September 15, 2012 | 2
He was a family practitioner. He had a good relationship with the couple, helping to deliver their first baby two years earlier. He was happy to learn the reason for their appointment was that were expecting another.
The second pregnancy could not have gone worse. Though she showed all the telltale signs and felt as though she was carrying a child, the four tests were consistent: No pregnancy. No pregnancy. No pregnancy. No pregnancy.
He knew the couple would be devastated. Mom’s tears showed he was right.
It was only midway through the D and C to clean out her uterus that Dr. David Hilfiker came to the horrifying realization that the fetus inside had been alive.
A story like this could destroy a doctor’s career. Editors at the New England of Medicine, the place where it was submitted, understood this well. That’s why one of them called Hilfiker in the fall of 1983 to make sure he still wanted to go through with it. He did, and it was published in 1984.
Why did he do it? Why tell this story publicly, risking his practice and his reputation?
The case was deeply disturbing. But perhaps one of the most disturbing parts was that it was not unique. Hilfiker goes on in the piece to tell tales of other errors, from the severe to the more mundane. A boy whom he diagnosed with a dislocated foot but who actually had a severe case of compartment syndrome that required immediate surgery. A woman with chest pains whom he advised not to go to the emergency room, and who twenty minutes later went into cardiac arrest and died. Unnecessary hospital admissions that waste money and resources.
Given the number of decisions doctors make on a daily basis, he said, errors are inevitable. The problem is that there is no forum to talk about them.
“The medical profession simply seems to have no place for its mistakes. There is no permission given to talk about errors, no way of venting emotional responses. Indeed, one would almost think that mistakes are in the same category as sins: it is permissible to talk about them only when they happen to other people.”
1984. What was the climate of medicine like?
When the piece went public, one hundred and fifty people were moved to write letters in response. But according to Hilfiker, among those only two were negative, questioning his ability as a doctor. The rest – many of them from other caregivers – expressed feelings of identification, of sympathy, and of praise. Letters from around the nation thanked Hilfiker for speaking out about something that was universally experienced but that never dared to be uttered.
Then there were others. In the moving piece “The day Joy died,” Dr. Gary P. Brandeland speaks of the painful aftermath of a 1986 incident when a 21-year-old patient of his died because of an anesthesia mistake.
“For months afterward, I felt like I was being beaten with a baseball bat, physically and emotionally. Out of the 52 doctors in our clinic, only one, an ophthalmologist, asked me how I was doing. For everyone else, it was business as usual. This lack of support from colleagues was a surprise and a huge disappointment. I was treated like some kind of disease they might catch.”
Another, a reflection piece by a doctor who trained in the 1980s and who preferred to remain anonymous:
“Early in our training we learned that doctors had a higher instance of alcoholism, drug abuse, suicide, marriage, break up and a lower life expectancy than the general population. In sharp contrast to other at risk groups, we were not offered any strategies to deal with these risks – it seemed that it was up to me.”
Common themes are not difficult to find: a culture of expected perfection; no room to be open about mistakes; and the healing of physicians ignored.
Since the 1980s, there have been big movements in both reducing the number of errors doctors make and disclosing them to patients when they happen anyway. Things like checklists and electronic health records may accomplish the former, while research showing that the risk of litigation actually decreases with increasing disclosure encourages the latter. In 1999, the Institute of Medicine released “To Err is Human: Building A Safer Health System,” which formulated specific recommendations for cutting down on preventable adverse events.
But there still remains the next step: a doctor recovering for him or herself.
We certainly ought to focus on reducing errors. But no matter how great the strides, mistakes will never vanish completely. Errors do not have to stem from gaps in competence to have consequences. Being tired or careless can lead to devastating outcomes. But so too can taking risks to help a patient.
“Don’t expect to be perfect,” an older doctor once advised me soberly. For doctors-in-training, the idea that we could someday be responsible for a major injury or death is an unbearable thought. We study hard and hope that will be enough. But we know in the back of our minds that it doesn’t work that way.
We can’t expect to never make mistakes. We can only prepare for how we will grapple with them.
When I first read Hilfiker’s piece, I had two main reactions. One was appreciating the genuine and courageous character that shone through his writing. Two was thinking how foreign his world felt.
A few months ago, I wrote about a challenging patient encounter I experienced as a first-year medical student. I walked into a room on a general medicine ward and ended up in an emotional minefield I felt unequipped to navigate. My patient desperately needed help, but it was help I couldn’t provide. I left shaken, worried that my visit had done more harm than good.
When I reported the case to my three preceptors, they were just as interested in how I was holding up emotionally as in how well I had gathered my patient’s history of present illness. Each had words of wisdom on how to bounce back after an incident like that. I was able to discuss things I felt I did right and others I felt I did wrong. I received feedback on how to improve, without feeling judged.
The relationship went both ways. One time one of our preceptors told us about a difficult patient situation of her own that was causing her guilt, and she welcomed our thoughts on grappling with it. We were in a safe space that focused on improvement over perfection and that encouraged us to embrace our emotional impulses.
You could argue that as a student, I am expected to make mistakes, and that the “yoke of perfection” Hilfiker talks of does not yet apply to me. You could also argue that my experiences with these doctors are not universal, and that for every caregiver who welcomes the expression of emotions there remain others who eschew it as a sign of weakness. All this would be true.
But from my limited experiences in settings of care so far, there seems to a shift in climate away from what Hilfiker bemoaned. It is certainly not absolute. But we recognize today that doctors are human beings with feelings: feelings that will be damaged when things go wrong, and feelings that need outlets for healthy processing and healing. We recognize that we should be cultivating that type of openness, not stifling it. My education reflects that awareness. As patient safety activist Linda K. Kenney captured the change:
“Back in 2002, a literature search on physician/clinician support would turn up very little. Today, that same search would yield a tremendous amount on the subject. Physicians are more willing to speak more publicly about the emotional impact of these events.”
I am grateful that “how are you feeling?” is a question not just for patients anymore. And I hope it continues.
Because one day, I may make an error that falls in the category of more than mundane. I am terrified for that day. But if it comes, I pray I will be in an environment that cares for me so that I may be strong enough to care for the one I hurt, for my other patients – and for myself.