I had an off week a little while ago.
Nothing terrible, mind you. No catastrophes. But things felt a little more tedious. I had to schlepp around a little more than usual And a few clinical judgment calls I made turned out wrong. Patients who I had thought would get better got worse instead, and my management played a part in that.
I can go back and look at both judgment calls and see the reasoning behind the decisions I’d made. In fact, after things didn’t go the way I would have hoped with one of those patients, I had the chance to explain my rationale to her parents, who were able to understand why I made the call I did. I could point to X and Y, which led me to make decision Z. And again, nothing catastrophic happened.
But still the wrong outcome. And two wrong calls in one week made for an off week indeed.
What troubles me more than simply having been wrong was that I remember being annoyed when I walked into one of the patients’ exam room. It would be the very definition of imprudence to go into detail about why I was annoyed. Suffice it to say that some pre-existing detail of the patient’s management had irritated me, and I carried that irritation into the appointment. Did it negatively impact my decision-making? As I said, I can look at the details of the visit and justify my decision on the merits. I could quite easily have come to the same conclusion in the most perfect of moods.
But in this case, I’m not sure if my mood didn’t play a part in my clinical decision-making, reasonable as it may have been. I’m not sure. I’m not sure.
All of this sprang to mind when I read this essay about doctor burn-out.
Analyzing questionnaires sent to more than 7,000 doctors, researchers found that almost half complained of being emotionally exhausted, feeling detached from their patients and work or suffering from a low sense of accomplishment. The researchers then compared the doctors’ responses with those of nearly 3,500 people working in other fields and found that even after adjusting for variables like gender, age, number of hours worked and amount of education, the doctors were still more likely to suffer from burnout.
[snip]
The doctors’ burnout appeared to have little to do with hours worked or even the ability to balance personal life with work. Instead, the only factor predictive of a higher risk was practicing a specialty that offered front-line access to care. More than half of the doctors in family medicine, emergency medicine and general internal medicine experienced some form of burnout.
It behooves me at this point to make clear that I don’t actually think I’m burned out. I think I was having an off few days, and have had plenty of good days since. I love my job as much as I can imagine loving any within the medical profession (I’m still willing to consider a career in Oscar-season color commentary… call me, E!), and enjoy my colleagues and patients a lot. I get up most days glad to go to work, which wasn’t true with any of my previous jobs from residency forward. I’m happy to be doing what I do.
But I sure can see how it would be easy to get burned out, and how burnout would lead to compromised patient care. If I can remember being merely annoyed during a clinical encounter and wonder if that made a difference in the choices I made, surely feeling disconnected on a consistent basis could negatively impact clinical decision-making over time. And patient care is far too important an endeavor to be treated with indifference or resentment.
I think there are a number of factors that can lead to burnout. One of them is something I’ve already alluded to in this post. Everyone has off days in their job, I’d imagine. Not to get too highfalutin’ about medicine, but in the case of doctors a bad day or wrong judgment call can mean someone gets sick or worse. In both cases I mention above, I made decisions that seemed sound at the time, and even now easy to explain if I were made to do so. But simply making the wrong call led to a couple of patients getting worse instead of better. I’m relatively young in my career, but I can certainly understand how a couple of decades of reasonable but wrong judgment calls could wear on a doctor.
Furthermore, there is still an ethos within the medical profession that tells doctors that their vocations should subsume all other aspects of their lives. That I think this attitude is for the birds does not mean it isn’t still quite pervasive. Not only do I think it is for the birds because it isn’t good for doctors, but it’s also not good for patients. The time I spend with people I love, with my friends and family, leaves me happier and more ready to attend to my work when I am there. The things I do for recreation (running, reading, being a part of this online community) give me some distance and respite from the depredations of a stressful career, and when I do have an off week allow me to bounce back and have a better one next time.
As that “doctor as god” mentality is rightly consigned to the rubbish heap of time, I hope a few things can occur that will be better for physician and patient alike. Indeed, I think they are already beginning to happen. I hope that doctors and patients can find better ways of communicating with each other, so when reasonable but wrong clinical decisions are made it doesn’t immediately become adversarial and litigious. (This doesn’t apply to situations where incompetence or negligence are factors in the mistakes, which are a different ball of wax altogether.) And I sincerely hope that newer generations of physicians are happily abandoning the notion that all other aspects of their lives must be subordinated to their careers.
As I said, I had an off week not so long ago. But my patients are fine, and so am I. Hell, I might actually be a little tiny bit wiser for having made a couple of wrong clinical decisions. I’m still delighted to do what I do. But I hope I know how to take care of myself well enough to keep a bad week from becoming a typical one. My patients deserve more, and so do I.
I probably don’t even need to tell you this, but I liked this post a great deal. Even though Clancy has not been a full-fledged doctor long, she’s been feeling a lot of this. Not just the hours, but the emotional exhaustion of being on the front-line.
Russell, this is interesting. We had a less-than-ideal experience yesterday (Pediatric ER all day! Completely terrified.) in which the Dr. there told us something (not posited as necessarily the primary cause of our visit, but possibly contributing, or perhaps entirely coincidental) that our pediatrician in our followup this AM gently but firmly contradicts.
Now, this contested info/piece of the puzzle is not life-or-death (we don’t think), but I don’t understand how the ER Dr. could make this mistake – it seems something that to me as a layman seems like the sort of thing that should be simple & obvious to a Pediatric ER Dr.
But stress and irritation and burnout could be a possibility, or maybe he just made a dumb mistake; or, maybe our pediatrician is the one who’s wrong and the ER Dr. was right – as laypeople, how do we know?
First of all, sorry both that you were stuck in a pediatric ED for so long, and that it ended up being terrifying. I hope everything is working out OK?
I can’t really speak to what you were told without knowing specifics. If the pediatric ED doc was at a good institution, you’d think he would know what he was talking ab0ut. But we’re all capable of errors. Either one could be wrong.
Stipulating that nothing I write in any communication comprises anything other than an opinion, and in no way constitutes actual medical advice, if you wanted to e-mail me at the Gmail account mentioned in my bio above, I’d be glad to tell you what I can if you want to get more specific in a more private way.
Oh gosh, Russell, that wasn’t my point, but thanks so much for the offer, I really appreciate it. We have already decided to go with the pediatrician over the ER Dr. I don’t need any advice, but as a fellow parent, I hope you’ll just let me unload (and you are welcome to comment as parent, or as doctor, or neither, as you want, however you feel is appropriate, given your oath and lawyers :-).
Since ‘Glyph’ is fairly private and there’s apparently nothing crazy-unusual about what happened (that we yet know of) I will give a brief rundown – after waking up seemingly fine yesterday AM and eating a horse-sized breakfast, my 3-yr old boy complained of not feeling well and went to lay on the couch with his blanket and watch cartoons. He seemed to be running a mild fever, so we let him rest while we went about our work. He is a hyper kid, so any period of relative inactivity is unusual, but not entirely unwelcome, especially if you have a lot of tasks to accomplish around the house in a short time. He eventually drifted to sleep on the sofa – again, unusual for him, but if you are not feeling good, nothing wrong with a little nap on the sofa.
Anyway, I was finishing mowing the yard when my wife came flying out of the house, hysterical, with him in her arms. He was convulsing, throwing his head back, eyes rolled back, turning blue. She’s yelling to call 911 and I tell her than I can have him in hospital quicker than we can make that call and wait for an ambulance (hospital’s maybe 15 blocks away).
As I am saying this, convulsions stop and he goes limp, and now we are well and truly terrified (he is not responding to us at all and we cannot tell if he’s breathing). At least when he’s convulsing you know he’s still alive.
Throw him in the car, talking to him the whole time, the usual mantras/prayers I would imagine, get him there, run him in, where once they can get me calmed down they tell me that kids this age can have febrile seizures if they have a sudden spike in temperature (=101 as they took it there).
They get him on IV, run some bloodwork, his electrolytes seem low, and even after they get both ibuprofen and acetaminophen in him, his temp & heartrate aren’t coming down as quickly as they’d like, though he is now responsive (if pretty unhappy/scared).
Anyway, one thing they turned up in the exam was that he supposedly has an ear infection. He’s had these before (I was also prone as a kid) so they put an antibiotic in the drip and gave us a scrip for Amoxicillin. Note that at no point did they state that the ear infection was the cause of the problem (fever could be viral), but ear infection might have contributed (or not, could just be coincidental).
This AM though, our pediatrician doing the follow-up says there is no sign of ear infection.
None.
Which also doesn’t shock us, because he had shown no signs, nor made complaints, about his ears prior to this incident.
But I don’t understand how something fairly basic like ‘ear infection’, that presents basically externally/visually, could get completely opposite diagnoses from 2 experts. We’re going with our pediatrician, who said if it was his kid, he would not take the antibiotics, but the whole thing is confusing/frustrating at a time when we are worried about the much bigger picture (monitoring/managing his temp to avoid any sudden temp spikes and worrying about any recurrence of seizure, which could indicate a larger problem).
The crazy thing is, by the time we got home last night (around 9 PM after stopping at pharmacy) it was like nothing ever happened. He’s hyper, racing around, motormouth, opinionated/argumentative (he gets this last part naturally 🙂
The whole thing was exhausting.
Okey-dokey. Here are my two cents:
1) Febrile seizures can be terrifying, certainly for people who have never seen seizures before, and certainly for parents who are seeing their kids seize for the first time. I am so sorry you had an awful time of it. However, nothing you describe seems anything other than typical for an uncomplicated febrile seizure.
2) What you were told about febrile seizures in the ED is not considered current at this time, at least as far as I am aware. It used to be that they were attributed to rapid rise in temp, but more recently that opinion has fallen out of favor. Febrile seizures aren’t really related to how rapidly the temp spikes, merely to the fever itself.
3) With the major caveat that there are plenty of exceptions to any broad generalization, it is my experience that ED providers are way, way too quick to call ear infections. I didn’t see your son’s ears, so I can’t say for sure. But I’m not surprised that they would have seen some minor abnormality and seized on it (pardon the unintended pun), when in reality there was little basis for the diagnosis.
In short, I’m tentatively with your pediatrician, albeit from afar based on guesswork.
Hey Russell (Doctor Saunders), thanks, and know that you will be held completely harmless for anything said here. I appreciate it.
Not sure how old your kid is, and I know you have the knowledge and experience to not panic if it did, but may nothing of the like ever happen to you & yours.
For the record, “Russell” is just fine. I would have to be a prat of epic proportions to insist on an honorific for my pseudonym.
Just making a little joke since you were speaking in semi-professional capacity. I’ll thank you to address me as Mr. Glyph! 🙂
Again, thanks for taking the time, and I hope you never have to go through anything like it. Truly terrifying. But should it happen again, hopefully slightly less so.
How difficult is it to deal with parents when something turns out to be a wrong call? A story from my childhood makes me think it could be challenging at times.
When I was a kid, my mom took my ill brother to our family doctor and was told it was scabies. I later came down with the same thing he had. This meant we had to wash ourselves and all our clothes and linens in this horrible-smelling stuff; after that, we were supposed to no longer be infectious. My brother and I went back to school.
Within that week and the next, virtually our entire classes came down with chicken pox. Evidently, the diagnosis had been wrong. My mom went back to the doctor with me, approximately livid. His response? “I told you Peter had scabies, not Katherine. Yep, this is definitely chicken pox.”
I was young and don’t remember all the details, but mom had plenty to say about the doctor. He was a good doctor generally (had a tendency to respond to visits about my and my brothers’ colds with “take them home and feed them chicken soup”), we kept going to him, but that incident stuck in everyone’s minds.
which meant we had to wash our
Well, the way I usually handle it is:
1) If I’m not entirely sure about the diagnosis, I say so. I try to be as transparent about what I’m thinking as possible.
2) When I’m wrong, I try to say so as well. I tend to put in terms of “things didn’t go the way I would have thought,” rather than “I fished that one up royal, didn’t I?”, but insofar as I am given chances to explain myself, I take them.
I don’t know how old you are, but were you vaccinated against chicken pox? I have a hard time believing that a wild-type case of varicella could be mistaken for scabies.
I’m not sure. I got all the usual infant vaccines (MMR, DPT, polio) but maybe not chicken pox. I was under the impression there’s less risk of shingles in adulthood if you catch it as a kid (since it’s usually not seriously dangerous) than if you get the vaccine.
I’m 25.
The varicella vaccine wasn’t licensed until 1995, so you probably didn’t get it. Since scabies and chicken pox (as typically presented in unvaccinated kids, at least) look nothing alike, that’s a pretty strange diagnostic snafu to make.