I’ve been impressed by (and I’m envious of) some physician authors I’ve read lately, including Abraham Verghese and Nortin Hadler. But I was particularly dazzled by Harvard surgeon Atul Gawande’s book Complications . This was not a confessional about a bunch of blunders, but an exploration of how we in medicine get into trouble and end up doing things that, if we had them to do over, we would do differently. That book described a kind of care that recognizes the patient as the person in charge, and the doctor as professional but human, subject to moods, struggles with relationships, frustration, and (yes) mistakes.
For many years I looked after 78-year-old Inderjit Bhalla at home, where he lived with his daughter. This guy had been a successful engineer both in India and Canada, but lately strokes and heart disease had confined him to his house and interfered with his formerly flawless social demeanor and judgment.
Much as I enjoyed talking Indian food with Mr. Bhalla and his charming daughter, my patient always presented a long string of bitter complaints which I had typically heard, investigated, tried to treat, and ended up concluding there wasn’t much I could do for, many times before. And the urgency and persistence of these complaints varied for reasons I could never understand, sometimes getting really desperate. His neck, for example, was always sore. X-rays and a couple of trips to the emergency room only confirmed my impression of simple degenerative disease of the cervical spine.
The neck pain complaints reached an unprecedented crescendo one November, and every time I saw him and examined him I was struck by “pain magnification behavior”: shouting and grimacing when very little pressure was applied, but apparently unaffected by much harder pressure when he was distracted, kind of thing. Several times I explained to the daughter that I thought her dad’s terrible neck pain was mostly due to psychological distress.
Long story short, two weeks into a holiday I went on they called my replacement physician and another x-ray showed osteomyelitis in the sixth cervical vertebra. Infection in the bone. An unusual, dangerous, difficult-to-treat, and certainly extremely painful condition. Hospital physicians rescued Mr. Bhalla eventually, the problem was treated surgically and with antibiotics, and he recovered.
Another time very late one night I was paged by the husband of Marjorie O’Leary, also age 78. She just didn’t look right, he told me. The background here was that the O’Learys both drank alcohol excessively by every standard, Mrs. O’Leary my patient had insulin-requiring diabetes that was always way out of control, and she also tended to get angry at attempts to discuss the diabetes, alcohol, in fact just about anything. Certainly she had early dementia, and enough severe arthritis to confine her to home, where I visited her.
I tried my best to get Mr. O’Leary to elaborate. Doesn’t look right? Do you mean her color is different? Is she speaking normally? Is she in any distress (short of breath, making like she’s in pain)? Does she seem confused? Have you tried giving her some orange juice? The answers weren’t much help, mostly noncommittal or non sequitur. Finally I asked the real question: Do you want me to come and see her? Well, she just doesn’t look right, was the reply. You know Mr. O’Leary I think she may just have had one too many, probably things will settle down, I said.
The next phone call two hours later was from the emergency room doctor at our city’s major hospital. Mrs. O’Leary had come in by ambulance in full cardiac arrest and they had been unable to revive her.
What I did and didn’t do for these two very difficult people sticks out in my mind, but I have no doubt there have been dozens of other similar situations over my 35 years of practice. Could I have made a difference to Mrs. O’Leary if I’d got in the car and gone and seen her? Would a referral, an earlier x-ray, or a bone scan have identified Mr. Bhalla’s bone infection sooner, and made the treatment easier? Hard to say. But there’s no question that in both these situations I the doctor was wrong.
They say we bury our mistakes. Certainly our malpractice insurers carefully try to keep us from admitting them. But that’s the problem. Of course we’re not perfect, but I think we compound the fault of a mistake, by failing to say we made it. I don’t like that patients and their families rarely know what questions to ask and are afraid of confronting us, but do I ever have a problem with our smugness in hiding behind how complicated things often are, so we don’t have to present ourselves to someone whose mother would still be alive if we had done our job really well, and say so.
With my “Geriatric doctor-in-law” hat on, I saw this another way. My wife’s mum Liz nearly died from a complication of a simple procedure in the hospital last year, and the meeting to discuss what happened, while very polite and serious, was essentially exculpatory. No sincere “sorry”, no admission of fault, no offer of compensation, and a not-very-credible explanation of what happened and why. I was angry for several weeks, and considered making a public fuss to expose the people responsible, with whom I felt embarrassed to be professionally associated.
And then, thinking over what might come of my doing something in the media, I wondered what about if Liz (or my wife, I, one of my kids) needed inspired beyond-the-call care by that community of specialists in the future? I said nothing.
What’s the solution? Be honest! Shoot straight! We are good at what we do, and we shouldn’t mind somebody looking back at the record. Imagine the impact on a worried patient if he knew he could trust me to respect what he really wanted, do my best, and admit my mistakes.