The Physician may be a Patient

July 9, 2009
Doctor and Patient
When Doctors Make Mistakes
By PAULINE W. CHEN, M.D.

I met Ed (not his real name) during internship, the year after we both graduated from medical school. Built like a competitive wrestler, Ed was an Ivy League college graduate and one of his medical school’s top students, a 27-year-old who wanted nothing more than to become a general surgeon. Like me, he was enamored with the fearlessness that seemed to characterize the specialty. At a dinner during our first month on the job, Ed told the rest of us, “I love that nothing scares a general surgeon.” A dreamy look passed over his well-chiseled face as he continued, “They can take care of it all.”

Ed was determined to be that kind of surgeon and applied his intelligence and good nature to the huge workload we always had at hand. One night when I was on call I found Ed, who was supposed to have gone home for the night, in a patient’s room. A small mound of discarded alcohol swabs, blood-stained gauze pads and used test tubes stood by his side as the patient, an older woman, laughed and encouraged him on. When Ed saw me, he smiled sheepishly. “I never learned to draw blood in medical school,” he said. “It takes me a few tries.” The patient patted Ed’s hand and nodded as he continued, “If I can’t draw blood, how am I ever going to be able to operate?”

But several months later, I learned that Ed had gotten in trouble one night for not responding to a nurse’s page about a critically ill patient. “He must have been overwhelmed,” I thought, remembering that only a few nights earlier I had likewise forgotten a nurse’s request after several trauma patients rolled into the emergency room and I never returned to the wards as promised. I silently vowed to do better the next time and now hoped that Ed would do the same.

But a couple of weeks later, I heard that Ed overslept and missed morning rounds. A month later he was publicly reprimanded for examining and placing undue pressure on a patient’s freshly sewn incision. And a month after that, he was placed on probation because he had pulled a surgical tube out of a patient when it should have stayed put.

Suddenly it seemed as if Ed, the promising young surgeon, had disappeared into a vicious cycle of errors and mishaps and couldn’t pull himself out.

But Ed, the friend, had gone missing, too. He stopped smiling when we passed one another in the halls and refused to meet up with the rest of us for meals. “I’ve got to read,” he would say, his face stony. “I’ve got to study.” He still roamed the wards at all hours, but now he was like a man possessed. With his list of patients crumpled in one hand and a pen in the other, Ed studied patient charts and reports for hours, furiously jotting notes down on his list.

Despite his efforts, Ed continued to stumble. He soon developed a reputation for being testy, not only with other doctors and nurses but with patients. He argued, lost his temper and was too rough during procedures. One afternoon I heard Ed’s voice bellowing from a patient’s room: “But I never said that to you! Why did you have to tell the senior doctor that? You got me into trouble!”

Ed finally gave up on becoming a surgeon. In trying to understand what had happened to our once aspiring colleague, the other young doctors and I talked about how stress is inevitable and surmised that those who collapsed under the pressure were probably better suited to other lines of work. We speculated that Ed lacked a certain sense of humility.

But all of our ruminations finally boiled down to this: each of us was only one misstep away from that lonely and vicious cycle of errors that could unexpectedly and irrevocably spiral out of control.

In the years since, I have worked with other doctors who have had similar experiences. And while the discussions at disciplinary meetings and at morbidity and mortality conferences tend to focus (and rightly so) on the effects of these physicians’ errors on patients, there is rarely any time devoted to how such errors affect doctors and their subsequent interactions with patients.

I called Dr. Colin P. West recently, a practicing general internist and the associate director of the internal medicine residency training program at the Mayo Clinic in Rochester, Minn. About three years ago, Dr. West and his colleagues published an article in The Journal of the American Medical Association on the effect of errors on physicians-in-training and on the outcomes of their future patients. The researchers found that self-perceived errors not only increased the risk of burnout and depression but also adversely affected subsequent patient care. Over time, young doctors who believed they had made errors in the past felt less and less empathy toward their patients, which then led to an even greater risk of subsequent errors.

“What we are learning is that there’s clearly a cost for doctors and patients,” Dr. West said. “There’s probably a certain amount of stress that’s constructive, but when you deal with it for too long and take it too far, that’s when work suffers.”

While doctors should strive for as few errors as possible, “you can’t go through training without making an error unless you are not taking care of patients,” Dr. West said. “And if you are really invested in the care of patients, there’s a personal cost when things don’t go well.”

That cost can extend to patients. Doctors who are depressed are as much as two times more likely to make subsequent errors than doctors who are not. “From the point of view of the patient,” Dr. West observed, “it’s important whether the doctor treating you is experiencing symptoms of depression or burnout.”

And while Dr. West’s research focuses on doctors-in-training, he added, “I don’t think that as a practicing physician you ever stop thinking about how you could have done better, even sometimes with those events you probably couldn’t have prevented.”

Greater support for doctors from both the training process and patients could help to improve patient outcomes and strengthen the patient-doctor relationship. “In 21st century medicine, there’s no reason for a patient to accept suboptimal care,” Dr. West said. “At the same time, patients need to balance their expectations against the reality of the physician experience. And the medical establishment needs to do a better job of helping patients understand what physician lives are really like.”

“This doesn’t mean that physicians need to be coddled,” Dr. West continued, “but they need to be supported from within and by patients. They need to be supported in developing those relationships that help them to flourish. The reward is a stronger physician-patient bond. And that leads to more effective health care for everybody.”

Join the discussion on the Well blog: "For Doctors, the Personal Toll of Mistakes"