What do we do when we can do better?

As hospitalists, we talk a lot about improving quality and patient experience. These are two things that are considered points of emphasis for us. Maybe even points of pride when we point out successes. Unfortunately, sometimes we are just not at our best. Sometimes we are not as connected with our patients as we should be, or we make mistakes. I had one of those weeks my last week on service.

“Jay” (not his real name) was my last admission of a very long day. It was late enough that I could have turfed him to my night colleague, but I thought I would just quickly knock this one out. I had taken the triage call from clinic – a previously healthy 36 year-old with progressive shortness of breath. A CT scan done by his primary physician showed multiple bilateral pulmonary emboli. No past medical history, no prior medications and vital signs were stable. We even pondered handling this as an outpatient. It was 6pm on a Thursday night and his doc thought he’d be pretty anxious, so we decided to “Obs” him overnight.

I was looking forward to a straightforward admission. My week had been otherwise dominated by high numbers of patients, cryptic signs and symptoms, unclear diagnoses, and patients worsening despite my best efforts. When I received the page that he was on the floor, I strode down the hall ready to rush through this one. Draw some labs, start some anticoagulation. That’s it. I had this one. Easy. Maybe even a high five on the way out since this was something I could actually intervene on and fix. Tonight I would finally get home to see my kids (the past two nights I’d been leaving home early and working late and had only seen them in bed).

Within seconds of entering the room, I had the sinking feeling we all get when we realize something is going to take much longer than originally planned. Jay (with stable vital signs) was perched on the edge of his seat clinging to the armrests. His eyes were wide, as were those of his father sitting next to him. And though a quick and straightforward history and physical exam confirmed the diagnosis from clinic, there would be no high five on the way out.

What I had forgotten to prepare for in my quest to get home before my kids’ bedtime was the impact of this diagnosis on Jay. Like most healthy thirty-six year-olds he had minimal prior contact with the medical system. He had one young child at home and another one on the way. He was the typical American male –overweight, sedentary job, less-than-optimal diet. Recently trying to get in shape he had done two recent 5k races. While the diagnosis and work-up were easy for me, he needed to understand why this had happened, he needed to know what to expect, and he needed reassurance that things would be okay. Counseling on these, and the list of questions they generated for Jay and his father, took well over an hour and spun into more and more questions. While I sat there answering his questions (hopefully appearing calm and patient), part of me couldn’t help being irritated with his continued questions and the time it took to answer them.

Reflecting on Jay’s situation and my response to it was a good reminder that our patients’ experiences and perspectives are vastly different than ours as providers. We have a responsibility to do our best for them. We need to care for them, not just deliver care to them. As a consumer of medical care myself, if anyone should remember that, I should. It didn’t feel like my best effort as a doctor, and I knew I could do better.

Last week I had several less-than-shining moments. I ordered the hemoglobin but not the creatinine on a patient with anemia and renal failure. She had required three attempts to get her blood the first time, and I had to send the lab tech back in to dig around in her arm AGAIN and find a vein, causing her more pain and irritation. This was all because I forgot to order both of the necessary blood tests prior to the lab rounds. The next day I mixed up two of my patients, greeting one by the other’s name (one was an 87 year-old with COPD in for a CHF exacerbation, the other a 78 year-old with CHF in with a COPD exacerbation – both short of breath). There was also the patient who had been constipated who was successfully unblocked with several interventions the day before. She received her daily dose of laxatives despite having six loose stools in the past 24 hours. She would now have extra trips to the restroom to look forward to. Oops!

Many strategies have been suggested for decreasing the trauma of hospitalization. Detsky and Krumholz suggest decreasing the trauma of hospitalization by many interventions, including encouraging personalization, minimizing uncertainty, reduce stress and disruptions, avoid unnecessary tests, encouraging activity, and providing a post-discharge safety net. These are all excellent suggestions, and they give us actionable items, but on a more basic level, I think that most of these things come back to the Golden Rule – treat others as you would want to be treated. We need to empathize with our patients and to enter into their suffering with them.

However sometimes empathizing with our patients is not even enough. Sometimes we have a bad day. Sometimes we just plain forget. So what do we do when we are less than perfect? We are human after all.

With Jay, I took a deep breath and reconciled myself to the fact that I would not see my kids that day. For the others, I spent a lot of time apologizing: “About your diarrhea – sorry. I did that to you.” Or, “I am sorry that I forgot to order your kidney function test, but it’s really important and I need to ask our lab tech to poke you again. ” Or (hand slapping forehead), “Agh! I just saw another patient with that name. How embarrassing!” None of these are medical errors that I expect to land me in a malpractice suit, but at least some of them made a worse day for my patients.

We are told that we learn from our mistakes. I would like to say that I won’t repeat mistakes like these again. The sad reality is that I probably will. We do our best to create systems that minimize major medical errors, but what about the smaller ones? I am confident I will forget to order labs on a patient again. Working with people I have never met before, I will probably mix up names again. And I can’t always get in to see someone before the morning meds have been passed.

I can, however, apologize if I make a mistake. I can try to find it in me to forgive myself, to laugh at my own humorous shortcomings, and to apologize when appropriate; I can try to forgive myself too. I find that most of the time when we are honest with about mistakes patients are very understanding. And I don’t know why, but for me, it seems like shortcomings or mistakes happen in clusters. Here’s to a better week the next time I’m on service.

Brett Hendel-Paterson

Dr. Brett Hendel-Paterson wears several varied professional hats. He is board-certified in internal medicine, pediatrics, and palliative care. He is a med/peds and palliative care hospitalist at HealthPartners Regions Hospital in St. Paul, MN. He also has tropical medicine training with a CTropMed® from the American Society of Tropical Medicine and Hygiene (www.astmh.org), where he is a counselor with the clinical group. He is an assistant professor of internal medicine and global health at the University of Minnesota (www.globalhealth.umn.edu), and he is a codirector of the University of Minnesota Global Health Course.

His professional passions and interests span medical education, palliative care, health disparities, internal medicine, tropical/travel medicine, and immigrant/refugee health. When he is not attending he is active working with the global health track in the University of Minnesota internal medicine residency.

He received his undergraduate degree from Grinnell College, attending the University of Minnesota-Duluth for medical school, and the University of Minnesota for his med/peds residency.

Outside work, he spends his time chasing down his two sons in elementary school, enjoying the outdoors, exercising, cooking, and music. His recent diagnosis of Chronic Lymphocytic Leukemia in the summer of 2013 has required some significant work/life rebalancing and has underscored the importance of caring for patients in an empathic and kind manner in times when many are feeling particularly vulnerable.

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