Please begin this series at Part 1.
At this stage in our training as residents, we are at high risk for making mistakes. These mistakes can vary in range and type. It is impossible to go through residency without making an error, no matter how big or small. We are not omniscient beings, and having been doctors for mere months, cannot rely upon personal experiences to guide our clinical decisions. These mistakes can range in severity, whether it involves forgetting to order morning labs for a patient, or incorrectly dosing antibiotics for a patient with decreased renal function, or performing a procedure which kills the patient. There are many established systems to try to prevent mistakes from adversely affecting patient care. Regardless, some mistakes in retrospect appear to be unavoidable. Coping with them is challenging. As author Dr. Pauline Chen adeptly states, residents are often “only one misstep away from that lonely and vicious cycle of errors that could unexpectedly and irrevocably spiral out of control.”
On a sunny Wednesday in November, I admitted an otherwise healthy 45-year-old woman, Mrs. A, with a three-day history of headache and high fevers. After a lumbar puncture, I started broad spectrum antibiotics to cover for bacterial meningitis. This included acyclovir. Unfortunately, what I didn’t do properly was remember to start my patient on IV fluids. I didn’t realize my mistake until the next morning when I looked at her morning labs. Her kidney function started to worsen over the next several days, her creatinine value doubling within the first two days of admission.
I talked with my patient, and we discussed what had happened and what we were going to do to remedy the situation. As her renal function continued to worsen over the next several days, we began to discuss whether she would need temporary dialysis. Her urine output began to decrease, and her creatinine, which was initially 1.0, continued to climb to 8.4. I was terrified. Things became real. I slept very poorly that week.
After six terrifying days, , Mrs. A’s renal labs began to plateau and eventually downtrend. Her kidneys began to recover, and I was able to discharge her home on Thanksgiving with her family.
A few weeks ago, my fellow colleague saw Mrs. A in clinic and told me that she was doing great. Her kidney function has returned back to a normal level, and she has no lasting sequelae from the mistake I made as an intern. It does not assuage the guilt I still feel whenever I think about her, but it lets me sleep at night and go back to work the next morning. I will never forget about acyclovir-induced nephrotoxicity ever again.
Working in the hospital is being part of a giant team. As an intern, you know that you are being watched by those more senior to you, and that your attending physician is overseeing everything that you do. But when events do inevitably happen, no matter how big or small, you can’t help but feel wholly responsible.
How can we constructively work to prevent these errors? We should not let fears of inadequacy hinder our ability to communicate with others. We have to recognize when we may be out of our depth, and ask for help. This does not mean we are incompetent. This shows that we recognize and acknowledge our limitations. There is greater strength in seeking assistance than trying to shoulder more responsibility than an intern can handle. Do not risk patient safety and care in order to prove a point. There is a time and place to demonstrate our autonomy. We just have to be patient.
When errors do happen, acknowledging and addressing them is a difficult task. The current medical culture seems to suggest that physicians are infallible. Not only is this fallacious reasoning, the cultural and legal implications around medical errors makes it difficult for one to admit them when they happen. Aaron Lazare discusses the role of guilt and shame in apologizing for errors. Whereas guilt is directly tied to a specific event and can be mitigated by the act of apologizing, shame involves admitting that one has utterly failed in the eyes of the other person. Guilt can be resolved by apologizing; shame “reflects a failure of one’s entire being.” Fearing the act of apology makes it difficult for physicians to be honest and transparent with patients.
We as physicians are ashamed of making errors in our clinical judgment. A whole culture of shunning mistakes is deleterious to residents, especially when residency is meant to be a place of learning and improvement. This limited perspective makes it hard for others to be open and honest when these matters arise. An important role of preventing errors is having the strength to admit when mistakes do happen, and providing open forums for residents to discuss these matters openly in a frank manner.
Despite the isolating effect of long work hours and challenging situations, remember that you are not alone. Thousands of other interns in hospitals across the country are encountering the same situations and emotions you are experiencing. Our senior residents and attending physicians have encountered the same challenges we currently face. If they could make it through, then so can we. We will survive. So take a deep breath and keep going.