The box of pain
February 24, 2010 at 2:26 pm | Posted in Uncategorized | 6 CommentsIt takes a special talent to earn a collective facepalm from all of your attendings, but apparently I have it. While I can’t go into too much detail without violating HIPAA rules, what I can say is that it was entirely an error of my presentation, and not an actual medical error, or an error in judgment. There was a very important detail of the patient’s past medical history that I had actually considered in formulating my plan, but had neglected to present until well after the films had been shown and discussion was underway regarding what diagnosis they indicated. And with that one detail, a ~30% pretest probability turned into a nearly 95% probability.
So you know, it was like, important and all. And it didn’t help that the chief resident, not being privy to this detail, disagreed with my assessment and was arguing vehemently (not that he ever argues any other way) against it. All in all, a pretty spectacular FAIL on my part.
But there was plenty of FAIL to go around this morning. Not as entertaining in most other instances, but certainly more revealing.
We had a particularly bad outcome, which again I can’t discuss in detail, but it was the kind of outcome where no surgeon would ever choose to operate if it were more than a very unlikely possibility. And yet statistically it happens, and this patient was the one to whom it happened.
We all feel remorse on a professional level over outcomes like this. It’s the horrible and inescapable fact of being a surgeon: despite your best efforts, there will be some people you harm instead of helping. There are really only two ways to deal with that fact: to personalize or depersonalize. And the attending of record is someone whom I’d expect to be upset on a personal level as well. I have an immense amount of respect for that attending, for that very reason. And he clearly was upset.
But then I looked around the room, and noticed something that surprised me. Our supposedly “malignant” attending was actually wiping his eyes with a Kleenex. I use quotes because I disagree with that assessment, and not just because of today. Although this particular attending is uncomfortably direct with criticism, it is rarely misdirected and never personal. And on the one occasion that he actually sat me down for some extended constructive criticism, I think he was almost as distressed as I was over the process. Personally, I think that’s empathy and character rather than malignancy. But your mileage may vary.
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Hurricane Jill 
As a basic science professor with a PhD who teaches only first-year medical students, it is really fascinating to hear about this kind of thing. It gives me images of what my students will be going through after they leave my classes.
Comment by Comrade PhysioProf— February 24, 2010 #
My experience is only typical of surgical programs, and even of that subset, it’s found mainly in general surgery and neurosurgery. Most other specialties are far kinder and gentler to their residents. I’ve grown a pretty thick skin at this point, and I also use humor to detoxify things whenever I can. But when the point is valid, or the situation can’t be defused, I’ve found that the best approach is just to acknowledge the error, and its seriousness, and move on. That’s probably the take-home message for your students.
Comment by hurricanejill— February 28, 2010 #
I have always been a fan of your insight. I think I would have been proud to have someone like you as a co-resident. I really hope you land somewhere. I think you have the potential to be a great neurosurgeon one day.
Everyone makes mistakes, I’ve got a bucket full, and a few grave stones.
Comment by RJ— February 24, 2010 #
Thank you for the kind words. I hope I land somewhere too. 🙂
Comment by hurricanejill— February 28, 2010 #
As someone who has taught neurosurgery residents for many years-it is interesting to read your blog. In my experience, the best teachers were those who held us to a high standard and could practice on that high level, too. Demanding, yes but they demanded the same of themselves.
Dealing with bad outcomes has always been sticky in medicine and particularly in neurosurgery. There is the majority who blame everything on the patient or the disease, even when there were systems or human error that contributed. There is a small minority who become so paralyzed by fear and failure that they “shunt” everything out of the office and spend years playing an avoidance game.
For me, I feel my life has been immeasurably enhanced by my encounters with most of my patients and their loved ones-perhaps the most from those who are under the greatest of stress-trauma/brain tumors/etc. But this gift has come as I have learned to be more than a technician-to be a “complete” doctor. And none of this aspect of neurosurgery was ever taught to me or even mentioned when I was training.
May I ask what year of training you are in?
Comment by BRainDame— March 1, 2010 #
I am a clinical fellow, meaning I’m stuck in limbo between internship and residency, with no guarantee that anything will come of this year. Nor does it even officially count as a year of training, if anything does come of it.
Comment by hurricanejill— March 1, 2010 #