21 March 2011

The Graveyard

Bongi is an amazing writer, and if you haven't, I strongly urge you to read his latest post, titled "The Graveyard."

I imagine that a huge number of doctors know exactly what he means. I remember being told by a surgeon, while I was in medical school, that "you're not a real doctor until you've killed someone." I thought at the time (and still think) that there was a puerile bravado behind that admonition, but there is also a grain of truth. I have my own graveyard. Curiously, not all of its inhabitants are dead. They are the cases where I screwed up, or, charitably, cases that went bad where I feel that maybe I could've/should've done things differently.

The missed SAH

The missed DVT/PE

The missed AAA

The missed Aortic dissection

The missed MI

I remember them all, clearly and in detail. I remember which room each one of them was in while they were in the ER. (seven, eleven, ten, nine, five) I remember what they looked like. I remember what the ECGs looked like. Like Bongi, I tend to blame myself even when the lawyers and quality committees have exonerated me. I should count myself lucky that after ten+ years in practice the body count is so low (at least as far as I know). Rationally, I can see that these cases were not my fault, and in fact I am comfortable defending them, if I had to, which I am glad to say that I have not. But I carry the scars. The Aortic aneurysm died in front of me after a three-hour battle for stability. The dissection I found about the next day when I came back to work (she survived, miraculously). The horror of realizing that you were wrong in your assessment of this patient, and he or she died because of it is really something. It changes you. You carry it with you, on some level, every single day.

This is, I think, what the surgeon meant when he said "you're not a real doctor until you've killed someone." I thought he was full of bravado and being cavalier about the fact that your patients will die sometimes; I thought he was glorifying the toughness that some surgeons so revel in. Maybe he was; I don't know. But I have learned this -- it changes you, and until you have to go home and lay in your bed and consider how that person died and whether it was your fault, it's hard to understand. But it is true, that you are not really a doctor until you have confronted and surmounted that moral burden. Some never do. Some practice in terror of that moment, and some leave the profession because they cannot bear that moral responsibility. Some become jaded and cynical and try to blind themselves to the consequences by dehumanizing their patients (a failing particularly easy for ER docs to succumb to). Most of us don't talk about it -- especially surgeons, which is one reason to highly commend Bongi for putting it out there so starkly. I play at being cavalier in the ER; it's a facade, my clinical persona. But the memory of these cases where I was so catastrophically wrong also keeps me humble (yes, really) and keeps me alert to the possibility that I might just be wrong again, reminds me to keep an open mind. I like to think this is wisdom, hard earned.

I don't want to seem in any way like I am looking down on my colleagues in specialties with low mortality rates. They're doctors as much as I am. I always hated the "It's a black thing, you wouldn't understand," or the idea that you couldn't really understand what it is to have kids until you have your own. I don't like that sort of exclusionary thinking. But wisdom comes in part from experience, and experience forms us. So I won't say that someone cannot understand the weight of this responsibility until they have gone through it. But I will say that I am a different person now for having done so, and I understand things differently for it.

Well done, Bongi, for illustrating it so eloquently.

5 comments:

Bongi said...

thanks for your kind words. it is clear you understand what i was talking about.

Threehills said...

Both posts were exellent and something to think about in years ahead.

rlbates said...

Well, done to both you and Bongi.

Carolyn Thomas said...

Thanks for your thoughtful piece, and for the link to Bongi's post as well.

Meanwhile, on the other end of the stethoscope, we patients who survive misdiagnoses (not all do, of course) can have a far more traumatic experience. Some patients spend years in a desperately futile search for somebody, anybody, who is able to accurately diagnose their condition. Consider "It Wasn't Heart Disease - But What Was It?" at: ttp://myheartsisters.org/2011/03/14/mystery-diagnosis/

As horrific as missing a diagnosis may be for the physician, it simply pales in comparison to what it's like for the patient who survives.

Carolyn Thomas said...

Sorry, mistyped that link: should be: http://myheartsisters.org/2011/03/14/mystery-diagnosis/