Several years ago, a California internist saw another physician's patient—a heavy smoker with severe COPD. "A chest X-ray
showed a suspicious infiltrate and I ordered a CT of the chest, which showed a lung mass suspicious for malignancy," says
the internist, who requested anonymity. "A biopsy was positive for cancer, so the hospital scheduled a lobectomy. But because
the patient's pulmonary artery was damaged during surgery, she ended up having a pneumonectomy."
The patient, who lived for several years after the surgery, nonetheless sued the internist, as well as the pathologist and
the surgeon, claiming misdiagnosis, surgical error, and debility from the pneumonectomy. "Even though I was dropped from the
suit, the episode was a months-long nightmare," the internist recalls. "Not only was it the first time that I'd been sued,
I felt guilty and wished that I had gotten a second opinion from a different pathologist and surgeon."
Another internist, who also requested anonymity, maintains, "One of the hardest things about being a physician is the weight
of responsibility we shoulder when caring for patients. And when things go wrong that burden only gets heavier. I've spent
months haunted by 'what ifs' and deep regret over medical decisions that become much clearer in hindsight. Had I known that
these experiences were part of being a doctor, I might not have chosen this career path, despite its many rewards."
There you have it. Mistakes—even those for which you aren't directly responsible—often result in self-recrimination, second-guessing,
and extended periods of simply feeling awful. Compounding the problem, the medical profession has a long history of tacitly
encouraging physicians to stiff-upper-lip their way through mistakes, lawsuits, and other events that might leave the practitioner
in dire need of help but with nowhere to turn.
In recent years, however, physicians' advocates have made the case that a damaging medical error—even if the patient recovers
fully, and even if no lawsuit is forthcoming—often has an emotional impact on the physicians involved. In response, hospital
and practice administrators, and even some insurance companies, have put mechanisms in place to help doctors cope with, and
get past, missteps. If you don't have access to such a program, there still are things you can do to handle the distress of
not living up to your own high standards.
Overcoming the conspiracy of silence
Coping begins with the frank acknowledgment that, in a 30- to 40-year career, you're going to make mistakes, despite the fact
that society demands perfection from physicians.
"The goal is to make as few mistakes as possible, rectify them as quickly as possible, and face up to what went wrong so that
you can take corrective action," says David Posen, a family physician who is now a stress management consultant in Ontario,
Canada. "A mistake should upset you, because it often means that someone got hurt. But it shouldn't overwhelm you to the point that you're unable to
do your job. If you make a mistake and don't acknowledge it, you nullify the possibility of fixing anything."
Physicians spend inordinate amounts of time replaying mental tapes of what happened and dwelling on what they could have done
differently, says medical sociologist Richard Frankel, a professor at the Indiana University School of Medicine. Like Posen,
Frankel insists that if you don't share your anguish over a mistake, you negate the possibility of understanding what happened.
Instead, "what we often see is fear of reprisal or closing ranks," says Frankel.
John-Henry Pfifferling, director of The Center for Professional Well-Being in Durham, NC, talks about the need to change the
culture that prevents physicians from finding solace and support when they slip up. This culture, Pfifferling maintains, begins
in med school and is reinforced from internship on. He recalls trying to get teachers at a medical school to disclose their
own errors to students and indicate how they coped in the aftermath. "The instructors and some of the assistant professors
were willing to do it, but the higher-ranking faculty members said No," Pfifferling notes. "In effect, the students learned
not to talk, not to trust, and not to admit they needed support."
Seeking help in the right places
"Every doctor should have a family doctor—someone who can listen nonjudgmentally, and refer him or her for counseling when
necessary," says Posen, author of Staying Afloat When the Water Gets Rough (Key Porter Books, 1999), and The Little Book of Stress Relief (Firefly Books, 2004). If you've made a serious medical error, the first thing to do is admit it to yourself. Then, if you're
having difficulty handling the emotional aftermath, tell someone else—a close colleague or friend, a mentor, spouse, or sibling.
Or seek professional help.
Frankel, who teaches CME courses on dealing with medical errors, agrees that talking with colleagues and family members can
be enormously healing and helpful. Writing about your feelings can also be cathartic. But he warns about the dangers of holding
onto such writings, because those notes—not to mention conversations with other physicians—might be discoverable in the event
of a lawsuit. "If you're worried about legal action and want to play it safe, talk to a clergyperson, a psychiatrist or psychologist,
or the risk manager at your hospital or malpractice insurance company, because they can't be subpoenaed about those conversations."
Some malpractice insurers, mindful of the havoc that adverse medical events play with doctors' psyches, have mechanisms to
help physicians cope. One of these is the emotional support program run by the ProMutual Group, a medical malpractice insurer
headquartered in Boston.
Launched in 1994, the program makes confidential peer support groups available to physicians who are involved in malpractice
litigation or who made a mistake that resulted in an adverse outcome. Psychiatrist and Harvard Medical School professor Miguel
Leibovich, who facilitates many of the groups, says that participants discuss their feelings about the event that brought
them there, but they don't specifically describe the event. Leibovich keeps no records, and when he bills ProMutual for the
sessions he doesn't name names. (The only participants whose identities are known are those who ProMutual requires to be in
the program because they've been sued for malpractice several times.)
"Many of the physicians who come to us are anxious and remorseful," says Leibovich. "We help them acquire perspective by teaching
them that their anger, guilt, and other feelings are normal responses to the situations at hand. Just talking about these
issues and sharing experiences with colleagues is very beneficial."
Increasingly, too, medical ethicists are recommending that patients be told about harmful errors, and that these disclosures
be coupled with an apology and an explanation of how such errors will be prevented in the future. Such disclosures, the ethicists
say, can be healing for physician and patient alike. (You'll find details on the safest way to go about apologizing in "Should you apologize," in this issue.)
Being proactive in minimizing mistakes
Many researchers who've studied medical errors point to the aviation industry as a model for addressing and learning from
errors. "In medicine, mistakes are typically concealed owing to shame and fear of litigation," says Richard Frankel. In contrast,
when an airline pilot makes a mistake, everyone—no matter which airline they work for—wants to know what went wrong in the
cockpit. So for more than 25 years the industry has had an anonymous error-reporting system, coupled with practical safety
advice for the crew and vigorous efforts to deduce what happened.
Medical practices, too, can benefit from similarly structured error-reporting and feedback systems. "It doesn't mean you can't
have high standards, but everyone benefits from an environment in which professionals learn from each other," says Pfifferling.
The system should also contain mechanisms for educating new recruits in how the practice addresses errors, helps physicians
cope when mistakes occur, and minimizes mistakes.
An effective means of bringing error rates down, experts agree, is patient education. ED physician John C. Johnson of Valparaiso,
IN, provides an example: "If I'm not sure what's causing a patient's abdominal pain, but I think it might be appendicitis,
I'll say, 'Appendicitis presents as such and such. . . . If you're still having symptoms in 12 hours, come back to the ED
and get checked again. If you get worse sooner, come back sooner.' This way, the patient can make an informed decision if
the disease progresses."
In the end, says Frankel, you can only do your best. He tells the story of a young physician who participated in a workshop
he facilitated. "One of this doctor's patients had committed suicide 10 years earlier, and he indicated that he thought about
that man constantly and wished that he had recognized his depression and treated him accordingly," Frankel says. "There was
a long silence. Finally, a colleague asked what happened to the man's wife, who had also been this physician's patient. He
replied, 'She came to see me for the next 10 months or so, then moved to another town.'
"The colleague replied, 'Did it ever occur to you that she continued to see you because, despite the outcome, she wasn't
angry with you?' The physician was stunned and said that in his grief during the past 10 years he had never considered the
possibility that this woman didn't blame him for her husband's death."
The lesson here, says Frankel, is that if you don't share your grief over the loss of a patient or over a mistake, you negate
the possibility of understanding what happened, gaining a more comprehensive perspective, and forgiving yourself.
