The conversation that extended my career

We all mistakes. It’s better to talk about them.

My heart is pounding. My stomach is in a knot. I can’t think straight.

I made a mistake.

The mistake itself doesn’t matter. It’s happened a number of times. An overlooked vital sign, a forgotten lab value, or that time in medical school that I used epinephrine in a digital block. (I feel less badly about that now.) The specifics don’t matter, because the outcome is always the same. I can’t concentrate. My chest feels tight. My bowels feel loose. I’m shaky. The last thing I want to do is see another patient. I feel like a failure.

To err may be human, but at work I am supposed to be super-human. I’m a physician. People are relying on me. I need to be perfect.

Luckily, my mistakes (that I know about) have mostly been minor. But they never seem minor to me. They knock me from my pedestal. They cost me sleep. They hurt.

For years, I toiled through these errors on my own. I would think about them. I would try to learn from them. Then I would think about them some more, usually at the cost of a good night’s sleep. But the one thing I would never do is talk about them with my colleagues. I didn’t want to lose their respect.

Tonight, I made another mistake. I misread a number on a chart. Ultimately, there was no real harm, but I still felt like a failure. My heart raced. My hand shook as I tried to chart. I couldn’t eat. I could feel the rise of adrenaline that was certain to cost me another night’s sleep.

Then I talked to a colleague. As the words left my body, so did the stress. My breathing slowed and the shaking stopped. I had gained perspective.

There is nothing I love more than discussing medicine with my colleagues. Chatting about interesting or difficult cases always leaves me excited to practice medicine. I have learnt something new from every conversation I have ever had with a colleague.

However, I have always been hesitant to discuss my mistakes. I like having the answers. I like being the calm, collected leader in the resuscitation room. I like that people can rely on me. The last thing I want is to be seen as a bumbling fool.

So, I would reflect on my own. I would read and I would struggle to improve, but always alone. I thought this would make me feel better; stronger; smarter. Really, I just felt alone; isolated; scared.

I am glad I opened up to my colleagues tonight. I know people often hear legal advice about who you should talk to after making a mistake. That isn’t what this is about. This is my experience of stress melting away because I opened myself up. This is about my colleague’s ear providing me with a good night’s sleep. This is a supportive colleague extending my career and beating back the dark spectre of burn out.

Emergency medicine is grueling. You can’t do it alone. You don’t want to do it alone. That is why I love my colleagues. I couldn’t do this without them.

Author: Justin Morgenstern

Community emerg doc, FOAM enthusiast, evidence junkie “One special advantage of the skeptical attitude of mind is that a man is never vexed to find that after all he has been in the wrong.” - William Osler

4 thoughts on “The conversation that extended my career”

  1. Thank you for this, Dr. M! I stumbled upon this post via LITFL (which I follow) and I wish more docs could follow your lead in simply talking through mistakes as they happen. I think such willingness makes for a better doctor.

    As a heart patient who was sent home from Emerg in mid-MI with a GERD misdiagnosis, I’m particularly interested, of course, in how diagnostic errors in emergency medicine happen. That they do happen is not in question, but pretending they don’t by refusing to talk about them, report them, or learn from them is not working, according to the Institute of Medicine’s 2015 report “Improving Diagnosis in Healthcare” that concluded: “Urgent change is warranted to address this challenge.” Patients don’t expect our docs to be super-human, but we sure as hell expect them to communicate when errors have occurred – if only to help protect future patients from being harmed and to help themselves manage the understandable angst you describe.

    As long as the culture in medicine remains a significant barrier to such discussions among peers, these errors are unlikely to ever be reported or even discussed. Despite the urgency of their report’s findings, even the IOM’s committee chair said on two occasions during the report’s media launch: “Now is not the right time for mandatory reporting of diagnostic error.”

    But as our fellow Canadian and patient safety expert Dr. Pat Croskerry once said about his early experience in his Halifax hospital: “When I first inherited the emergency department, we would have people presenting cases at rounds mostly on their diagnostic triumphs. But we weren’t looking critically at what we were doing. We really put a concerted effort into improving feedback. To have a system operating without feedback, as we often do in emergency departments, complex patients just disappear into the ICU or disappear into the morgue, and you haven’t really learned anything. So we implemented a number of strategies that have significantly improved our feedback.”

    Improving feedback means improving patient safety. Part of that strategy must include supporting a work culture that accepts and encourages such feedback. My question to the IOM, and to others who insist that mandatory reporting of errors in medicine is somehow different than what already happens in aviation or construction or any other workplace environment is simply: “If now is not the right time for mandatory reporting of error, when might that right time be?”

    Thanks again for this important essay,
    regards,
    Carolyn Thomas

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    1. Thank you for the very insightful comments Carolyn.
      I am acutely aware of the issues of diagnostic error in medicine, but I am also very concerned about the consequences of a culture of medicine that is far too focused on certainty. There are two sides to this very misshapen coin: missed diagnoses and overdiagnosis. Personally, I think both patients and doctors need to become more comfortable with the inherent uncertainty in medicine. Communicating this uncertainty can be the difference between a error and a simple reassessment along the road towards the correct diagnosis. Some more thoughts on diagnosis uncertainty here: https://first10em.com/2016/10/31/communicating-diagnostic-uncertainty/

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      1. Excellent article on diagnostic uncertainty – thanks for referring me to that one. Saying “I’m not 100% sure” is clearly not taught in med schools…

        I too waffle between worrying about those two extremes: missed diagnosis (nothing’s wrong with you, so go home!) and overdiagnosis (something might be wrong with you, if we order enough tests). But I’d even dare to throw in a third factor: catastrophizing (what, you again?) which I’ve written about here: https://myheartsisters.org/2011/01/05/catastrophizing/

        That last one is so tricky. I know firsthand how awful it feels not to be believed by Emergency staff and dismissed, feeling so embarrassed for having made a fuss over ‘nothing’, while making all the truly sick people out in the waiting room line up behind me. But that’s how catastrophizers feel, too – except there’s actually nothing physically wrong with them.

        The trouble is: catastrophizers will return to the Emergency department, again and again. But for heart patients like me, the more definitive and confident the dismissal, the greater the likelihood that we will be highly reluctant to return to Emerg when symptoms worsen (and of course they will!) – but by then, it may be too late.

        And for women, this can be especially dangerous.
        Thanks again,
        C.

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