My Human Doctor

Dr. Peskin brings to light that in many medical schools across the country future physicians are not properly taught how to professionally handle medical mistakes or when they harm a patient. Physicians are upheld to ethical standard to practice both beneficence and nonmaleficence. Beneficence is when the physician must promote the welfare of patients and protect the rights of their patients. Nonmaleficence includes the “do no harm” mentality where the physician must refrain from providing any damaging or unfavorable treatments. Although many medical mistakes are not made with the conscious decision to purposely hurt the patient, they unfortunately still occur. Since physicians are human and are going to make mistakes there needs to be a system set in place to productively handle these situations. Physicians need to be able to confide in the superiors in order to fix the mistake if possible and discuss how any further mistakes can be prevented all together. Additionally, physicians need to be able to have an open, honest discussion with their patients, which should include an apology and explanation if possible. Physicians need to be held accountable for their mistakes, seek to improve patient safety by analyzing the mistake, and keep an honest patient- physician relationship. By doing this, physicians will be able to promote both beneficence by seeking the best interest of patients, and nonmaleficence by growing from the opportunity and improving future patient safety.

Dr. Peskin discusses such an important topic in this article. Doctors hold a lot of responsibility for patient wellbeing as well as for being role models in the community, but they’re not taught how to address their own faults. Much like any other profession, making mistakes in one’s job will affect other people. However, doctors are expected not to make mistakes because when other people are affected, it can have very serious consequences. Because of these serious consequences, people convince themselves that doctors are beings that can’t err; how can you put the status of your health and wellbeing into the hands of someone who could? In training, doctors are heavily taught about the concepts of beneficence (do the most good possible) and non-maleficence (do no harm; or the least amount possible). Doctors are taught to uphold these values and that, if they don’t, they’ve broken the ethical code of being a physician. These values don’t make room for mistakes; in fact, in their simple definitions, they don’t even acknowledge the existence of mistakes. This is because making a mistake would be (unintentionally) doing harm and definitely not doing the most good. Being taught that doctors don’t make mistakes, even if it’s in a roundabout way, leaves doctors terrified of them and of acknowledging them; if a doctor errs, can that person truly identify as an adequate physician? One could argue that doctors shouldn’t make mistakes, so they don’t need to be taught how to address it.

Doctors: If your new patient is at no apparent risk for Type 2 diabetes, but has a family history of diabetes, do annual blood work. Hyperglycemia can happen, be controlled, of course, but cause permanent neuropathy that could have been avoided. A friend of mine was unduly caused to live with avoidable Type 2 diabetic neuropathy simply because her physician failed to do an annual blood screen before she became hyperglycemic. When she became a client of her family practitioner, she indicated a history of diabetes in her family, but had no risk of symptoms: She’s wasn’t overweight, had a healthy diet, good exercise—no reason to consider her at risk of Type 2. But stress on her job (evidently) let to slowly increasing hyperglycemia, which didn't come to her attention until she began experiencing numbness. The hyperglycemia was quickly brought under control, and she has had normal A1c for a decade (without need for major medication). But the neuropathy is permanent (though it has receded slightly). She not only lives with the neuropathic pain, but with chronic anger about doctor’s negligence.

I once apologized for having to put a severely manic patient into four-way restraints. He asked for the apology after I asked him to apologize to a nurse he offended. Within a few moments, he went over to the nurse and calmly apologized to her for offending her. She was astonished, and asked me what I said to him. Not much I said. Modeling the behavior you want to see someone demonstrate can be quite effective. I tell that story to all my nursing students.

“An apology is a statement of remorse, regret, and responsibility and essentially proves a case for medical negligence,” authors of one study write, ... as if that justifies avoiding the truth, concealing the truth, lying. Nothing destroys patient trust in the medical profession worse than that. I don't expect doctors to be infallible practitioners of an exact science, but I expect them to be ethical and honest. Or, rather, I used to. Never again.

"In her office note, my doctor wrote “she is unhappy with her care.” In response to her mistake, my doctor had removed herself from our doctor-patient relationship." Adding additional false pretexts and "banning the patient", usually from a larger group or hospital practice, is the more common "defensive medicine" practiced by most doctors in the US.

Medicine in the United States is primarily about turning a profit and getting rich. Apologizing for mistakes, of which there are many, imperils that motive. That’s why doctors don’t apologize.

I am a physician and I tell my patients when I make a mistake. I also tell them about mistakes that I have made in the past with other patients, and how that affects the decisions I make today (ex with them, the people in front of me). As far as I can tell the honestly is only appreciated.

Hypertension, hypercholesteremia or diabetes. She's got a chronic disease, just not MS.

Beautifully said and soooo true.

"Don't believe everything you read on the internet," said Dr. A. I asked the office manager to change me to a woman primary care physician. She did. The woman, Dr. B., left town on her honeymoon. I got an UTI. I called for a prescription, but since Dr. B. was out of town and had assigned no one to cover for her, I couldn't get a prescription. Her assistant had a suggestion: Try cranberry juice.

I'm a nurse practitioner, not a physician. I use verbal and non-verbal communication when I apologize to my patients; I might move closer or sit beside them, place my hand gently onto theirs, and maintain eye contact as I speak the words. After years in practice, it never ceases to AMAZE me how quickly a sincere apology diffuses tension and even anger, particularly when I catch and pre-emptively apologize for a mistake before the patient is aware of it, but that might impact their care. I believe that my patients feel comfortable being totally honest with me because I always try to relate to people as a fellow human with feelings and vulnerabilities, and as a result I'm often able to get a better clinical picture during my workup. I understand the concerns about formal complaints and lawsuits. In my experience, though, saying "I'm so sorry that this happened" can make hard feelings disappear very quickly.

I hope doctors can learn to reconsider what they've learned about standard treatments, too. I reacted to Levaquin, a flouroquinolone-class antibiotic (ie, Cipro, Avelox, etc.), as if it were a toxin. The adverse effects still affect me. This is called Fluoroquinolone-Associated Disability (FQAD) by the FDA. FQ adverse effects were little known in 1998 when I was dosed. But as problems were discovered through the years, and product warnings were changed to include new information, the gap between what doctors are aware of and trust as reliable, and new realities, became pretty big. With the right diagnosis, even someone with longstanding FQAD (like me) can improve. Some newly-affected people may be able to avoid the most disabling symptoms completely. But that can't happen when doctors put past practices ahead of fresh information. Because of physician resistance to, or unawareness of, changes to warnings about FQ-class antibiotics, not only can they not recognize and treat related problems, they also may inadvertantly contribute to new FQAD instances, simply because they're unaware of what they can do to minimize FQAD risk. I see a strong parallel between the need to reassess diagnoses, treatments and prevention methods when new infornation comes to light, and the story you shared here. Doctors shouldn't be afraid or too proud to say: things have changed; so, let's see if something needs to change with how we're treating our patients.

I’m a sports doc. Just like everyone, I make mistakes all the time. And apologize. I think folks appreciate it. They’re occasionally angry about the mistake. But never the apology.

Physicians who make errors like this should continue to hone their diagnostic acumen rather than focusing on improving their apologies. This piece is pretty hollow on multiple levels. Obviously, the physician who initially diagnosed this patient with MS made an egregious mistake and should be held accountable. On what basis was this diagnosis made? Were the MRI findings really that characteristic of MS? Or was this a form of gross incompetence? Did someone notify her previous neurologist of his/her mistake? Are there other patients who may have been similarly misdiagnosed? And does this patient have an alternative diagnosis, perhaps a metabolic condition? By far, the easiest mistake to admit is the error of another physician, so I am not particularly inspired. Instead, this piece seems to play to the lay public's focus on customer service when a CORRECT diagnosis would have been far more important to this patient than their therapeutic relationship. And can you really call it a therapeutic relationship if you're prescribing the wrong medication?

Doctors will never feel comfortable or safe truly and genuinely apologizing for their human fallibility as long as the medical malpractice system stays as it is. Pure and Simple. If the apology isn’t genuine (and you can’t teach a genuine apology in a course) what’s the point?

I saw a “Best Doctors in New York” physician and during my follow-up, inquired about probiotics. “Absolute nonsense. Don’t bother; you’re just wasting your money.” A few years later I went back to him and saw a counter filled with probiotic samples to give to patients. “Oh, probiotics!” I said. “I find that so many patients are helped by them,” he replied. “You should take them; they’ll probably help you,” he said. I told him that I already took them! And, I didn’t remind him that he’d gone from skeptic to devotee.

Doctors, law enforcement and our current president, Trump have one thing in common: you don't apologize for your mistakes. A club to avoid, and i would have hoped it were no true but in my lifetime, i've never heard a doctor who made a mistake while treating me, aoplogize. It's long overdue for medical schools, police academies and those who mentor up and coming politicians, to revamp their protocols.

Thanks for your candor. It's not easy to admit mistakes.

I haven’t told a patient that I made a mistake very many times. The response rarely was anger, usually neutral and occasionally “you tried your best.” Patients value candor.

Excuse me Dr Peskin but if you were taught in medical school how to research then you must be familiar with the concept of the null hypothesis. The idea that you should always assume that your premise is incorrect unless statistically significant evidence supports it. Come to think of it, that was probably taught to you in middle school with your first science courses. I can't tell you how you yourself were trained but I can certainly vouch for the training I underwent and how it was repeatedly drummed into me that over confidence and hubris are counter productive to being an effective healer. Admitting your mistakes is actually the correct answer on a question in the internal medicine board certification examination so I just don't feel the issue you have chosen to write about is an issue at all. Of course experience has taught me that this paper never let's the facts get in the way of a sensational article even if its premise is incorrect

I never had a problem with appropriate apologizing, when it was necessary, during my 30 year practice of psychiatry. I do support, though, the phrase, “I’m sorry this happened,” as opposed to, “I’m sorry that I did this,” especially b/c we live in a litigious society. I have never been named in a lawsuit, and people have appreciated my clarifications and apologies when necessary. I wish I could say the same about my colleagues. Some psychiatrists seem to have a problem with acknowledging that the human condition applies to them, too. Since psychiatrists are the virtual and actual determiners of sanity, it is real easy to make a patient feel crazy for protesting or even questioning a line of inquiry, a drug or a procedure. When a psychiatrist experiences personally something like depression, acknowledging the truth of their humanity, improves their practice. I don’t necessarily advocate telling patients about one’s own problems, but allowing the idea that life is tough all over allows more compassion into the room, and a greater degree of success. Not treating patients like they are their diagnosis or their lab results helps a lot, too. And as to the doctor that our resident neurologist saw who couldn’t even say, “Next time I’ll do differently,” she has more problems than I can shake a stick at and the author is well rid of her.

Some MD's apologies lead to malpractice suits.

Since medical school, I have been taught to acknowledge and explain mistakes, apologize for the mistake, and explain what will be done to prevent future mistakes from happening to others. I have agreed with and utilized this full transparency approach in my practice. Over time, I have also come to recognize that the full causes, responsibility and preventive actions for a mistake might not be known with reasonable certainty for some time or even ever after an adverse event. It is also important to recognize that some events are beyond human control or rare known side effects for medications or procedures. It is also important to be aware that not all mistakes cause harm, or that a bad outcome might not be due to a mistake that happened. Thus, when discussing and taking ownership of a mistake, a health care provider should also acknowledge their human limitations by trying to be aware of and acknowledge what they might not know about circumstances and consequences of the mistake.

Medical school teaches us to examine, to research, to treat. We don’t learn to err and recover. Nobody stands behind a podium and declares: “Each of you will make mistakes, and some of them will hurt people.” This is simply not true and paints another unfavorable view of physicians and physician teachers. At the University of Pittsburgh where I graduated medical school in 2012, professors and mentors did exactly what you claim doesn’t happen, on multiple occasions and they were incredibly moving and humbling experiences. They told very personal and painful stories about mistakes they had made and how they navigated their admissions to the patients and families involved. Further as students we had practice apologizing to standardized patients for fictitious mistakes we had made. It is unfortunate that this was not a part of your medical school curriculum. My cohort in medical school and residency is acutely aware that we will all make mistakes and at some point will harm a patient during our career. I am saddened to see this categorical statement published by a physician no less in the New York Times.

Yes, it is amazing how US physicians just gloss over their ignorance and mistakes, and get away with it. Just agree to spend $272,000-$336,000 and 4 years of your life in med school, and you too can get an MD diploma entitling you to parrot pharmaceutical company propaganda, and order a lot of needless, expensive tests. And when that propaganda proves to be totally fabricated, and the tests worthless, you can dismiss all the damage you have done with a wave of the hand. It's no wonder that the super-expensive US healthcare system is ranked only 37th among the world's health systems (Cuba is 39th) by the World Health Organization.

Don't take patronization, negligence, or insults to your dignity from anyone who wears a white coat and calls themselves a healer. Take your health and well being elsewhere. Pay the people who treat you like you matter.

No offense to the writer, but there’s a big difference between being a resident, where you’re not truly responsible for your actions (legally), and being in practice, where any mistake potentially invites a lawsuit that will take years to resolve, hours of time away from life, and potentially cost you any money you’d hoped to save after giving up 10 or more years of life in training and debt to become a doctor. After her first lawsuit, let’s see if she’s still so quick to say sorry and admit guilt.

In her office note, my doctor wrote “she is unhappy with her care.” It's easier to blame the patient. I saw my records once and the doctor had written that I was angry but never noted why. After seeing that it explained why he always treated me like the enemy. Luckily for me I didn't have to deal with him very often. A similar sort of thing occurred when I called my mother's gynecologist after she told me she'd taken DES. All I wanted was some information. The doctor refused to tell me anything despite my needing it for another doctor. He hung up on me. Then there was the therapist I was seeing. She didn't believe what I was telling her. I learned that after I saw her case notes. She didn't have the courage to ask me if I was lying. But it was in the notes and what she believed. And she got a few fundamental things wrong about my relationship with my brother again, despite being told differently. What's bothersome here is how often doctors and others refuse to consider or reconsider their initial impressions of a patient. Another disquieting fact is how often they get the information wrong after being told the same thing multiple times. Our current health care system doesn't encourage honest or thoughtful interactions with anyone. That's unfortunate since trust is based on just those things.

I am a physician and think a lot about the best way to handle things when I, a trainee, or a colleague makes a mistake. I generally enjoyed this essay but was annoyed by this sentence: "Nobody stands behind a podium and declares: Each of you will make mistakes, and some of them will hurt people.'” I have absolutely heard at least one physician stand behind a podium and say that, and the physician I'm thinking of also talked about how he had made mistakes, some of which hurt people. The essay would have been stronger without an unsupportable universal statement to set up its argument.

There is a big difference between honest mistakes and mistakes made through neglect - not taking enough time with patients, ignoring best practices strategies, not staying up to date on research, etc. For honest mistakes, it'a always better and respectful to apologize without following the apology with the word "but" or "because" (example, "I made a mistake because you weren't clear enough about your symptoms"). Patients also need to become informed, which is easier now than ever before, and seek corroborating diagnoses for complex/dangerous situations.

We are so quick to blame lawyers for the problems doctors face, but good lawyers don't file frivolous lawsuits. Maybe doctors need to dive deep within and examine why they posture themselves to patients as so superior and know-it-all. So few doctors have compassion for suffering and are quick either to fix it or give up because there is no quick fix. So many doctors, especially specialists and those who label themselves "experts," think they are superior in all ways and that whatever they conclude is the only answer. Maybe doctors can also consider why they so routinely order procedures that are so invasive and expensive when there are less invasive and equally effective procedures available, except they can't be billed out at the same high dollar amount. For example, how often is a tracheostomy performed when non-invasive procedures can be as effective and sometimes more so, and at a much lower cost for the patient~

For many years, lawyers and insurance companies made it a condition of coverage to refrain from admissions of guilt. I was around for that, in one of the first Risk Management offices. Years later, after life as a hospital counsel, I helped start a peer support program for clinicians to help them face mistakes and provide support from other trained clinicians who had experienced the same thing. I suppose this was in part to make up for the part of the culture I had helped perpetuate. When Amy Waterman and I began to develop the Peer Support program, this was long after we required telling the truth to patients and supporting them. The peer support was always step 2. The old ways still remain among older clinicians and younger clinicians who have been taught to mistrust the literature which clearly states that maintaining the MD/Patient relationship through trust and telling the truth results in few lawsuits, as if that was the only reason for telling the truth. There are still subtle and not so subtle battles within even the best institutions where the truth is not regarded as the North Star. Patients must be the top priority and truth is essential to trust. But the devil is in the details.

It's not just doctors that have trouble apologizing. Most people prefer to get defensive. If only we could teach children in school it's ok to apologize if their parents haven't taught them yet. Apologies go all long way if they are heartfelt.

I would add to this article the following: that the doctor has to acknowledge that he/she could have made a mistake and they need to stop stereotyping patients. I developed a DVT post-surgery, which resulted in bi-lateral PEs, as my surgeon and his office dismissed my concerns as another person complaining about the boot. I subsequently went to my PCP who sent me straight to the ER, as she knew me and knew that I wasn't a 'complainer'. The surgeon left me a voicemail asking, what I did to cause this. There was no apology, there was no acknowledgement that they did anything wrong. I had no intention of suing and didn't, but the surgeon's office went straight into protective mode. They had stereotyped me rather than listening to me. I had the same thing happen in an ER, where I had totally ruptured my hamstring, but I was dismissed and told you'll be fine in a couple of days. I asked a friend who is a Doctor about it and she told me that they probably thought I was someone looking for pain meds, which I hadn't even asked for and actually avoid because I can't tolerate them. Again, the treatment I received was dictated by the Doctor's own biases. So yes, please acknowledge that a mistake can be made, but mistakes can also be avoided by listening to the patient rather than one's own biases.

I did not have the money to see the specialist in his private clinical setting, so I saw him while he was seeing patients, surrounded by medical students and talking to them as he went. He had an excellent reputation, and I trusted his diagnosis: nasopharyngitis. I followed the prescribed radiation treatments and again appeared before him and his coterie of medical students. He examined me thoroughly and then intoned: "You don't have any infection. You never had one. I made a mistake." And then, turning to the students, he said: "Never be afraid to admit your mistakes." This was more than sixty years ago, but I still remember the doctor's words and his honesty.

The author hasn’t even finished her residency. She’s not even fully trained. Can’t blame her for not changing the diagnosis. She was one of likely dozens of doctors in training who did the same thing. It wasn’t until a fresh set of eyes looked at her case did the correct diagnosis get made. Beware where you get your care. If you are seeing a new doctor every time, like in a training hospital or other such clinic, you might also have someone relying on someone’s misdiagnosis to refill your wrong meds. This wasn’t one mistake but a series of mistakes.

I hate to think of that poor woman thinking she had MS for ten years! I wonder if she'd ever gotten a second opinion?

I was a practicing Internist for 35 years retiring in 2015. I professionally "grew up" in the era of rapidly expanding technology,especially imaging. This story, one that is dominated by a "test" (MRI) superceding clinical presentation and clinical course was and remains an all too common occurance. I am not advocating a return for the "good old days", but an appreciation and an appropriate financial reward to a physician who takes the time to reevaluate the diagnosis and treatment of a "chronic" condition.

One reason that apologies are more forthcoming, and awards for malpractice (and malpractice premiums) are lower in many other countries is that they have relatively comprehensive social safety nets. Without a large insurance payout, many patients who suffer catastrophic injury and their families have to rely on Social Security Disability, SSI and Medicare or Medicaid - often for the rest of their lives. Those programs provide for subsistence, not more. If a person of median income in the US is injured, they're unlikely to be able to pay for their children to go to college. They may not be able to afford transportation to take care of ordinary tasks - like grocery shopping. They may lose their home and many other trappings of middle-class life. When a relative in England was partially paralyzed and suffered cognitive deficits due to an error by a surgeon, the doctor and the hospital helped his family file a claim against them. The amount they were awarded (and that they needed) was paltry by U.S. standards, but the state took over payment for their housing, heat, electricity. They are provided with free car service. Their children's university education is paid for by the state. The cash benefits they receive allow them to buy food, clothes and even have one or two weeks of vacation abroad each year. In the U.S. they would have needed an insurance settlement of around $5m to maintain their lifestyle. In the UK they asked for $1m and got it in a few months.

I think Dr. Peskin makes an excellent point in her article that there is a lack in teaching current medical students how to deal with situations where they have made a mistake. In medical school one is taught about beneficence and to always act in the patient's best interest. One is also taught what qualifies as negligence, both intentional and unintentional. However, it doesn't seem to be common practice to teach students how to handle these types of situations from talking to the patient and if one apologizes/admits they have made a mistake. I think there could be more done to better prepare young doctors for these difficult situations and how to handle them.

What about errors in judgement rather than diagnosis! Your suggestions?

It's not just the medical/industrial complex that is increasingly controlled by the interests of insurance companies and malpractice attorneys. When was the last time anyone apologized to you for an error in the course of a business transaction? Wider cultural influences of mistrust of other people and their motives prevents ability to see and apologize for a simple human error. I'm glad Dr Peskin is able to describe her experiences as both patient and provider. Having some idea of what it is like for the other party in a transaction can improve understanding of the relationship. Health care is unlike any other sort of transaction, and our decision to apply capitalist principles to the health care system have created much more harm than benefit.

Medicine is not an exact science, physicians are humans and mistakes are made. What can be changed is a very strong look at the profit motives of the medical-industrial complex with change to more humanity and a good influx of common sense. We don't need hospital administrators and insurance CEOs making millions of dollars, while the nursing staff in a hospital are overworked and understaffed. If you want to see examples of this, look at major surgical suites in hospitals productivity is graded higher than patient care. I could write a book--in fact, I am.

In How Doctors Think, a book I use in teaching healthcare advocacy at UC Berkeley Extension, the author, Dr. Jerome Groopman, gives myriad examples of how excellent doctors may make mistakes for all kinds of reasons. But the ones who are able to step back and be willing to look at the data again, before accepting a diagnosis, can sometimes avoid that pitfall. Having the courage to apologize when you’ve made a mistake is priceless. You could be my doctor any day.

Harlan Krumholz at Yale found that colonoscopies had a complication rate of 1.6 %. That's 2 out of 125 people who suffer enough 7 days after the procedure that they go to an ER, Dr. Peskin needs to understand that the profits gouged out of the 98.4 % more than offset the losses paid out to the 1.6 %. Don't rock the boat or you will incur the wrath of the medical industrial complex. Look at what happened to Gilbert Welch.

Thank you for this beautifully written piece.

As someone who works in a cardiac surgical subspecialty I can tell you that most of us teach our residents and fellows that they will certainly hurt people. It is an unfortunate reality that statistically certain complications or 'errors' will occur. The main problem in the US is our litigation system. The author is correct that in our system we pit doctors against patients and all of us wish these situations were handled differently. Let's not forget that the VAST MAJORITY of lawsuits against doctors have absolutely no merit and are frivolous. Unfortunately dealing with a lawsuit that the doctor may eventually win is a very long, time-consuming and stressful process. Thank the lawyers yet again for making life miserable for all of us.

This is gets at the heart of a problem that seems to be intractable in American health care: seeing bad outcomes always as the result of bad intent, incompetence or negligence, with punishment as the solution. The medical and legal professions both perpetuate the standoff. In many cases, in larger practices and hospitals that now dominate care, administrators, advised by risk assessment lawyers, are more at fault than practicing doctors for perpetuating the war model of handling medical mistakes. And the legal industry has a huge source of income at stake: $3.6 billion in 2012, most in settlements, on 12,142 incidents (Becker's Hospital review). That's only the awards - not the cost of armies of lawyers representing medical insurers and practices. This is a cold war with occasional hot battles. Neither side wants to concede anything. A chorus behind medical providers repeats that they must maintain high walls and fear the patient. Patients end up feeling that everyone has lied or concealed information, and that the only way to be made whole - even to get information - is via lawsuits. With your doctor: her entry might lead (I suspect) another Dr reading it to conclude that you were a patient to avoid. She went to defense mode instead of listening, and then labeled you. Apologies and explanations resolve tensions: Drs don't have to live with secret fears. Patients feel they matter. Big reform may make sense; but these smaller steps can improve the relationship now.

The greatest skill a physician can attain is that of an expert diagnostician. Unlike the surgeon or other practitioner of complex technical skills, the best diagnosticians have an intuitive gift, honed by medical education and experience but it is something some humans are born with. I'm not a doctor but I've worked with internists and specialists for decades, watching them assess symptoms and test results. Occasionally, they get an intuitive sense that leads them to suspect something unusual. Very often they are surprisingly and correct. I hope more of the women and men who truly love the practice of medicine become doctors, rather than for the money or the prestige.

I graduated from medical school in the late 70s and sure heard more than one of my teachers telling us that we would make mistakes and that some of them will hurt people. Also, I know that having spent a career in academic medicine that I have and colleagues have said the same thing to students over the year. And at many morbidity and mortality conferences I have attended, we have talked about the effect on those who have hurt patients unintentionally. Dr. Peskin's teachers may never have said this to her but that doesn't mean it doesn't occur in any medical schools.