There are these moments

There are these moments between when a doctor knows something and when a patient does not.

Potential spaces.


And, while for patients, such space may be filled with hope or dread or some combination of the two, the same space means something different for the doctor. After all, it's not my pregnancy or my heart; it's not my father's chest x-ray or my son's leg bone. But it is my patient. And my patients' experiences inevitably become a part of my story. My story fills in every day with all of these unique moments-- the discovery of an unintended pregnancy, the surprising death of a father, the unanticipated complication, the missed lab finding, the remarkable recovery. The good and the bad.

What I say, the look on my face, or the gesture I make may be remembered forever. Especially if I do it wrong. Or even if I don't get it quite right.

Sometimes these potential spaces are wonderful--  the few seconds between when I put an ultrasound probe on an anxious pregnant woman and see the blessed heartbeat and when the words come out "all is well". The pathology report coming across my inbox announcing the mole was not cancerous. The marked improvement in a heart's ejection fraction.

Then there are times I wish I didn't know. Or at least I didn't have to be the one to tell. The times I must walk into a room, sit upon a stool, take a deep breath and deliver the bad news. The life-changers.

Three times this week, five times this month: the cancer in the colon of the woman who'd been losing weight, the non-viable pregnancy in a woman who tried for six years, the brain tumor in the young dad who'd been having headaches, the syndromic features in the baby born just yesterday.

Who am I to do the telling?

I am just a regular human being whose fridge has moldy leftovers and whose car is in desperate need of an oil change. I have children who I get impatient with, toenails that need trimming, and a tendency to be a bit of a know-it-all. But I also went to school for a very long time and have spent many years of my life trying to understand how to distinguish between health and sickness, learning how to communicate the difference effectively, and practicing how to be present with patients through all of it. Some days, I feel unequivocally qualified. Other days, I literally look around and think, "Me? You're trusting me?"

Am I sure?

So often, I am not. And yet patients want me to be. They want me to be sure when I reassure them: "No, don't worry. Yes, you will recover. No, it's not serious." They also want me to be sure when I give bad news. And so do I. I want to be 100%-absolutely-without-a-doubt sure. I want to know as much as I possibly can about this diagnosis or your lab result or this condition I am going to name for you.

Years ago, I told a young man I was confident he did not have cancer; several months later, we discovered, in fact, he did. He died shortly thereafter. I will never forgive myself for my naive certainty. I will never again be as sure as I want to be. But I do my best, my very best, to gather as much information as possible, to be informed, and to be thoughtful. I trust that there is tremendous science behind much of  medicine,and I try to be clear with my patients where the science gets soft and where my knowledge runs out.

All that said, to be perfectly honest, no, I'm never sure.

How much do I say? 

We were taught in medical school that when you deliver bad news, people hear the first few sentences and then shut down. I've seen it, it's true. Their eyes blur, their ears get fuzzy, they literally float away.

And there I sit. On the stool. With more to say.

In each of those moments, as I watch my patient hover overhead, I find myself confused, insecure, and surprisingly unprepared. Do I stop after the first few sentences? Do I leave them to their fuzzy blur? Do I smile? Do I frown? Do I give them the reference? Do I hand them a piece of paper? Do I hand them a tissue? Do I warn them to stay off the Internet? Do I . . ?

There is no one correct answer to any of these questions. For each of us is unique and needs something  different in each of these unique moments. And this is why relationship is so very important-- how, by knowing you, I can provide you with the right amount of answers in the right amount of time.  Too bad relationship is so undervalued. Too bad, too often you have no idea who I am. I just met you seven minutes ago. Too bad you don't know that I, too, struggled with infertility, that I lost a dear cousin to alcoholism, that I want nothing more than to be with you, right now, in this moment (despite my body language stating the opposite). It was for these very moments I became a physician, after all. Yes it was.

A few weeks ago, I supervised a physician in training giving bad news. I had literally never met the patient, and I stood there in the corner, watching the learner do what she will do hundreds of time, perhaps for the very first time. I wondered. Who is this woman? What does she need from us right now? How can we best serve her? Will I ever see her again? One thing I do know, from my experience as a patient and as a physician, she will flash back on this moment forever-- the buzz in the hospital room, the lighting, the words tumbling toward her. She may not remember the faces or the names, but she will surely remember the feeling, the emotion, the tone.

And it's not just her that remembers. It's me too. My big errors are not necessarily the procedural ones (though I have written in the past about some of those). My biggest errors are the human ones. The times I didn't say enough. Or the times I said too much. The time I put my hand on the doorknob before you were done, the times I was human.

What if I want to cry?

Sometimes I do cry. But usually I don't. And I'm not sure if it's professionalism or paternalism or some other -ism that prevents me from doing so. Probably mostly it's just that I am a private crier. 

But also, this moment, this little space in time, really isn't about me-- it's about you. I am merely a blessed witness, a privileged counsel, a space holder. Some higher force put me in this room, in this moment, in this space to be with you and to offer you-- I hope-- exactly what you need. If I cannot, if I did not, I am sorry.

What I can promise is this: when I leave the room, I stuff this moment into my bulging bag of moments, into my disorganized file cabinet of doctoring, and carry it around with me forever. It changes me and challenges me and teaches me and hopefully makes me better the next time I have to do it again.

So, thank you.

For these moments.

What happens when a doctor does harm?

When I was in my third year of medical school, I remember telling my mom (a dedicated nurse for over 45 years) about a negative experience I had during a rotation on the hospital wards.

I don't remember even the vaguest of details surrounding the actual event, but I will never ever forget my mom's response that day: "Some day, honey," she said, "It won't be about you anymore. It will be about your patients."

I remember feeling rather hurt at the time, as though my mother was being dismissive of my feelings-- chastising me for thinking I had a right to be a medical professional and a real person at the same time. (And believe me, medical school already does a doozy on one's sense of person hood). I wanted to be part of the story. On some level, I wanted the story to be about me.

A few years later, as a brand new resident physician, I shared her advice with several of my similarly-green colleagues. We all chuckled at the time because so many of our first experiences as newbees (e.g. first deaths, first postpartum hemorrhages, first cancer diagnoses, first arguments with a floor nurse, first morphine prescriptions, first you-name-its) seemed to have everything to do with us. We were learning, after all. And though we were learning through the real life experiences of living breathing patients, we were still our own main characters in our own personal novels--  fumbling our way through a series of awkward and sometimes painful lessons on the way to becoming experienced clinicians and, hopefully, healers.

Now, surprisingly enough,  in the the almost-eight years since our conversation, my mom's once painful words have comforted me through many challenging situations.  I have carried her counsel through frightening birth experiences, challenging family meetings, heated discussions about end-of-life choices, angry patient encounters, awkward teaching moments, even through my own painful infertility journey while caring for a plethora of fertile patients.

When things have gotten complicated, I have repeated her counsel to myself, and I have found relief rather than resentment in the reminder. 

"This isn't about me," I tell myself. "This is about my patients."

It's about his sick body. Her mental illness. His struggle with weight and substances. Her wishes. I am so often privileged to bear witness, to hold hand, to give counsel, to be present, to help guide. But, in the end, it is not about me. It's about my patients.

This isn't to say that I have completely removed myself and any emotional investment from my patient care. No, no, no! Quite the contrary.  In fact, by reminding myself that a patient's particular situation is not about me, I am able to really hold the space for that patient and be as present as possible for them during his or her journey.

Except when I cannot.

Unfortunately, this month, I have been confronted with myself yet again (gosh darn it, I just cannot get away from myself as the main character in my own story)-- in a very raw and real way. This time, however, I am also featured as a main character in someone else's (i.e. my patient's) painful story, and I wish it weren't so.

This week, I must confront the most serious medical error I have made in my career. I messed up. I did not keep my patient safe. In fact, I caused harm. To another human being.


What happens when a doctor does harm?

And what happens when I am that doctor?

Is any part of it about me?

***

Obviously, my first responsibility in reconciling my error is to my patient, to the very patient to whom I have vowed to do no harm. That person to whom I have pledged to care for and guide and counsel, and who has entrusted his/her body to my skill, my experience and my fallibility. And to that patient, I must apologize. This much is very clear.

I am sorry. I am so sorry.

But then what?

Do I apologize again?
And again?
Beg for forgiveness?
Do I throw myself on the floor and cry?
Do I stay up all night trying to understand exactly what happened?
Do I stay up a second night trying to justify a known medical complication?
Do I consult a higher level expert? A more experienced clinician?
Do I dwell?
Do I stop doing what I am doing for fear it will happen again?
Should I second guess my training?
Even worse, second guess my judgement?

All of the above, I guess, and then some.

Yes, I have gone back to review the literature.  I have also reread my own documentation of the event, reconsidered the circumstances, imagined how I could have done something differently, sought the advice of my esteemed colleagues, talked to my boss, taken a long swim, summoned my inner perfectionist along with my well-trained professional side. And cried a little.

After all, I hurt someone. And I cannot really take that back. Ever.

In so processing, I have also to remind myself that errors happen-- that, in fact, that this error I made is actually well-documented and, to a certain extent, expected. It happen somewhere about 1 in a 1000, and I'm getting closer and closer to that thousand. The longer I am in practice, the more procedures I will perform. The more procedures I perform, the more errors I will make.

Ok fine. But is there room in my own head and heart for error? Can I forgive myself?

Like most physicians, I am a pretty much a Type-A-obsessively-compulsive-perfectionist who-- despite the appearance of both my refrigerator and my underwear drawer (both are always disasters)-- doesn't really let myself off the hook very much. I expect perfect from myself. Always.

***

And so, I ask myself--after I first make darned well SURE to take care of my patient-- isn't  my second responsibility to myself? Isn't there also a part of this that is about me?

Me the woman, me the physician, me the fallible one, me the healer?

"Oh big and dangerous ego," I say to all those mes, "Take a step down my dear, you are so fortunately imperfect. You screwed up." And, though this one particular case may have had a different outcome, screwing up is inevitable. "You will screw up again, no doubt."

While this is not my story, I am still part of the story. And though I have not been physically damaged by this turn of events, I will never be quite the same.

I am certainly not alone in making medical mistakes-- even big mistakes-- ones that my patients will have to live with forever. Knowing that I did nothing with mal-intent or beyond the scope of my training. Granting that next time I will be more nervous, more tentative, and hoping this is an acceptable outcome for myself. And that if I move forward from this circumstance changed, may the change be a positive one for all who I serve in the future.

My I continue to be as good as I can be.
May I be self reflective.
May I be humble.
And may I accept-- not just occasionally but always and inevitably-- my own imperfection.