On feelings

The patient’s blood culture results were positive.  I had misread them, and reported them on rounds as having been negative.  It could have been bad.

Thankfully, I must have sounded kind of shaky on the details, and the attending physician clearly didn’t take my report as the final word.  Plus, I was just a junior medical student doing one of my first internal medicine rotations, so there were more senior students and residents there to double-check the results before the patient was discharged, potentially before his infection had cleared.  I don’t remember much about the case beyond that I had been wrong, but I do know the patient was kept in the hospital.  And I remember the conversation that came next.

The attending physician, who was to serve as my primary clinical and educational mentor for the duration of my schooling, called me into his office to discuss why I had missed the correct result.  He had observed my interactions with the patient and my reports of him on rounds, and was pretty sure that I didn’t like him.  (He was correct.) And he thought perhaps that antipathy had led me to work less hard, to be less vigilant in his care.  Given that the alternative explanation (mere carelessness) was hardly a rousing defense, there wasn’t much I could do but accept the dressing-down I got, with the very clear imperative never to let my personal opinion of a patient inform the quality of care I delivered again.

I did not feel lucky at the time.

However, the above experience popped into my mind immediately when I read this article by Danielle Ofri in the New York Times about how doctors deal with their feelings.  (Thanks to the perpetually mensch-y Tod for passing the link along.)

By now, even the most hard-core, old-school doctors recognize that emotions are present in medicine at every level, but the consideration of them rarely makes it into medical school curriculums, let alone professional charters. Typically, feelings are lumped into the catch-all of stress or fatigue, with the unspoken assumption that with enough gumption these irritants can be corralled.

The emotional layers in medicine, however, are far more pervasive. Emotions have been described by the neuroscientist Antonio Damasio as the “continuous musical line of our minds, the unstoppable humming …” This basso continuo thrums along, modulating doctors’ actions and perceptions, while we make a steady stream of conscious medical decisions that have direct consequences for our patients. Emotions can overshadow clinical algorithms, quality control measures, even medical experience. We may never fully master them, but we must at least be conscious of them and of how they can sometimes dominate the symphony of our actions.

The piece touches on a lot of fraught interactions between doctors and patients, starting off with the possible reasons that physicians may not be fully honest with their patients.  I have said before that doctors must not lie to patients, and was kind of unsettled to read that more than one in ten doctors reported having told a specific falsehood in the previous year.  Most the the essay concerns itself with shades of gray, when providers are cagey about a patient’s prognosis or are not forthcoming about having made an error.  I know that I have, within recent memory, been in situations like these.

As it happens, the one time I was cagey about a medical error was when I was not the one who had erred.  For what it was worth, I became involved in the patient’s care after the error had occurred, and I was reasonably confident both that I delivered the best care possible and that the family knew I was not the one who had erred.  However, it was relatively clear that a mistake had been made by another physician at the same hospital where I worked.  At the point when I assumed care for the patient, I focused as much as I could on my own clinical decisions when speaking with the family.  When asked about the patient’s care up to that point, I simply said I couldn’t be sure.  This was true — I could not say with certainty exactly what had happened given the information I had at the time.  Further, I did not feel the need to do the malpractice attorney’s work for him.  (FWIW, if a lawsuit was filed I have not heard of it thus far, and would have expected to long before now.)  If being fully honest meant saying “I share your suspicion that an error made by another physician here caused the problems we are dealing with now,” then I was not fully honest in that way.

But from the perspective of my own emotions, that case was easy.  While I was sorry for what the family was going through, I was not burdened by guilt or fear.  I had done my best and I knew it, and so did they.  But what about times when I had missed a diagnosis?  What about when I did feel bad?

The most recent time I know I missed a diagnosis, it was a big one.  And I felt terrible.  My bad feelings were mitigated somewhat by the fact that I had lots of company — almost everyone had also missed it, including the subspecialists we had consulted specifically to rule out the diagnosis that ended up being correct.  In fact, it would likely have been missed for longer had not one particularly astute fellow from another subspecialty found something incredibly subtle on his exam (which I, sad to say, disagreed with) and strongly recommended the study that finally led to the correct diagnosis and treatment.  (Shortly after I received the test results, I paged the fellow and thanked him personally.)

So what did I do?  I said I was sorry.  I told them exactly what I had been thinking throughout the whole ordeal, and why it had taken so long for the diagnosis to be made.  (In everyone’s defense, there were lots of confounding factors.)  I told them that I wished the diagnosis had been made sooner, and for my part I wished I had seen things more clearly that in retrospect were clues.

I have a fantastic relationship with this family to this day.  (It probably doesn’t hurt that the patient is doing great.)

The bottom line is that medical providers are going to be confronted with emotional hurdles continually throughout their careers.  However, when the subject of how emotions impact our patient care, usually it’s the patient’s emotions we end up talking about.  But obviously we’re going to have to deal with our own, as well.  Pretending otherwise is foolishness or pride or both.  Sometimes the feelings will be relatively petty: any time you deal with human beings, you’re going to encounter some who are frustrating or annoying.  Sometimes the feelings will be overwhelming, whether grief or guilt or fear.  And oftentimes medical providers are ill-equipped to know how to deal with them.

It turns out that, even though I didn’t know it at the time, I was lucky.  I was given a clear lesson by a wise and attentive mentor about how important it was to be aware of what was going on with my emotions when taking care of patients.  If the topic came up during any formal lectures or classes, I don’t remember it.  But clearly I still remember the patient I didn’t like and the blood culture I didn’t see, and it’s a lesson I hope not to forget.