The Last Time I Made a Mistake as a Doctor
Forewarning: You are about to enter the territory of a doctor’s interiority. If you would rather see your physician/all physicians as gods who make no mistakes, or if you are in healthcare and aren’t ready for your “it’s always the other guy’s mistake” bubble to burst, or if you aren’t kind about other people’s vulnerability, please STOP right here. Thank you.
A large proportion of people experience medical mistakes when seeking care. And over half of these mistakes are diagnostic errors made by clinicians. For instance, one wrong drug is given in every 133 cases of anesthesia. Up to 3% of cancer patients have had the wrong chemotherapy medication given to them. And one in five people has had a wrong tooth extracted. Even with the low frequency of autopsies performed, medical errors have been named a leading cause of death in the US. But when surveyed, fewer than 1 in 10 surgeons think they have made a mistake. And only 10.5% of physicians admit to having made any medical mistake in recent months. There is a high mismatch rate between a doctor’s confidence and the reality their patients live in.
There are many reasons for physicians’ overconfidence. And some studies found that the worse diagnosticians have higher confidence. Additionally, when medical errors occur, we assume they are made by others, not ourselves.
This led me to look inward and ask myself: when was the last time I made a mistake as a doctor? I pondered this question while going on a long walk with Moshi Moshi, my Labradoodle puppy. The answers opened my eyes.
“The last time I made a mistake was NEVER,” I mumbled. Moshi cast a doubtful look toward me and tilted her head as if to say, “Really, mama?” She quickly disabused me of the delusion, so I kept searching. I meant that the last time I made a fatal mistake was never (I hope).
It must be the time when I was an intern (first year of residency) when I thought a young woman had a heart attack after quickly reviewing her EKG and seeing “ST elevation” everywhere — a buzzword for “big bad heart attack,” and called the “STEMI alert.” This was 3 am. Needless to say, I woke up the entire hospital, including the heart cath lab team, the anesthesiologist, and an interventional cardiologist who was sound asleep at home. My senior resident glanced at the EKG and ran to the phone to cancel the alert. “Zed!” He tried to remain calm between breaths, “call me next time before you push the STEMI alert button. The patient has pericarditis (inflammation around the heart), not a heart attack.” Oh crap. I called the cardiologist to apologize to him, and he kindly gave me a lecture on how to differentiate the two diagnoses. And my senior resident, as the protective teacher he was, took it upon himself to apologize to the patient and family for the scare.
Moshi Moshi wagged her tail at me when I looked down at her.
Ok. Ok. I rolled my eyes. This wasn’t the last time I made a mistake. This was just the last time I was publicly embarrassed by it.
How about the time when I was a third-year resident when everyone assumed I sort of knew what I was doing, and the interns looked up to me, and I told a first-time mother-to-be she was not in labor and sent her home in a snowstorm? As it turned out, she was not only in labor but progressed very fast. Luckily, she returned to the hospital (in the snowstorm) just in time to have an uneventful birth.
Moshi Moshi stuck out her tongue and pulled her fluffy ears back. FINE. That was just the last time I had a memorable near-miss kind of diagnostic mistake. I will keep digging.
Oh! I know! During my first year as an attending physician, full-fledged, practicing under my own license, I injected steroids into a patient’s thumb for “arthritis,” only to find out later that her pain was due to a flare-up of her fibromyalgia. Moshi Moshi got bored and started to pull the leash, chasing after a squirrel. No? Hmmm…Oh! There was a time I misread the normal X-ray of a young boy’s knee and told his mother he had a fracture. No, those were still a couple of years ago, which in medicine, feels like a lifetime ago. They couldn’t be the LAST time I was wrong.
How about this one? Right before fellowship last year, an uninsured patient came to me with recurrent skin cancer on her face and asked me to cut it out. Although this was not an aggressive kind of skin cancer (aka melanoma), I recommended that she go to a dermatologist for it since it was in a cosmetically sensitive area. She told me she couldn't afford it due to her lack of legal status and insurance and that she would be ok with taking the risk of having me cut it out. After a few failed attempts to find her resources and persuade her to reconsider her options, she convinced me to give it a try.
The surgery went well enough, as in, the cancer was out, and the patient did fine throughout the procedure. But I was terrified. My heart was pounding, and my forehead was sweaty. After a few months into my dermatology fellowship today, I am painfully recounting the things I could have done better and the potential bad outcomes that could have resulted from my lack of training — all the thoughts scary enough to send me into cold sweats. Ok, now we are getting somewhere now, right, Moshi?
Six months and many feminist healthcare-related books ago, I underestimated a woman’s pain because she commented on my outfit while telling me about her pain. “How much pain could she possibly be in if she was still paying attention to my clothing?” When I talked about this incident, a friend kindly reminded me that this dismissal and disbelief of a woman’s pain was precisely why we have a gender pain gap in medicine. “I would still be polite and show my appreciation to the doctor even if I had 10/10 pain,” my friend said. She was right. I was participating in the problem of sexism and maybe even misogyny in medicine. Feeling very ashamed, I thanked the friend and got myself educated. And the last time I self-inspected for intrinsic bias was last week. And I will introspect again this week, next week, and all the weeks and days after.
I gave a determined look to Moshi Moshi, who was now slowing down and paying more attention to me.
At this point of our walk, Moshi Moshi and I have made it almost back home. We passed by a historic house which is now a museum, and decided to sit down in the garden to gather our thoughts. The puppy looked at me with her tongue stuck out, tired and panting. “Moshi, it looks like whatever we think our last mistake was, it wasn’t really the last.” Pant, pant, pant. “And I think that’s ok. Right, Moshi?” Pant, pant, pant. (She agreed.)
Research shows that medical students are underconfident in their diagnoses, while residents and attendings are overconfident. Specifically, residents have the most significant mismatch between being confident that they are right and being actually right. This is very interesting. How do we go from the underconfident, humble medical students to the overly confident physicians-in-training so quickly? Where, along the way of our young careers, do we shed some humility and put on some complacency?
The answer is complicated, of course. Perhaps it’s the transition from a non-decision-making member of the team to someone who carries liability, with more to lose. Maybe it’s burnout. Or it could be time constraints or the pressure to produce and perform. Whatever the case, it’s beyond the scope of our little walk and the thought exercise. Pant, pant, pant.
As I opened the gate of our apartment complex and started to walk upstairs, Moshi Moshi watched my every step like the good girl she was. “The last time I made a mistake as a doctor was probably….” She tilted her head again, waiting for me to arrive at the correct answer.
“Yesterday. And I probably will again tomorrow.” Pant, pant, pant.
The goal isn’t to never make mistakes again. The goal is to listen to and believe patients, know we might be wrong and will be wrong, seek feedback, and look into ourselves. Now I am sitting on the floor of my apartment, stretching. Moshi Moshi came over with her little face wet after gulping water and put her paw on my leg. Oh yes, and the goal is to take more walks with the good puppy. Pant, pant, pant.
Disclaimer: Patient information and stories are significantly altered to protect their identities and privacy. No harm has been done in the above experiences to any patient.
