I Screwed Up and I'm Sorry and Damn It, I'm Going To Say It Out Loud

Genmedmom here.

Anyone who practices medicine knows that sooner or later, we all screw up. Mistakes can be big or small, can result in harm or not. Misdiagnosis, missed diagnosis, delayed diagnosis. Unnecessary tests ordered, necessary tests overlooked. Medication errors, communication errors, clerical errors. Handoffs gone bad, poor signout, lack of discharge followup. Procedural disasters, frank bodily injury.

I've seen examples of all of these; I've been involved in some. I could tell you shocking stories from training. I could tell you shocking stories from last month.

People don't go into medicine planning to screw up, but it's inevitable, and we need to think about what we're going to do when it happens.

When I rotated through surgery as a medical student, I was fascinated by the weekly morbidity and mortality conference (M + M's). It was a highly anticipated event, and the goal was a complete and bloody dissection of a bad outcome. Grizzly semi-retired surgeons, department chiefs, educators, and every trainee sat in a full hall and listened to one poor soul deliver an objective case report, which then was scrutinized, interrogated, discussed. In the end, everyone learned something, and the presenter was, in a way, exonerated. It was a ritual similar to a public confession. 

In internal medicine training, the culture was largely one of finger-pointing. Other people's mistakes were a source of gossip and ridicule; your own mistakes were glossed over, rationalized. Alot of excuses were made. Yes, there were halfhearted attempts at surgical-style M + M's. Mostly, people stewed in their own guilt and shame. It was toxic.

I work in a much healthier environment now, one in which integrity is valued. Error reporting is encouraged, not for blame and punishment purposes, but rather, for learning purposes. The reporting can be done privately, on a systems wide computer application called something like "Patient Safety Reporting". There are occasional medicine rounds M+Ms, and they're run well, but they're just not that common.

It's taken years for me to figure out my own personal M + M's. Writing up a patient safety report is part of it, but, there's more. When there's been a mistake, I try to analyze it, maybe, discuss it with a colleague or two, and then, most importantly, tell the patient.

I had to do this recently... Of course it was a lovely, salt-of-the-earth patient I have known for several years. Someone I've seen many, many times in the office, who I'm very fond of. Such a good person.

When I first realized there had been an error, I started to go in the old, toxic direction. I was just so embarrassed. I imagined the inpatient team on rounds, skewering 'the dumb primary care doc'. I studied the chart to see if there was any possible defensible position, any good excuses I could use.

But that just doesn't feel good. It feels gross. It feels like.. weaselly.

I have a mantra I repeat when I decide to take responsibility, to own the error: I'll take my lumps. It's an old-fashioned saying, but that's how it feels. I'll take my lumps. 

After a long and painful chart analysis, I marched myself up to the patient's room in the hospital and explained to her what had been missed by me in the past, that, if caught back then, may have prevented her medical issue now.

"I really prefer to be straightforward about these things," I stood with my hands folded in front of me. "I'd rather you hear it from me first. And if it turns out that [what I missed] was the cause of [her issue], then I am very sorry."

Then, I waited, waited for any one of a hundred possible responses.

She was quiet for awhile, I think, digesting what I'd said. Her face was serious.

Was she going to kick me out? Fire me? 

Her face softened into a smile. "Oh, don't beat yourself up, doc," she said. "I know no one's perfect. I know you care. If I thought you didn't care so much, well, that's a different story," she laughed. "No, I prefer to move on, go forward. I don't dwell in the past. What's the point?"

We touched base on this again later, and she said the same thing. I've seen her several times since, and she's not mentioned it again. As it turned out, what I missed didn't pan out as the cause of her illness.

Did I get lucky? Maybe. I am aware that one of these days, my M + M approach may end with me getting sued.

But I'd rather be honest and upfront and be sued, than sit in a toxic stew of guilt and shame. No weaselly excuses.

I'll take my lumps.