By Dr. Robert C. Reiser
It looks like spring is finally here. Just as my lawn is freshening up so, too, are my interns beginning to freshen up. No longer scared little lambs, they have gained competence, confidence and some cockiness. They challenge me in ways that would have been unthinkable back in June. This is a good thing. It marks progress for them and keeps me sharp and sometimes amused.
Paradoxically, my senior residents are humble and tractable. They are constantly picking my brain for treatment strategies with an urgency that tells me that they recognize that in a few short months they will be on their own.
When I was a senior resident I received some advice that proved prophetic. I was told by my favorite attending that two things would surely happen in my first year out of residency. One, I would kill somebody, and two, I would piss off a prominent member of the hospital staff. Very likely the two events would be related. It took all of three months for this prediction to prove true.
While knowing that this was so commonplace as to be predictable helped me cope a bit, beyond that I received no training in coping with the unique stress that comes with the practice of clinical medicine, the stress of knowing that your mistakes can harm others.
A recent phone call from a former resident dealing with a tough case of his own reminded me that we really need to do better in teaching future doctors how to work through these universal but little discussed tragic moments. To that end (and with the author’s permission) I share an edited exchange with another former resident.
Hi, Dr. Reiser!
I hope all is well at UVA and with the Reiser crew. I miss UVA and Charlottesville a lot— I had no idea how nostalgic I would be for residency and everyone in the ED.
I’m writing because I’m having a lot of trouble processing a case where I missed a posterior circulation stroke.* I wanted to ask you how you deal with making mistakes. I’m discovering a pattern of every few months, learning about a bad outcome, or a mistake without any associated bad outcome, and I spend a few days or a week feeling absolutely awful. I feel tremendous guilt; I replay the case over and over in my head, read through the chart and think about what I should have done differently, and sometimes talk it over with colleagues. I know many of the mistakes I make in these early years are because of limited experience, but I imagine I will always make mistakes, no matter how careful I am and how much experience I gain.
At times I feel like this amount of responsibility is too much for me. Why did I choose a profession where the stakes are so high? I could have been a massage therapist or a track coach and helped people just as much—without the potential for so much loss and grief. I am not sure I want to feel this much guilt every few months for the rest of my life. It makes me angry and irritable with the kids, and it feels terrible. Yes, I learn a lot from every case like this, but I wonder if it is worth it. I probably shouldn’t be surprised that these issues are all coming together now, halfway through my first year out of residency. The learning curve is steep, and I’m sure I’ll remember some of these cases forever. I am curious to hear how you have learned to process these kinds of cases over the years.
I’m making work sound like a huge bummer, but it’s actually been great, for many reasons.
Thanks for reading, Dr. Reiser. Give my love to Bernie and your kids.
*Editor’s note: The brain has several sources of blood flow. One of those sources, the posterior circulation, runs up the back of the neck and supplies both the cerebellum—responsible for all balance and coordination, and the brainstem—responsible for breathing and consciousness. Strokes in this posterior circulation are rare and can be both subtle to diagnose initially and ultimately devastating with high degrees of disability and high rates of mortality.
Dear Young Doctor,
The issues you bring up are profound. How profound? I missed a posterior circulation stroke, too, that I still think about. When did I miss it? 1991.
You wonder if it is worth it, the potential for so much loss and grief, the stakes so high all the time.
Yes, it is worth it and I would not have missed it for the world. Here’s why.
What we do, if we do it right is sacred. Being present, being an experienced guide, through the most profound human events, birth, death, loss, grief, suffering, pain, saving the occasional life, grinds us down, chipping away so much superfluity, and elevating us to the level of nearly priestly. But it is hard. No one else sees what we see.
The first year out is the steepest learning curve after intern year. You will get better. I almost never wake up at three in the morning anymore with the sudden insight that I should have ruled out a deadly pulmonary embolus (a blood clot in the lung) in the patient I instead sent home. But I still do make mistakes. Not many, but it is unavoidable. Good medical decision-making is a science built on probabilities and so error is necessarily built in to the science. The only mistakes that haunt me are the ones I make through lack of care. By care, I mean caring about the patient. I am not a saint, no one can care about 30 to 50 strangers a day, day in day out, and so I do the best I can.
I do several things that keep me refreshed and resilient, able to go back and help others.
1) Limit my hours. I am not very good at this.
2) Having limited my hours, fill the time off with meaningful or just plain fun things. Kid time is great because it is both. I was the only father on my kids’ field trips, a bonus of our crazy ER schedule. Adjusting to them being grown and gone has been a real struggle for me. Just ask Bernie.
3) Go to church. It forces me to sit still for an hour a week and contemplate. After all, religion also deals with birth, death, suffering, pain, loss, etc. The parallels are striking.
4) Reflective writing crystallizes in attention the parts of our practice that are sublime, and the parts that are absurd. I strongly suggest it. I have included one of my recent columns below which sort of gets at what you are asking. So, write.
5) Show and tell people that you like or love them. We don’t do this enough.
It is good that you are struggling with this. Many don’t. It has been suggested that a certain sociopathy can be adaptive in doctors. While that is true, it is not who you are.
I can’t wait to see you. In the meantime keep the letters flowing and call anytime.
Oh, Dr. Reiser, thank you so, so much. I am convinced, in this moment, that I should keep going. I’ll see how I feel after my next overnight, but for now, you fortified me 🙂
Thank goodness we get better at what we do. I still get very nervous before every shift, and my heart races every time I see a kid pop up on the track board. My current daily level of adrenaline is not sustainable. Maybe it is peaking.
I’ll keep coming back to this message to remind myself why we do what we do. I have to get back to reading your Annals, too. They’re the best. 🙂
I will keep writing with questions, if you don’t mind. Thank you again.
This correspondence was years ago. This physician is now one of the most balanced practitioners I know. We do get better at what we do. And we are not alone.