Viewpoint: Our mistakes make us better physicians

January 25, 2013

Making a mistake can be difficult for a physician to handle, but we can learn from them to become better.

Last month, I had a rare opportunity in primary care practice: I almost certainly saved a life.

Marco O’Neil (not his real name) is a 53-year-old man whom I follow for familial hypertension; his father had a premature cardiac death.

Mr. O’Neil comes in with reluctance for blood pressure checks, and he has been slow to initiate lifestyle changes, although I have encouraged him to do so. At his most recent “routine visit,” his blood pressure was good, and he said he had been feeling well. He had no concerns.

After practicing medicine for so many years, however, I have learned to ask the right questions, and I have fairly good intuition. I sensed something was wrong, and in discussion with Mr. O’Neil, I learned that he was getting short of breath occasionally at work. “No big deal,” he said. “I need to drop a few pounds and start exercising again.”

I thought otherwise and proceeded. Mr. O’Neil had an abnormal stress test the next morning, followed in quick succession by an abnormal angiogram and a successful multi-vessel coronary artery bypass graft. He is now at home with his wife and children, doing well-and working on those previously discussed lifestyle changes. Without these urgent interventions, and given the severity of his disease, Mr. O’Neil may have suffered a terminal cardiac event relatively soon. I probably did save his life.

How do I feel about what I did? I feel good that I did my job well, privileged to have the chance to do so, and also fortunate, because on a different day, I might not have pushed so hard and might not have received as good of a result.

NOT ALWAYS SUCCESSFUL

This experience also reminded me of a patient I had 37 years ago, the first week of my residency at San Francisco General Hospital., a patient for whom my efforts were not as successful.

I never knew his name or his age-or anything else about him other than he had been brought to the emergency department (ED) in the middle of the night after being found on the street. I’ve thought about him a lot over the years. Let’s call him Mr. Edwards.

I was the admitting first-year and was called to pick him up in the ED with the admitting diagnoses of pneumonia, dehydration, renal failure-and chronic alcoholism. I found Mr. Edwards to have signs of acute and chronic illness; he was not responsive. No family or friends were with him.

I reviewed his care plan with my senior resident: antibiotics, intravenous (IV) fluids, oxygen, and I was told to “add some extra potassium to his IV because he is very low.” (I don’t recall the number.) And he added, “He  probably won’t make it, but give it a shot.”

I wheeled Mr. Edwards  out of the ED, down the hall, into the elevator, and into the medical ward, explaining to him who I was and what we were going to do. He did not respond.

I got him settled into bed with the help of the floor nurse, and I made certain his IV was running well and that his IV antibiotics were flowing well. Then I went to the medication room and took two vials of potassium chloride. I gave Mr. Edwards both vials, as I had been told to do, but instead of adding the potassium chloride to the IV bottle, I gave each one as an IV push, first one, then the other 5 minutes later.

STILL NO RESPONSE.

Writing my note at his bedside, I noticed a few minutes later that Mr. Edwards, who had not been breathing well, was no longer breathing at all.  He was gone.

I beeped my senior resident, who came immediately.

“Should we code him?” I asked.

“No, let him be,” he said. We’ve got four other admits in the ED.

“Did you give him the potassium like I said?” he asked.

“I did, “ I answered. “I pushed two vials.”

‘Nice going, [expletive],” he said. “You killed the son of a [expletive].”

And then he walked away. I don’t recall his talking much to me again for the rest of the year.

STRUGGLING FOR ANSWER

I understood immediately what he meant; I was wrong to have given the potassium by IV push. I should have diluted it into the IV bottle.

“Did that really result in his death?” I asked myself.

I struggled through the rest of the night. I considered just walking out the front door of the hospital and applying to law school.

At 8 a.m., I met with the assistant chief of medicine, a woman who later and rightfully became too well known in academic medicine for me to mention her name here. She told me that she had reviewed the case and decided that my patient was not going to survive no matter what we did for him. He was too ill. My actions had not contributed to his death, she assured me.

“Still,” she said, “you did not do a good job. You had an obligation to do your best for your patient, and you did not do so. You made a mistake. You screwed up.”

“You’re right,” I said. “I’ve learned from this. I’ll never make another mistake.”

“Dr. Waltman, “ she said, “You’ll be making mistakes for as long as you practice medicine. We all do. Give me something else if you want to stay in this program.”

I thought for a moment. “I’ll do the best I can for every patient,” I said.

“Works for me, “ she said. “Now go be the best doctor you can be.”

And then she gave me the most awkward hug I have ever received in my life.

My next patient came through the ED just a few minutes later, a teenager with sickle cell crisis. I didn’t know very much about sickle cell disease then, but I learned a lot about it very quickly, and I did a good job for that young man, good enough that he asked for me by name when he came back to the ED with further acute flares the rest of that year.

And I have continued the same approach for every patient since.

KEEPING A PROMISE

I have carried Mr. Edwards-and the recollection of that awkward hug-with me for more than 37 years. Both remind me of the same promise I made: to do the best I can for every patient. I have been true to that promise.

Over these years, I have treated countless patients and have made thousands of important decisions and choices. Most of the time, my efforts have brought successful results, whether treating an acute otitis media or urinary tract infection or chronic problems such as diabetes or depression.

Along the way, I have had some “saves” as well-a few aortic aneurysms, two or three pulmonary embolisms, some malignancies identified at an early and treatable stage, and a few folks who just needed to talk a bit longer than a doctor usually allows.

And I have made some mistakes, most of which caused no harm and some which probably did have a negative effect, although none with dire consequences. Thank goodness for that.

I have worked hard. I have learned a lot. I have been careful. I have been attentive. And most of all, I have cared.

And I truly have done the very best I could do for every patient. That has been enough to make me keep going and feel good about what I do.

A GOAL FOR TOMORROW

Have I done a good job? Yes.

Might I have done better at times? Yes.

Am I going to try to be better tomorrow? Yes.

Am I the best doctor? No, but I believe I am the best doctor I can be.

And do I love and cherish what I do? Yes. Nothing compares with the privilege of being a physician.

I do think often about that night at San Francisco General. I am forever grateful to that insightful and awkwardly hugging the assistant chief of medicine. She was great.

I remain eternally thankful for having spent time with Mr. Edwards. He is still a great teacher and a great colleague.

Thank you both.

The author practices family medicine in Tacoma, Washington. From the Board columns reflect the opinions of the authors and are independent of  Medical Economics. Send your feedback to medec@advanstar.com. Also engage at www.twitter.com/MedEconomics  and www.facebook.com/MedicalEconomics.