Attending

by Ronald Epstein

  In a prescient essay in 2000, internist Albert Wu described how physicians can be “second victims” when medical errors happen:

  Virtually every practitioner knows the sickening feeling of making a bad mistake. You feel singled out and exposed—seized by the instinct to see if anyone has noticed. You agonize about what to do, whether to tell anyone, what to say. Later, the event replays itself over and over in your mind. You question your competence but fear being discovered. You know you should confess, but dread the prospect of potential punishment and of the patient’s anger.10

  Wu described the hospital team’s reaction to a resident who had misread an electrocardiogram a few hours previously. The patient had pericardial tamponade, a life-threatening situation in which the pericardium—the sac that contains the heart—fills with fluid. The patient was rushed to the operating room in the middle of the night in extremis, a situation that could have been avoided had the EKG been interpreted correctly. On rounds, the resident’s colleagues were stunned and silent, perhaps because they were secretly afraid that they might have made the same mistake in similar circumstances; they were unable to respond with compassion to their classmate’s shame.

  When I was doing one of my medical school rotations, I was paired with a student who was struggling. He had grown up in a culture where the interpersonal norms were radically different from the environment on the wards of a Boston teaching hospital. When being grilled on rounds, he spoke slowly and modestly—a virtue in his culture—which only invoked the impatience of his superiors. I tried to be supportive, but didn’t know how. I had a sense that his experience invoked feelings of shame, but I wasn’t sure even about that. He withdrew further. No wonder doctors become emotionally unavailable to their patients—they are beaten into not even being available for themselves.

  Even aviation does better. Aviation is not known for being a warm and fuzzy industry; yet after near misses crew members are debriefed, counseled, and given time off. They aren’t returned to the workplace until everyone is assured that they’ve recovered sufficiently.11 Yet, after being present at a stillbirth, we doctors are expected to go straightaway into the next room to deliver a healthy full-term child. An anesthesiologist, after the death of a patient on the operating table, typically will move on to the next case with barely five minutes to regroup. Medicine has learned a lot from aviation in terms of checklists, teamwork, and error prevention,12 but much less about managing the emotional impact of disasters and near misses. Given the imprecision of clinical practice, it’s remarkable that doctors should think of themselves as more infallible than pilots. While feedback and debriefing are now more common, support is often brief and superficial. Without tools to deepen self-awareness and without exploring thinking processes and emotions in greater depth, the wounds fester and no one learns. Unexamined exposure to repeated trauma cannot but cause trauma itself.

  The consequences of secondary traumatization—being the second victim—weren’t talked about much until recently. It has become clear that when things don’t go well and doctors don’t get the support that they (or anyone) need, they often go down with the ship. They are at greater risk for depression and burnout. They feel badly about themselves and, as a consequence, are distracted and less emotionally available to their patients; they become less empathic. They lose their self-confidence and are more likely to make errors in the future.13 They fear future humiliations. Too often, despite experiencing strong emotions, they bury their feelings and instead just focus on survival strategies; awareness and mindful responsiveness take a backseat.

  REMEMBERING

  Physicians remember their mistakes and are haunted by them. They hold them in silence for years, sometimes decades. Their stories reveal their psychological vulnerabilities—unrelenting perfectionism, unforgiving intolerance of error, unease in the face of ambiguity, a desperate need for certainty. While many physicians will acknowledge these vulnerabilities if asked, during everyday practice they usually lurk just outside awareness.

  During one workshop, Mark, a psychiatrist, told of a patient who committed suicide with the medications that Mark had prescribed for him the day before. Mark had never told anyone for fear of being chastised for having given the patient a month’s supply of pills. Mark had been living with a discomfiting sense of ambiguity about his own role in the tragedy, still having intrusive dreams, waking up in a sweat. Should he have done a more thorough assessment of the patient’s suicidality? Should he have prescribed only a week’s worth of medication at a time? He lost his self-confidence. One afternoon at the workshop was devoted to errors in medicine—how we respond when things go wrong. Mark put on paper his recollection of what had happened, what he felt in his body at the time, and the accompanying thoughts, feelings, and emotions. Then he spent twenty minutes sharing his narrative with a partner who had been instructed to listen deeply—to suspend judgment and to try to understand and be curious about the situation and Mark’s reactions. As difficult as it was to listen with openness without trying to console or offer advice, Mark’s partner was able to be present and not avoid or turn away from the painful moments; this invited Mark to do the same. A burden of fear and apprehension was lifted; he was reenergized, more attentive, less afraid of the difficult moments in his practice. He was able to move on. It seemed simple enough, but in the four years since his patient’s suicide, there had been no natural place for Mark to disclose and examine his reactions.

  I could relate to Mark’s story. I also had a patient who committed suicide with medications that I had prescribed that day. My colleagues tried to assuage my guilt without really listening to the impact that event had on me. Everyone just assumed that was part of being a doctor. Get over it. Move on. I later learned that I’m not alone. It is the norm in medicine for colleagues to offer brief words of consolation, then shut down feelings. Yet the wounds fester and never heal; clinicians remain troubled and act in ways that make patients feel that they’re not all there. Some physicians—family doctors, surgeons, psychiatrists—have committed suicide in the aftermath of an error. But when doctors are given the chance to address the impact of a bad outcome, they feel a sense of relief. It’s no longer a secret. Addressing errors means accepting their imperfections, paving the way for kindness and compassion toward themselves, which can then enable physicians to do their jobs better, less encumbered.

  CONFESSIONS

  One of my colleagues in Rochester, Suzie Karan, a senior anesthesiologist, is well aware of how rarely errors and near misses are disclosed and discussed. Anesthesiologists administer powerful medications as a matter of course; without ventilators, IVs, and monitors, these medication doses would be lethal. The work of anesthesiologists in the OR is 90 percent routine and 10 percent terror. When things go sour, there is no tolerance for error or delay. Yet errors do happen and until recently there were few opportunities to debrief.

  A few years ago, Karan started the “confessions” project, now implemented in residency programs at several medical centers. The project has been remarkably effective in bringing errors to the collective consciousness of the house staff and faculty—not only with an eye to identify the causes and prevent future errors, but also to address the psychological and educational needs of the clinicians involved. The mandatory sessions occur weekly for beginning residents, then several times a year for the more senior residents and staff. Each resident brings an account of an event, printed on an eight-and-a-half-by-eleven page in 12-point Times New Roman font to ensure that the reports are anonymous. They record their recollections and impressions, what happened, who was there, what they did, and how they felt, then fold the page and place it into the “confessions” pile.

  Even though the tone of the word confessions implies something gone terribly wrong, the residents do sometimes confess something positive, a disaster averted. At the meetings, the confessions, one from each person, are distributed randomly, and the residents, one by one, read them aloud, not knowing who the writer might
be. The residents discuss the event and what they can do going forward. Sometimes the discussions are emotional. Whether the disclosure is about a major catastrophe or a near miss or an everyday mishap, the goal is to help the residents grow their ability to self-regulate while building support and camaraderie.

  One story was written by a doctor who accidentally spilled an anesthetic medication on the floor. Foolishly, he tried to clean it up himself, and even though he kept as close to the floor as possible to avoid breathing the highly volatile gases, within a minute he became woozy, nearly unconscious. No one discovered him. He got his bearings after several minutes, left the room, and never told anyone. Another resident accidentally gave ten times the dose of an intravenous anesthetic, and while the patient (fortunately) did fine, he never told anyone for fear of being reprimanded. The discussion inspired a collective sense of mindful vigilance and important safety initiatives, all born out of greater self-awareness. I believe that the real power of Karan’s project is in changing the culture of medicine from a culture of secrecy to a culture of inquiry, of curiosity, in which clinicians are vigilant not only of their patients but also of themselves. Karan’s approach emphasizes collaborative problem solving, forgiveness, and learning—all in one gesture—to help the residents to direct their attention to what matters right now, learning from the past rather than replaying the events over and over; the residents could see the events more clearly without the distractions of self-blame or self-justification.14

  GRIEF AND LOSS

  I admitted Ruth Miller to the palliative care unit. She had been diagnosed just a few weeks before with an unusually aggressive lung cancer, which had already spread to her ribs, spine, and brain. She had started radiation treatments, but things only got worse; she was confused, disoriented, and in considerable pain. I informed Ruth’s family—already in shock from the diagnosis—that she likely had only a few weeks, perhaps as long as three months, to live. Her cancer was not of a type that would respond to one of the new targeted chemotherapies, nor to anything else. Family members from different parts of the country were making plans to fly in to visit.

  With medications we controlled Ruth’s pain and cleared her confusion enough so that she could talk and interact with her family over the next few days. She was in her best spirits in weeks. Her family left for the evening. Two hours later, David, her nurse, made a routine check, and Ruth wasn’t breathing. One of the brain metastases had likely hemorrhaged, sending Ruth into an instant coma followed by respiratory arrest. Nothing could have been done to prevent it even if she had had the most aggressive care possible; hers was a quick and painless demise. David was stunned; he and Ruth’s family all thought they had at least a few more days to prepare.

  David was grieving but fearless. He had grown close to the family and wanted to be the one to call them. I overheard the conversation. He gave the news. Briefly. Then he waited and listened. He expressed his own sense of sorrow and surprise in a way that I later learned had made the family feel understood. He asked how their last visit with Ruth had been. He explained what would happen next. David’s grief was palpable to me; his response, though, was present, attentive, and generous at a time when he himself was in shock. He and I spoke for a few minutes afterward to debrief. His grief triggered compassion rather than self-absorption; he was strong enough to acknowledge and be with his own emotions, yet could set them aside to be present with Ruth’s family.

  FALLING SHORT AND FALLING APART

  Doctors tend to take death, errors, and other bad outcomes as personal setbacks. Perhaps a few Zen masters can consistently approach these kinds of ego-crushing experiences as fodder for growth, but the rest of us need help achieving the fearlessness that is required to look our failures in the eye. It means recognizing the fault lines, allowing ourselves to fall apart just a little bit to feel the pain of failure, but not so much that we become ineffective or overwhelmed. Attention training and other contemplative practices are powerful in part because they help you practice letting go of the need to cement things together.

  Grief can be even more intense when clinicians have known patients for months or years. Mitch Porter had seen me for his diabetes for over twenty years. A successful businessman, at age fifty-four he was at the peak of his career. In the past year, he had sold a small business, received a community service award from the local chamber of commerce, and bought a vacation house in Costa Rica. He came to see me because he was having worsening right-flank pain and blood in his urine. I ordered an ultrasound of his kidneys and bladder, expecting to see evidence of a kidney stone. Instead, the ultrasonographer saw a small mass in his kidney and enlarged lymph nodes nearby. Mitch and his partner were terrified and I was filled with dread. I ordered more scans and blood tests to see just how far the cancer had metastasized. The bone scans showed cancer in his spine and nearly every large bone in his body, from his feet to his skull. His lungs were filled with hundreds of metastases, and there was spread to his brain. I started grieving even before he and his family could begin to feel the devastation. I was about to lose someone who had entrusted his well-being to me, and now we were talking weeks.

  As the lab and scan results crossed my desk, one by one painting an increasingly lethal picture, I found myself wondering if I could have done something sooner. While trying to be in the present moment, again and again my mind would go in the same circles of self-doubt and self-reassurance. I felt stupid engaging in the seemingly useless exercise of trying to undo the past. I then asked myself, “Is this cycle useful in some way? Where is it directing my attention?” I watched the thoughts rather than labeling them as useless or obsessive, not grasping on to them, not pushing them away. Then the thoughts of self-blame gave way to a deep sadness. Letting go of self-blame didn’t mean giving up. Quite the opposite. It energized me to do what needed to be done now, rather than trying to undo the past. I contacted his oncologist and his radiation oncologist to discuss a treatment plan. Having entered into uncertainty and instability with my eyes open, I could clarify what I could and couldn’t control.

  A SMOKELIKE QUALITY

  Leeat Granek is a psychologist in Toronto whose mother died after a twenty-year bout with breast cancer. Granek felt a deep sense of connection with her mother’s care team and came to wonder how health professionals deal with their grief when their patients die. So she asked. She interviewed twenty oncologists at different stages in their careers. Although half of their patients will die of their cancer, oncology is a culture in which cure is seen as the goal despite sometimes great odds. Oncologists see their patients frequently. A bond forms. Even when patients have cancers that cannot be cured, many have a reasonable quality of life—for a while.

  Then things go sour. Patients lose weight. The chemotherapy stops working. The side effects become more burdensome, outweighing any benefit. Patients get weaker. Oncologists described how they’d drag themselves into patients’ rooms, consumed by a sense of failure. They would cry in the car on the way home. Some would excoriate themselves, wondering whether they could have done something differently. Some shut down emotionally. One oncologist said, “It is a very bad thing to become emotionally attached to your patients because you’re going to suffer.” Unexamined grief led some oncologists to offer more aggressive chemotherapy to subsequent patients than they might otherwise have, treatments that lead to more suffering with a negligible chance of improving either quality or quantity of life. Granek was moved by the interviews. She said that the doctors’ grief had a “smokelike quality . . . intangible and invisible . . . pervasive, sticking to the physicians’ clothes when they went home after work and slipping under the doors between patient rooms,”15 a feeling that they couldn’t set aside or wash away.

  Not all oncologists responded in dysfunctional ways, though. Some were more like David, Ruth’s nurse. They described how patients’ deaths molded and humbled them, helping them to be more present. Confronting loss made them more careful, more respectful, and less willing mere
ly to accept the status quo. They became activists on their patients’ behalf, whether this meant getting approval for a medication that an insurance company didn’t want to pay for or spending time talking with a family about how to care for their loved one during his final days. The doctors derived a sense of fulfillment from caring for the dying.

  Rachel Rodenbach wanted to find out how and why some oncologists had this capacity for equanimity, advocacy, and activism in the face of death, whereas others didn’t.16 Rachel was a medical student at the time, and now is a resident planning to go into oncology. She sought me as her supervisor for a year-long project, proposing to interview oncology clinicians—doctors, nurse-practitioners, and physician assistants—about their views on their own deaths and how their attitudes influenced their care of patients who were at the end of life. At first I had my doubts. Given how personal these interviews would be, I didn’t know how many clinicians would sign up. But Rachel’s project struck a chord with them, and the majority of those whom she asked ultimately did participate. Despite their impossibly busy schedules, they took the time to talk and reflect. Frequently, the interviews ran over the allotted time; they had a lot to say and found talking to be cathartic.