Sunday, August 29, 2010

Reflection of an Error-Prone Human Doctor on a Sunday: The Good,The Bad, and The Indifferent

"I'm only human
of flesh and blood, a man.

Human. . . .
. . . born to make mistakes."

- from Human League's "Human"


Sometimes things go wrong in the hospital. Something happens that you didn't want or expect, and as an involved caregiver, you sit there scratching your head or clutching your chest or wiping your tears because of it.

Sometimes it's because of something you did or you didn't do. Yep, I said it. Sometimes doctors make mistakes. Foul ups, bleeps, and blunders that many times fly under the radar, but other times become headlines on the CNN newsroll. This is not unique to Grady Hospital, at all. This is a universal truth that is no stranger to any hospital anywhere and one that, no matter how much we want to pretend isn't true. . . . .just is.

Now let me also be clear that what I deem as a mistake can be as small as telling a hospitalized patient that their test is at 9 a.m. when it was really at 8 a.m. (which depending upon what that test is might not be "small" at all) or as big as amputating the wrong leg. Fortunately, medicine has evolved a great deal, and many more measures are taken to avoid the whoppers (such as amputating the wrong limb.) But again. . . .the Institute of Medicine put it best in the title of their landmark paper: "To Err is Human." Doctors are humans. And humans . . .well. . .humans sometimes make mistakes.

My mentor, friend and fellow Grady doctor, Neil W., has an expertise in medical errors. We were talking recently during one of our mentor/mentee meetings about what happens after an adverse event or error in a teaching hospital. Our verdict was that, most of the time, it's handled pretty crappily. (Yes, I meant to use that word.) Either it is ignored, the person is berated, or the really common one, there is a discussion that seems to focus more on how "the system" plays into errors and adverse events to the point that the assailant gets off the hook.

But sometimes, a person just made the wrong choice. Sometimes they were supposed to do one thing, like say. . . .come back to check on a patient again. . . .and they didn't. In such situations, it isn't "the system" at all. Is it?

So here's the burning question:

At what point is it just your fault?

Bob Wachter, the hospital medicine guru/coiner of the word "hospitalist," and all around hospital medicine bad ass, wrote a lovely article about this very thing. He talked about physicians and accountability (or lack there of). . . and how at some point, (depending upon the error) folks are going to have to just own the blame for what they did or did not do. Period. A much less warm and fuzzy approach than the "it was the system" theory, but definitely one that made me take pause.

So Neil and I started chatting this day about working on better ways to process errors and adverse events with our learners (and ourselves.) From this chat we ended up putting together a lecture for our residents and medical students about that very topic. It was really well received.

This made me realize a lot of my own shortcomings both as an error-prone human (or you-man, if you pronounce it like Neil W.) and as a supervisor of other error-prone humans. I recognized my prior default over the years when I had a part in an adverse event: self deprecation. I'd always have this internal recoil where I'd replay something over and over again . . .repeatedly cringing and demanding of myself with disgust, "How could you not have fill-in-the-blank" or "I can't believe you fill-in-the-blank." Then there's the learners. My go to response for dealing with learners who have fallen short has admittedly been: "You're still a wonderful doctor. . ." followed by a launch into all of the system things that could have caused something to happen. Yeah. The system.

The more I listened to Neil that day--and to Dr. Wachter in that article--the more I knew that my approach to processing medical mishaps needed to be revised.

I know. . . the goal should really be to avoid mistakes altogether, right? Since we know they can and will happen, another acceptable goal is to make every effort to not repeat the same mistakes. This starts with learning from them, and learning from them starts with owning them. You have to own your part in an adverse event instead of chalking it all up to the system. . .otherwise, the take home point that you were supposed to get will be lost in the shuffle.

The other tricky part is that you want to learn from the whole thing, right? Like, sometimes you did some really good things but had a misstep at one point. Sometimes you did several suboptimal things and got lucky. That's why processing our individual part (and not just that of the team) in events that take place with our patients is so important. We have to find that place where we own our piece--the good, the bad, and . . . .well, the indifferent.

A few years ago, I had this patient who was very, very ill. The patient was in the stepdown ICU with complications of advanced AIDS, and we were treating him for a condition that could be life-threatening. He was turning the corner, and I spent several hours taking care of him and building a rapport with his family. At the close of one of the days I cared for him, I walked out of the hospital feeling extremely proud of the care my team had offered him, and even more happy with his improvement.

The next morning, I was walking into the hospital and overheard a code being called on his floor. When I reached the floor, there was the characteristic pack of doctors and students pouring out of the unit, swarming near the doors. I asked a couple of residents what was going on, and they told me that the person who had coded was indeed my patient. "But the critical care team has it under control," they told me. "He's been intubated and should do okay from what we saw." Whew.

Right before I started to enter the threshold of the stepdown unit, I heard my patient's family calling my name. They were crying and screaming and very upset. They ran up to me and clung to me. They even squeezed my hands and included me in their circle as they prayed for him boldly and loudly--not in the hushed voice that I often use when praying.

"Is he going to die?" his mother pleaded with me. "Is this it? Is the Lord trying to take him home? Oh please, Jesus! Please! Tell me. . .am I losing my baby?" She was shaking like a leaf; terrified at the thought.

All I had to go by was what those passerby residents told me. The mom in me imagined burying one of my sons. No, he will get past this, I told myself. I made a choice and started talking. I looked my patient's mother dead in her eyes and said:

"No, he isn't dying. He is sick, yes. But they have him on a breathing machine and the doctors who work in the ICU got to him very fast. He is still young and is a fighter. He is sick, yes, but you are not losing your baby."

I looked her dead in her eyes and said this. And it was a tremendous comfort to her, and this whole family who, before I began speaking, thought he was dead in their eyes.

Two seconds later, the doors whooshed open and the ICU came out looking very somber. I thought I would vomit the second I saw them. The first words from the ICU fellow:

"We are so, so sorry."

Damn. I told this family something that was completely untrue. I took a family on the brink of the horrible tornado into it's calm center through my unsubstantiated yet comforting words. . .only to see them dragged straight back into the twister again with the truth.

My patient had died. I told his family--no, his mother--that he was okay, when he wasn't. I didn't go see him for myself before saying that. I should have entered the unit and seen, for sure, what was happening with my patient and I didn't. I screwed up.

When his family collapsed to the ground crying, trembling, praying. . . .I wanted to disappear. It was awful. I wished so bad that I hadn't made things harder for them.

But now, I reflect on that differently. I should not have based such sensitive information upon a drive by account from two house officers who weren't even involved in his care. I should have told the family that I would be right back--and spoken to them after confirming his clinical status. That was a bad move on my part--and although it isn't as egregious as pushing the wrong medication into an IV line, on some levels it was just as hurtful.

This time instead of reflecting only on the bad, I also recounted what good things took place, too. He was diagnosed promptly, received standard of care treatment and therapy, and had nursing staff that responded quickly when he took a turn for the worse. I established such a great comfort level with this family that they felt safe enough to call my name from across the room, weep into the shoulder of my starched white coat, and pull me into their unapologetic petition to God before I could even process whether or not it was appropriate for me to do so. They treated me like a trusted family member--a distinction I achieved after only two days of caring for him in the hospital. I think that the approach I used in getting to know them provided a comfort to a patient and his family during a tough time. I learned that in the future, I can use those same skills when caring for my hospitalized patients, but must always remember the importance of having all my facts straight before opening my mouth.

Now I see the whole picture, instead of just the reciprocating horror flick of the family breathing a sigh of relief followed by the mob of ICU doctors emerging through those doors with their morose "somebody just died" expressions. The truth is that I took good care of a patient, but at one point in his care screwed up. That wasn't about "the system" either. That mistake was about me.

Ah hah.

Lord knows that this doctor is certainly a work in progress. But I can honestly say, I owned my part in that mistake. I learned from my part, and will make every effort not to repeat it. Now, through this exercise of processing all dimensions of what happened, what I know for sure is this:

With regard to this patient,
There was something I did that was good.
There was something I did that was bad.
But at least I can proudly say it wasn't because I was indifferent.


  1. Dr. Manning, I think your last 3 lines were a perfect summary, especially the last one. You CARED about this patient and this family and you hoped for them that the patient was ok. You secretly hoped he was going to be ok. And realistically speaking so did they. I took the responsibility on your shoulders to say some words of comfort. That takes a lot out of you. But you cared. You were not indifferent to their suffering. I think the worst in heathcare is when someone is indifferent. That's the worst because then there's no hope for you, whether you do bad things or good things. If you didn't care at all about the patient or the family, I would say that's a lot worse than saying something preemptively without ill intentions. And we all know physicians, nurses, staff members who just don't care...

  2. I remember this one... Gut-wrenching. The main part of your blog, about accountability, reminded me of the time, as a young test engineer, writing a test report. One of the technicians had failed to tighten a coupling which caused the ruin of some very, very expensive equipment that was to go into a satellite. The cause: technician didn't tighten the coupling. After much head scratching and re-writing, I wrote: technician inadvertently failed to sufficiently tighten a coupling, thereby allowing coolanol-13 to enter the chamber..
    My supervisor read the draft, gave it back to me and said "we can't say that.!". We must explain how we are going to revise the system to ensure that .... Humans don't make that mistake again...

    Things change very slowly... Keep on pushing


"Tell me something good. . . tell me that you like it, yeah." ~ Chaka Khan

Related Posts with Thumbnails