We have practice guidelines, checklists, timeouts, templates, and error-proofing electronic health records (EHRs). Whether these practice aids are considered friends or foes, they can never eliminate the inevitable gray areas. I found a definition of gray area that I really like: an ill-defined situation or field not readily conforming to a category or to an existing set of rules.

In the end, any of us — whether physician’s assistant, nurse practitioner, or physician — must be prepared to make complex, high-stakes medical decisions full of gray areas, advanced risk, and even the unknown.

I not only assess my practice but I am also charged with assessing the practice of others in my eighth and final year on the Washington Medical Commission. While being intensely rewarding, it’s been a heavy burden to be sure, evaluating complaints that come to the commission and making decisions about these complaints in ways that first and foremost protect the public, which is our most sacred duty.

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One thing I’ve relearned (I’m not sure how many chances I am given to relearn this!) is that the more I know, the less I know. The more I learn, the more I am reminded about the breadth of activity and humanity out there, ranging from patients who feel mistreated to the providers who treat them.

It reminds me of the complexity of practicing medicine. No matter the field (mine is addiction medicine), there is an ever-expanding set of practice guidelines designed to promote safe, equitable, and consistent practice in our various settings. Sometimes it seems that they just keep coming; if we create enough practice guidelines, then we won’t have to think anymore, we can just go to the internet, look up the guidelines, and push a button.

But, of course, this will never happen, mostly because we are human. Look at some of the most seemingly common-sense efforts to reduce error and promote safety. Take, for example, the surgical time-out that is part of the Universal Protocol mandated by the Joint Commission as a patient safety step in 2004. In an article published in 2009, the authors concluded that:

The Universal Protocol was mandated by the Joint Commission 5 years ago with the aim of increasing patient safety by avoiding procedures at the wrong site or in the wrong patient. Despite widespread implementation, this standardized protocol has failed to prevent such severe “never-events” from occurring.1 

In a more recent article, Geraghty et al cited data from the US.2 “It is estimated that wrong-site surgery occurs in approximately 1 in 100,000 cases but could be as common as 4.5 in 10,000 cases dependent on the procedure being performed.”3,4 All of this despite the widespread use of surgical timeouts to prevent such “never-events.”

This gets to the dangers and the promise of “gray areas” for medical providers. No amount of Universal Protocols or other practice guidelines will guarantee safe and even rational practice. In the end, it comes down to us, the medical providers, to use the safety tools we have and develop our own internal safety mechanisms. These include trusting our anxiety, knowing our limits, living the power of collaborative and team-based practice, and listening to our patients.

When all of these things fail us as providers, patient harm can occur. For those on medical boards and other bodies who evaluate related complaints, we hope that such bodies have the grace and wisdom to sort them out in fair and just ways that protect the public and help providers become the best they can be.

And in such decisions, just as with our medical practices, we all remember that “gray areas” will be lurking around every corner, waiting to see how we will respond, and testing our ability to find a way to do what is safe and what is right.     


1. Stahel PF, Mehler PS, Clarke TJ, Varnell J. The 5th anniversary of the “Universal Protocol”: pitfalls and pearls revisited. Patient Saf Surg. 2009;3(1):14. doi:10.1186/1754-9493-3-14

2. Geraghty A, Ferguson L, McIlhenny C, Bowie P. Incidence of wrong-site surgery list errors for a 2-year period in a single National Health Service Board. J Patient Saf. 2020;16(1):79-83. doi:10.1097/PTS.0000000000000426

3. Hempel S, Maggard-Gibbons M, Nguyen DK, et al. Wrong-site surgery, retained surgical items, and surgical fires: a systematic review of surgical never events. JAMA Surg. 2015;150:796-805.

4. Devine J, Chutkan N, Norvell DC, et al. Avoiding wrong site surgery: a systematic review. Spine (Phila Pa 1976). 2010;35(9 Suppl):S28-S36.

This article originally appeared on Clinical Advisor