasing weight. Now studies have been done. Plenty of studies have been done on this. In general, there's not that much of an increased risk with increasing weight on most surgeries or breast surgery in particular and certainly not much if any increased risk at such a low cut off of BMI of 27, 28 and 30. Now there are some increased risks that are associated simply with an increase in size or BMI. So for example, being heavier—even if you're perfectly healthy, no diabetes or the like—there is a slightly increased risk of backflow of stomach contents into the lungs during the surgery. It's called aspiration. I don't think that's enough to not allow patients who are heavier to have surgeries where otherwise the benefits way outweigh the risk. But I think that's one of the reasons that there may be a cut off here. The other is—and again I'm just spit balling here—perhaps it's assumed that heavier patients should instead focus on weight loss treatments which would then in theory significantly increase breast tissue and may then obviate the need for a breast reduction surgery. So certainly we heard that Melody has tried diet exercise and so forth and frequently that's not enough. Especially when you have severe obesity, that's very frequently not enough to make much of a difference. But if she hasn't had good in-depth counseling from an obesity expert like perhaps Dr. Sharma, if she hasn't considered bariatric surgery for someone with her level of obesity, I think those are things that are worthwhile to consider. What I heard from Melody earlier is that someone had mentioned gastric sleeve surgery and that that was just very distasteful to her. It seemed like inappropriate and it may or may not be, but it sounds like it would be worthwhile for Melody to learn a little bit more about what bariatric surgery is and what it isn't and whether it may be an appropriate option for her. Ultimately, however, I think it's very important that she have the autonomy to have a central input in what her medical care is going to be, whether bariatric surgery, whether breast reduction surgery or otherwise as long as the benefits are appropriate to the risks.

AMT: Okay. We have to leave it there. Dr. Scott Kahan, thank you for your thoughts.

SCOTT KAHAN: Thank you.

AMT: Dr. Scott Kahan, director of the US National Center for Weight and Wellness joined us from Washington, DC. We want to hear your thoughts on this. Is your BMI an accurate indicator of how healthy you are? Let us know what you think. Tweet us @thecurrentCBC. Find us on Facebook. Send us a message on our website, www.cbc.ca/thecurrent. And stay with us. This is The Current on CBC Radio One.

Back To Top »

Can anything be done to prevent hospital misdiagnoses?

Guests: Megan Shalley, Pat Croskerry

AMT: Hello. I'm Anna Maria Tremonti and this is The Current. There's been a spate of misdiagnoses in Canadian emergency rooms these past few months, some with tragic results. In Abbotsford, BC, a three- year-old girl died after her pneumonia went on treated despite repeated visits to the hospital. An 11-year-old girl in Mississauga, Ontario had her left arm and right leg amputated. Doctors originally diagnosed her with influenza and sent her home twice. In fact, she had a serious infection. Diagnostic errors such as these raise questions about why they happen and what if anything can be done to stop them. Megan Shalley’s five-year-old son Sam died of pneumonia and a coroner's report also stated he tested positive for Strep A—conditions that were not diagnosed in the ER. Megan Shalley is on the line from her home in Ontario. Hello.

MEGAN SHALLEY: Hi there. How are you today?

AMT: Well, I'm sorry to hear that this happened to you and I'd like you to take me through some of it. Can you take me back to that first visit to the ER? What was happening with your son Sam?

MEGAN SHALLEY: He was lethargic and fevered and he was really struggling to breathe. We went down to the hospital. We got there about 1 a.m., me and my mother, and we were told by an intake nurse that it was definitely croup and asked me whether or not I knew how to treat it. We sat in the waiting room for a little while and a fellow next to me told me that he'd been there for four hours and I thought I might as well take him home because I know how to treat croup and I didn't want him laying on the floor in there for four hours.

AMT: So you took him home.

MEGAN SHALLEY: So I took him home and I treated him with a vaporizer and the hospital did call that evening to check up on us. And I told them that that's what I was treating him for because that's what we were told that it was.

AMT: And he wasn't getting any better and you went back to the ER. When did it happen that you would go back?

MEGAN SHALLEY: We went back again the same day at 5 p.m. that day. He was at that point not eating. He'd lost weight. You could just tell by lifting him. He wasn't lucid so he wasn't quite in his right mind most of the time. I'm assuming that was because of a lack of oxygen to his lungs maybe. When we arrived, he was gasping for air and I ran him in my arms. They took him into triage and then after that, they were just about to send us back out to the waiting room when another nurse came around and said no, just wait, took us into a waiting room at the back and we still waited 22 minutes to see a doctor that day. I read the charts shortly after he passed away. And that day, they had put in this chart that he's “not breathing” at top of the charts and at the bottom of the charts, it said the mother is anxious, plus, plus and making the child worse. I’d be hard pressed to find the mother that wouldn’t be slightly hysterical when their son wasn’t breathing.

AMT: Yeah. Yeah. So Megan, take me back a little bit. So how many times did you go back and forth to the ER?

MEGAN SHALLEY: We were there 1 a.m. January 13th, 5 p.m. January 13th, January 14th at 10 a.m. and then he finally passed away on January 14th at 10 p.m.

AMT: 10 p.m.

MEGAN SHALLEY: So four times.

AMT: So you brought him back in the night of the 14th, the night he died.

MEGAN SHALLEY: Yes.

AMT: What were his symptoms? Like what was happening to him?

MEGAN SHALLEY: He couldn't breathe. He couldn't breathe. I'd called 911 but they're asking so many questions and they never told me that anyone was coming or I don't remember them saying that. I shouldn't say that. I don't remember them saying that anyone was coming and I remember thinking that he kept asking me questions and Sam, his lips were turning blue. The other two kids were there with me and I just loaded them all in the car and I drove him there as fast as I could. I'm very sure that he died in the car. My two kids ran—my two kids ran in behind me when he was in my arms. When I finally got him into the hospital, they couldn't resuscitate him. I think they tried for about 45 minutes and still even then, they thought it was croup. He never had a chest x-ray and he never had blood tests.

AMT: And what did he have? He had pneumonia and Strep A?

MEGAN SHALLEY: He had Strep A but that was not his cause of death. His cause of death was pneumonia. So we were sent home on two separate occasions with a child that can't breathe, without a chest X-ray.

AMT: They thought you were making the situation worse because you were anxious.

MEGAN SHALLEY: It says it right in the charts that I was making the situation worse. I was making the child worse.

AMT: So this was this was four years ago this past January.

MEGAN SHALLEY: This was four years ago.

AMT: Yeah. Are you taking legal action?

MEGAN SHALLEY: We’re considering it.

AMT: We did ask the hospital to comment and they sent us a statement and I'll read it to you. They say: “Although we will not comment directly on the details of this particular case as it is a legal matter, we have met with the Shalley family and have expressed our sincere condolences and apologies for their loss. We appreciate the difficult emotional toll that this continues to have on their entire family.” Are you satisfied with that?

MEGAN SHALLEY: Yes and no. They certainly did not reach out to us after he passed. I was also aware that that is standard practice that you put in a phone call to a family. You can apologize without having to worry about a lawsuit. You can see whether or not kids need counseling. You can call and see if the family needs anything. They never put in a phone call to us. They never offered us counseling. They never offered us any condolences until we pushed to have a meeting with them. And then they offered condolences. I guess at that point, once he's gone, what else can they do?

AMT: How have you been doing since Sam died? What are your days like?

MEGAN SHALLEY: Well, I don’t have much of a choice. I have two other kids that I have to raise. I try to stay strong for them every day. I will work on it every day. I have to get out, go for a walk, be in nature, go for a run. I meditate to try and keep myself as strong as I can because I need to take care of Ben and Ruairidh.

AMT: How old are they?

MEGAN SHALLEY: Ruairidh is 14 now. She has an outlet with the theatre. She works with theatre programs in her school and elsewhere. I think maybe that helps her deal with things.

AMT: How old is Benjamin?

MEGAN SHALLEY: He's 11 now. He was seven and Sam was five and they were inseparable. I couldn't find a picture in the house where they are not together or not touching at some point. Losing a child is a parent's worst nightmare. Absolutely no doubt about it, except for maybe the aftermath when you have to watch your kids struggle for the rest of their days. That might be harder.

AMT: And what about you? What do you remember about Sam? What makes you smile when you think of him?

MEGAN SHALLEY: He was the slowest guy in the whole world, I swear. He took in every single bit of everything around him. He would stop and smell the roses and pick the roses. It would almost drive you crazy how slow he was—just wandered all the time. He'd stop to watch snowflakes, rainbows. He was never in a rush. I remember him telling me once that he was the only kid in his class that never got a star because he was so slow getting off his clothes in the morning. He was always last getting off his coat and boots and things. He was a pretty special little guy. He wanted to be a firefighter when he grew up or a professional candy taster. [laughs]

AMT: That's a good one. In what ways do you think the health care system failed you and your son?

MEGAN SHALLEY: That's a hard question, isn’t it? When you lose a child to something as easy to diagnose as pneumonia, every way. A triage nurse shouldn’t have diagnosed him. A doctor should have. A doctor should have looked into a triage nurse diagnosing him. They should have given him a chest x-ray. They have so many people that are pushed in and out of there. They need to take more time. They need to take more time. And listen to Sam. I think if someone took the time to listen to him, he'd be alive. I know for sure if he got antibiotics, he'd be alive. That’s a pretty hard pill to swallow.

AMT: Well, I'm very sorry for what you've gone through. I'm very sorry that you lost him.

MEGAN SHALLEY: Thank you.

AMT: Thank you for telling us his story.

MEGAN SHALLEY: Okay. Thank you.

AMT: Megan Shalley’s five-year-old son Sam died in 2013. Statistics on misdiagnoses in Canadian hospitals are hard to come by. Patient and health advocates say there is not enough access to records. Natalie Mehra is the executive director of the Ontario Health Coalition.

SOUNDCLIP

The understanding that our hospitals are public, that they are funded by the public, they belong to the public, that we rely on them for quality of care and we rely on them from the time we're born till the time we die in our communities. It's something that the public has one particular view of and the hospital CEOs have a different view of entirely. And it's a problem because far too much information that should be out in the public without any question whatsoever is hidden and a lot of that has to do with mistakes, errors, all of that stuff. So it's not even known really whether or not to what extent hospitals are collecting systematically information on misdiagnoses, let alone having that information available for public scrutiny.

AMT: Natalie Mehra, executive director of the Ontario Health Coalition. Of course doctors are human and as with all humans, they have biases and pressures. They make mistakes. My next guest is an ER doctor who studies factors that can lead to misdiagnoses. He heads a ground-breaking program to train medical students to think differently and stop diagnostic errors before they happen. Pat Croskerry is a professor in the department of emergency medicine at Dalhousie University in Halifax. He's also the director of the department's critical thinking program. He's with us from Calgary today. Hello.

PAT CROSKERRY: Hi there.

AMT: We just heard that it's hard for the public to get information about misdiagnoses. What can you tell us about the rate of misdiagnosis in Canada?

PAT CROSKERRY: I think the best guess we've got would parallel what the rate is probably in the US and in Europe and that would be in the order of 10 to 15 per cent. That diagnosis is failing about 10 to 15 per cent of the time which would mean that the doctor has the wrong diagnosis, they've missed the diagnosis or there's been an unreasonable delay in making the diagnosis, as happened in the case of Sam.

AMT: What do you think of that rate?

PAT CROSKERRY: Well, there's two sides of the coin. The other side of it is to say that we succeed 90 per cent of the time or 85 per cent of the time. Nobody's quite sure what the real number is but we do know there is a significant failure rate. Personally I find it unacceptable and the people that I work with feel that way and many people feel that way. And our efforts at Dalhousie are directed—it has been demonstrated I think to most people's satisfaction that much of what you can see in this particular case, so Sam, there's a number of things involved here. There are other team members. There is probably a hospital emergency department that's crowded and everybody's being pushed. But nevertheless, there is general agreement that most of the time, probably 70 to 80 per cent of misdiagnosis is due to the way that the physician thinks and these other systemic issues of overcrowding and cognitively loading people certainly don't help. We know that people don't make good decisions under those circumstances but nevertheless, the physician is still seen in Canada at least, as the final kind of arbiter of the diagnostic pathway.

AMT: So what do you teach medical students in your critical thinking program?

PAT CROSKERRY: Well, just exactly that. We teach them the principles of critical thinking which not everybody follows. You would think by the time somebody gets to medical school that they're pretty critical thinkers. But the evidence is that we're not. None of us are particularly good at thinking critically by ourselves. So we coach them in the principles of critical thinking. We coach them in the things to look out for that may bias their decision making. Your earlier guest, Dr. Kahan referred to heuristics and rules of thumb and physicians and nurses and health care workers use a lot of these heuristics and most of the time they serve us well. In fact, we couldn't really get by without them. But occasionally they do have these catastrophic outcomes. So the purpose of bias training is to try to get medical students—not just medical students but also practicing clinicians and postgraduate students—to get them to recognize the biases when they see them looming.

AMT: So can you give me an example of—you make the point—in a crowd ER, doctors are making very split second decisions. They have to. But give me an example of where critical thinking can change a diagnosis when someone comes in.

PAT CROSKERRY: Well, there's many cognitive biases to choose from. There’s probably a couple of hundred. But let's take one like search satisficing and this is a way of thinking that works well most of the time. If you lose something, you start to search for it. If you find it, you call off the search. The problem in medicine is that you may not have discovered everything there is to find at the point at which you cut off the search. So it's a kind of stopping rule. Let me give you an example. As a cyclist falls off his bike and comes into emergency and complains of shoulder pain. You think he's probably fractured his collarbone. You send him down for an X-ray, comes back. You look at the X-ray, you see a fractured collarbone and you say fractured collarbone as the diagnosis and you stop your search there. That is a natural human tendency and it probably has evolutionary origins. But what you should do actually is to say yes, I found the fractured collarbone, but I should also check that there isn't a fracture of some other adjacent structure or there is not a collapsed lung or something that goes along with this, and sort of just dig a little deeper. So we can coach students in not cutting off the search too quickly which is just a natural human tendency. I don't think doctors are immune to these phenomena.

AMT: And what about social biases around race or gender or income level.

PAT CROSKERRY: Yeah. Well, they're a lot easier to identify. You can talk about racial biases and visible minority biases, ethnic biases and just earlier you can talk about from what you were discussing, you can talk about the bias against obesity and the bias against psychiatric patients and elderly patients and so on. Those social biases we tend to sort of group them together and call them that, social biases, but the ones that we really need to work on. I mean if somebody has got a racial bias you can identify it and you can say you’ve got to do something about this and they know exactly what you're talking about. But if somebody has got a bias like search satisficing or one of these other main cognitive biases, people often aren't aware of it and they need lots of illustrations of how the bias works and importantly how you can fix it. So these other sort of general cognitive biases are much more subtle and not so easy to detect.

AMT: And so in the case of the broken collarbone, they would have ordered more tests? What would they have done?

PAT CROSKERRY: Well, it may not even require further testing. You could look at the X-ray and say the collarbone’s broken. Let me check and make sure that there isn't an adjacent injury to another bone which you can also see on the X-ray because it takes in part of the lung fields, part of the shoulder or maybe even the other injury may be in the neck for example and you focused on the collarbone. You've anchored—which is another bias—you've anchored to the collarbone and you and you haven't checked the guy's neck or the cyclist’s neck.

AMT: Right and because the training is that you're doing this and you're doing it quickly and you're thinking okay, broken collarbone then I need to do ABC.

PAT CROSKERRY: Right.

AMT: And you just keep focusing on that. It's almost like you need to stop and think which is what you're talking about—critical thinking.

PAT CROSKERRY: That's right. So there are certain strategies where you do stop, you try to be reflective. It's called being reflective. They found this works in surgery. For example if you stop and just think about where you are, that fewer mistakes tend to happen. But that's very difficult. If you put people under all these pressures of modern emergency departments, it's a very difficult thing to do sometimes and it requires some presence of mind. When you think that you know the obvious and it turns out that there's a few more things that you should know as well.

AMT: You know you're not solely teaching of course. You're still practising as an ER doctor. How have you recognized misdiagnosis mistakes in yourself?

PAT CROSKERRY: Oh yes. Yes. Over my career certainly.

AMT: And how much do you worry when you send a patient home? Do you second guess yourself?

PAT CROSKERRY: I think a lot of emergency physicians worry. Whenever you commit somebody down a particular pathway with a diagnosis and with a plan, then then many emergency physicians will give the patient all kinds of caveats and say look, if this worsens this evening—and tell them some critical signs to look for—please return immediately to emergency or call an ambulance. So many emergency physicians do have these guarded kind of strategies that they use to try to minimize the problems that may arise if they got it wrong. And doctors have to realize that there's a tremendous amount of uncertainty in medicine and you are at risk for getting it wrong and the consequences, a lot of the time, the patient may well get away with it. I mean 85 per cent of illnesses, it is said will resolve spontaneously and the physician may never know that they were wrong and the patient will attribute the treatment they got to a correct diagnosis and appropriate treatment. But that may not be the case. You don't know that. And it's part of what your last guest was talking about, was the absence of feedback in the system and the absence of information often in the medical record.

AMT: We're almost out of time. But before I let you go, how is the program working? This is the first batch of students you are doing this with, right?

PAT CROSKERRY: Just coming through now. Yes, we started about four or five years ago. It's early days to say for sure what's happening. We get a lot of positive feedback from the students and we've discovered recently that the program has been replicated in other medical schools in North America, mostly in the US..

AMT: And by changing the conversation, do you see a change in conversation amongst your students then already?

PAT CROSKERRY: Oh, absolutely. I mean 10 years ago, you wouldn't have students talking about confirmation bias, search satisficing and biases like that. It was a language that wasn't part of medicine. But it is now. I'm hearing Calgary today giving a talk on it. And last night, I met a number of the physicians here who talked freely about these biases and that didn't exist so long ago. You know this is relatively new in medicine.

AMT: It sounds very promising. Dr. Croskerry, thank you very much for talking to me about it today.

PAT CROSKERRY: Thank you.

AMT: Dr. Pat Croskerry, professor in the department of emergency medicine at Dalhousie University, also the director of the department's critical thinking program. As he says, he's in Calgary today to speak about just this. If you have a story about misdiagnosis in the ER and want to share it, visit our website, www.cbc.ca/thecurrent, and let us know.

LISA AYUSO: Hi. I'm Lisa Ayuso, the web producer here at The Current. This week, the show was produced by Idella Sturino, Howard Goldenthal, Ines Calabrese, John Chipman, Sam Colbert, Lara O’Brien, Shannon Higgins, Sujata Berry, Kristin Nelson, Karin Marley, Liz Hoath, Samira Mohyeddin, Pacinthe Mattar, Ashley Mak, Willow Smith and our intern is Seher Asaf. Special thanks to Keith Hart in radio archives and to our network producers Mary-Catherine McIntosh in Halifax, Suzanne Dufresne in Winnipeg and Anne Penman in Vancouver. The Current’s writer is Peter Mitton. Ruby Buiza is our interactive producer. Transcriptions are provided by Eunice Kim and Rignam Wangkhang. Our technical producer is Gary Francis. Our documentary editor is Josh Bloch. Our senior producers are Richard Goddard in Toronto and Cathy Simon in Vancouver and the executive producer of The Current is Kathleen Goldhar.

AMT: That's our program for today. Stay with Radio One for q. Angie Thomas's debut novel, The Hate U Give, is being called the young adult book of the year. It doesn't shy away from very mature themes including race, class and police shootings. Angie Thomas is the guest. The guest host of q today, Ali Hassan. She’ll be talking about her whirlwind year and why voices such as hers are important in both politics and publishing. Now we were just talking about mistakes in the ER. We're going to leave you with part of a TED Talk given by Dr. Brian Goldman, the host of CBC's White Coat, Black Art. He's recalling a distressing experience from early in his career as a resident in the ER. It's a moment that has never left him. So here's Dr. Brian Goldman. I'm Anna Maria Tremonti. Thanks for listening to The Current.

SOUNDCLIP

I saw Mrs. Drucker and she was breathless and when I listened to her, she was making a wheezy sound and when I listened to her chest with a stethoscope, I could hear crackly sounds on both sides that told me that she was in congestive heart failure. And that wasn’t a difficult diagnosis to make. I made it and I set to work treating her. And over the course of the next hour and a half or two, she started to feel better and I felt really good. And that's when I made my first mistake—I sent her home. Actually I made two more mistakes. I sent her home without speaking to my attending and run the story by him so that he would have a chance to see her for himself. Maybe I did it for a good reason. Maybe I didn't want to be a high maintenance resident. Maybe I wanted to be so successful and so able to take responsibility that I do so and I would be able to take care of my attending’s patients without even having to contact him. The second mistake that I made was worse. In sending her home, I disregarded a little voice deep down inside that was trying to tell me, “Goldman, not a good idea. Don’t do this.” And so I signed the discharge papers and an ambulance came, the paramedics came to take her home. All the rest of that day, that afternoon, I had this kind of knowing feeling inside my stomach. But I carried on with my work and at the end of the day, I packed up to leave the hospital. When I did something that I don't usually do, I walk through the emergency department on my way home. And it was there a nurse said three words to me—that are the three words that most emergency physicians I know dread—do you remember. “Do you remember that patient you sent home? Well, she’s back,” in just that tone of voice. She was back alright. She was back and near death.

[Music: Ending theme]

Back To Top »

CBC would like to acknowledge the support of the Broadcasting Accessibility Fund.