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.

"Your child has a fever--Come get your kid"

Has anyone ever gotten this kind of call from daycare/school before?  (I am sure someone has...)

Yesterday I was nearing the end of my clinic day, without any more patients scheduled, when I got this kind of call.  It was about 2 PM and my first thought was, "I wonder if they can just keep her until 5?"  But they said no, come now.  I figured, "Well, no biggie, nobody is scheduled anyway."  

I went to the front desk to inform them that I was heading out early and was met with a sour face and a lecture on parenting.  The secretary informed me, "Now, you know that you need back-up child care for situations like these?"  (This actually went on for a few minutes while she proceeded to tell me how it was irresponsible of me not to know who was going to be picking up my child in case of emergency while I was in clinic.)  The conversation came to an end when she said, "When you're a real doctor, you're not going to be able to just take off, you will have actual responsibilities."  All of this, mind you, when I actually had zero patients scheduled the rest of the afternoon.

I was furious the entire drive home (still am, as you can see).  How dare she give me a talk on parenting and doctoring!  Then I thought of a million reasons other non-parents might need to leave clinic on a short notice.  Maybe they themselves aren't feeling well (crazier things have happened.)  Maybe another non-child member of their family has an emergency.  Maybe they have car troubles on their way in and actually come late rather than leaving early.

What do the other moms-in-medicine-without-reliable-husbands do in situations as above?  Does everyone have an emergency back-up besides themselves for sick days?  Is there a single person out there who has never, not once, been to work late, or had to leave early, or missed a day altogether, for a sick child/sick parent/sick themselves?  Are we not just human people working as doctors, that do have the same ailments as our very own patients??

Comfort

I used to think that I was drawn to hospice practice because I wasn't one of those doctors that had to fix everything. I'm comfortable with the incurable, the insoluble, the chronic and unremitting. I don't see death as a failure of my medical skills. Nope, not me. I'm not like that. I don't have a personal need to cure.

Except....I do still have a need to fix things. I don't feel compelled to cure; I feel compelled to relieve suffering. I need to make pain go away, ease shortness of breath, make the nausea stop. I need the furrowed brow and the tense muscles to relax. I need to make things better. And most of the time we can. We have morphine and humor and steroids and Haldol and ice packs and Ativan and massage therapy and music and pets and chaplains and social workers and aromatherapy and our own presence. When our patients are suffering, we can bring comfort.

It's more challenging to bring comfort to the families. Pain goes away. Grief must be borne. We can provide some companionship and support; in the end, though, grief is a solitary journey. A husband's tears or a daughter's anxiety leave me feeling powerless in a way that the patient's pain and shortness of breath do not. I want to do something, and I know I just need to stand there.

Today was a little different. Today, oddly enough, two different family members needed something I could give them. Something simple and available and entirely over-the-counter. They needed water. Twice this afternoon, I walked down the hall to our ice machine and filled a cup with ice and water, carefully placed a lid on top and collected a straw. I brought the cups back to the quiet rooms and placed them in the waiting hands. And I felt much better.

Home Alone

This summer, my three kids spent several weeks with my parents in their home in Connecticut.  For the kids, this is an amazing time when they bond with their grandparents and get away from the city.  For my husband and me, this is an amazing time to spend a few weeks focusing on work, spending kid-free time together, and getting a break from the day to day bustle of life with kids.

This summer I realized another bonus: that I could be HOME ALONE!  Yes, you heard what I said. At home with no kids, no husband, no nanny -- no one but me!

For people without kids, the simple pleasure of being in your own home with no one else around may not seem that exciting but for a mom who never (and I really mean never) gets to be home alone,  this simple pleasure is on par with fancy dinners, spa days, and juicy beach reads.  Being home alone is one of the most delightful experiences of my life as a mom.

When it first dawned on me that I could be home alone for hours at a time, I felt like the little kid from the movie Home Alone when he first realized that his family had disappeared during holiday break.  I wanted to sit in my pajamas, eat potato chips, and watch movies all day.

Of course, I had other things to do and couldn’t spend hours on movie marathons but during the two weeks when I had a few hours at home with no one else, I started to think about how rare and important alone time is.  

There’s something peaceful and rejuvenating about being in your own home when no one else is there. And it’s different to be home alone rather than other places alone.  I am alone in my office a lot but that’s different. I try to get along time by going to the spa or going to a bookstore but that too is different – it doesn’t last for long and I’m not in my own private space.

As working moms, I wish we could have more times home alone.  Not just quiet time after the kids are in bed but real time – hours when we are not exhausted, can have the freedom and comfort of home, and just enjoy the special place that we have built.  I think many of us are looking for the chance to let our hair down and if not literally but figuratively sit on the couch and watch a movie marathon.

In the months since summer, I have counted the hours when I have been home alone. I don’t think I’ve hit 5 hours yet.  I don’t know if I’ll add any more hours until next summer but there’s no question that I’m already anticipating my two week break and the bliss of my time home alone.

Things I wish I knew before starting med school with kids

1. That tired drinking out of a firehose analogy...unfortunately true. I remember being appalled when I read that med students study multiple hours a day on top of going to class. I foolishly thought on my days that end at noon (Monday and Friday) I can pick my daughter up from preschool / go to the gym / twiddle my thumbs. Instead, I am thankful for an afternoon with no class so I can hole up in the library and study. The endless studying is not death, falling behind is.

2. Wearing a half-face respirator during anatomy lab makes me look like Bane from Batman. But hey, that's a pretty good trade-off for formaldehyde-free breastmilk. And the puzzled looks I get when people see the lingering lines on my face after removing the mask -- extra giggles.

3. The lactation room is the mecca of multi-tasking. Pumping can be accomplished while eating, studying, napping, crying, making phone calls, etc. Bonus points for attempting three things at a time.

4. Whatever makes your life easier, and if you have the means, do it. Examples include ordering food, dry shampoo, a breast pump car adaptor, skipping a bath or two for the kids (hey they could have dry skin?).

5. GET YOUR CHILDCARE SITUATION FIGURED OUT AND SET (x10000000)

6. You will be older than some of the MS2s-MS4s, the same age as some residents or even attendings. Bless your eye cream and good genes, although four years of this will probably negate all of that.

7. Saying no is okay.*
"Want to study together at extremely-far-from-my-house coffee shop at extremely-inconvenient-hour?" - No.
"Want to go rage after block exam and stay out all night?" - No.
"Want to join a thousand interest groups and shadow everyone possible in the hospital?" - No...maybe second year?

8. *It is also okay to say yes.
"Need help?" - YES!

9. Your classmates will be amazing people who have done amazing things. Everyone is incredibly supportive and no one is trying to sabotage you unlike the undergrad premeds.

10. And now, a visual representation of your life:

still smiling though!!! 

Introducing Myself

Hello! I'm Jay. I've been hanging out here and commenting for a long time. I used to blog on Two Women Blogging (don't go looking - you won't find it) which shut down about three years ago. I've written under my real name for HuffPo and NYT's Motherlode. Last June, my essay about my father appeared in Pulse (do you read Pulse? You should!).

These days I mostly write narratives for hospice patients. I was a primary care doc for 20 years; for the past six years I've worked full-time as a hospice medical director. That means I see patients in our 10-bed inpatient unit, do a lot of home visits, attend three IDG* meetings weekly and take weekend call with our palliative care group. We have fellows and residents and med students so I do a fair amount of teaching, too.

My daughter, Eve**, will be 16 in January - she could tell you precisely how many days it is until that momentous occasion. I love having a teenager. I'm sure you'll hear more about that. I've been married nearly 31 years to Sam** and you'll hear more about him, too.

Thanks to KC for founding and maintaining this great site and especially for inviting me to join. I'm delighted to be here. Now if I only had something to say....***
____

* IDG = Interdisciplinary group, also called IDT (interdisciplinary team). The IDT is the core of hospice work and consists of nurses, social workers, chaplains, aides and doctors.
**The names have been changed to protect the mother.
***I'm really not worried about that. It's more likely I won't be able to shut up.

MiM Mail: Am I crazy?

I am a 31-year-old, hospital-based speech therapist in TX who will apply to medical school in 2016. As a newlywed several years ago, we found out my husband is gene-positive for Huntington's disease. Obviously it's a devastating diagnosis, but, fortunately, no one in his family has shown any symptoms prior to age 65.

I have always wanted to be a physician and my husband has been incredibly encouraging of my dream. We completed preimplantation genetic diagnosis with IVF and have 4 healthy embryos.

Now I/we have been hyper-analyzing when to implant. I've thought about everything from this January to M4. If we shoot for Jan/Feb/March, I could have nearly a year with my little one before med school starts. But I could look pregnant during my interview. Should I wait to ensure acceptance? Am I crazy to consider pregnancy now?

I would love your opinions!

MeriAnn

First outsourcing of help

Well, I have done it.  After years of considering this, I have made the decision to hire a cleaning lady.  I have always felt perfectly capable of doing my own dusting/vacuuming/etc. but the time has come that I feel it is too much of a burden with not enough reward.  I feel so so guilty about the money it will cost, but I know it is a small price to pay for extra hours with my family, or just some time to relax instead of clean.

This cleaning lady was referred to me by a coworker, and I was secretly hoping that when she came to meet, I wouldn't like her, or feel that she would do a good job.  But I had such a good feeling about her and all that she said she would do... Clean the windows???  Vacuum under the couch cushions??? For me, this is a one time per 6 months kind of cleaning (please nobody judge)!  After she left, I asked my husband, "Have we really gotten to that point in our lives?"  I am turning a blind eye to the money, and I know it's worth it, I know it's worth it... is it worth it??

Our foremothers

Foremothers? Maybe it's not even a word. I was trying to find a term like forefathers.

I often think about the women who have come before us. As I walk through the halls of our medical school, I see class photos from decades past with 1 or 2 women amongst a sea of male faces. I often wonder whether they had children during their training or afterward, or were they 'discouraged' from getting married or having children? How did they function as female doctors and perhaps mothers in a world that was probably less understanding than what we face today?

I would bet they faced great hardships--particularly sexism beyond what I can comprehend. They may have anguished over pregnancies they had to hide, grieved over the lack of child care options, and struggled to satisfy unrealistic expectations of their employers. And just maybe they dreamed about us--the women who would follow them--and hoped our lot would be easier.

It reminds me of a female doctor from my mom's era who didn't tell anyone she was pregnant in medical school then didn't show up for a test one day.  Yep, she had her baby and came back to school within a week!

I am forever grateful for the trails our foremothers blazed and admire their courage. They are true heroes to me.

MiM Mail: Advice for an ex-husband of a MiM-to-be

Hello!

Being a father not interested in medical school makes me a somewhat non-traditional reader I imagine.

I am ultimately writing for advice. I read a number of great posts on your blog, but I am coming at this from a different direction and was hoping one of you would be able to point me in the right the right way.

My ex-wife is a brilliant woman in her Junior year of her undergrad and planning to start applying for medical schools. We have a good co-parenting arrangement and try to do our best by our three boys (4, 5 and 7). I am no longer in the medical field but do have 8 years experience as a critical care paramedic so I can appreciate both how talanted she is and how hard her road is going to be. She is going to apply locally but is also looking at the Virginia area due to family there. I am willing to consider relocation if I can find appropriate work (I work in IT in a rather specialized area).

My question is, how can I best approach the subject of custody? I don't want to take the kids away from her by any means (she is a fantastic mom!), but I am concerned that raising three young school age boys while attending medical school will be overwhelming. She can accomplish anything she sets her mind to, but even she can't accomplish *everything*.

My initial thought is to offer/ask to take the custodial role, freeing her up to apply herself 100% at school while still affording the boys a stable home life and predictability in routine. I don't know for sure how she would receive this, but suspect she would at least be willing to consider it. Then again, as a divorcee my ability to mis-read her intentions is a matter of public record. : )

There has to be a mutually beneficial way to handle this situation that benefits all of us, and I am looking for advice on where I could look for information. I have looked at some of the schools websites for information on family services offered by medical schools but it's hard to find in a lot of cases.

If you have a moment, would you be able/willing to point me in the right direction, or even offer some insight from your own experiences?

Many thanks for your time!

Life in between my notes

Instead of doing notes this weekend I:

• made a fall collage with Zo using leaves and clippings from free magazines
• went on a date night with the hubby during which we ate amazing food and had delicious lavender mojitos and then both almost fell asleep during the movie (don’t go see the new 007: Spectre, it sucked!) and remarked countless times how we wish we had just stayed home and caught up on the Walking Dead
• caught up on the Walking Dead with the hubby. (spoiler: Glenn no!!! and geeze how does Rick run soo far in those cowboy boots and tight black jeans, I’d have blisters and chaffed thighs!)
• listened to Oprah and Deepak’s day 6 and 7 morning meditations. It’s beautiful but I don’t quite know how to pronounce the meditations.
• washed clothes and then folded them with Zo. Who knew 4 year olds were such excellent folders?!?
• made amazing pumpkin chili (check out http://www.popsugar.com/food/Pumpkin-Chili-Recipe-35890481)
• am thankful that after finishing this post I’m just going to go to bed and it’s only 10:21pm and I’ll start the note writing again tomorrow morning at 5am. Only 38 to go!

Cheers to a week of chaos

This past week was pure chaos. Our nanny of three weeks did not show up Monday morning. Nor did she show up Tuesday or Wednesday. It is now Tuesday the week after and I have yet to hear from her despite multiple calls, texts and emails. I'm not quite sure what happened. At first we were worried and imagined the worst, but a little social media sleuthing revealed she is alive and well, but decided to take a vacation and just doesn't care about coming back. I'm shocked that people act like this (I mean really, are you ever going to give my keys and carseat back?!), but I'm over it. This isn't the focus of my post, but rather, the amazing people in my life that rally and always seem to help make things work out. I am a little late to the thankful train, but I am very very thankful for...

My husband who handles chaos like a pro and always reminds me we're on the same team.
SK for being as patient as a 4 year old can possibly be while watching me stream respiratory lectures. She was very confused as to why I don't learn about mermaids in school and suggested that I bring this up to the administration.
SE for sleeping 9-10 hour stretches at 5 months (bless you) and being the happiest, smiliest baby ever.
My amazing mom who jumped on a plane as soon as she heard about our nanny nightmare.
My kind classmate who volunteered to switch spirometry labs with me so I could work out alternative childcare plans.
The timing of this chaotic week...at least it was the week before Thanksgiving break and now we are all together celebrating with family and friends.

Happy Thanksgiving all (even you, former nanny).

MiM Mail: Making residency safer for pregnant residents

Mothers in Medicine! I am seeking your advice/expertise on the difficult subject of how to treat pregnant residents. A little background: I am a chief resident at a busy anesthesia program that takes frequent and draining 24 hour calls in the OR. Those calls are such that, most of the time, the call room is a distant fantasy. I am also a mom to an active preschooler and pregnant with #2. All was going well until after a particularly exhausting 24 hour call, when I started having frequent, regular contractions at 20 weeks. I had to take several days off work and (thankfully!) things calmed down. I'm now trying to ease myself back into the OR call rotation.

My question for all of you who have been through a resident with tough, frequent 24 hour calls or night shifts... how did your program handle pregnant residents? I've heard from friends at other programs about policies that were put in place to limit calls because so many pregnant residents were going into preterm labor. Other programs limited night shifts for the same reason. Obviously, these changes put strain on non-pregnant residents. Was there widespread resentment to enacting such restrictions?

Amazingly, I'm the first resident to be pregnant at our program in over a decade, but I know there are many women behind me hoping to do the same. I'm hoping to find some common sense changes that can be made to keep pregnant residents working, but in a safe way for mom and baby.

Thanks in advance!

Welcome to Topic Week: Being Thankful

Welcome to our MiM Topic Week! Posts from regular contributors and readers will be spread out over the next week. We hope you will join us in reflecting on this topic as we explore being thankful from our different perspectives and experiences. Thanks for reading and being part of this community.

Scroll below to find the posts.

It Takes a Village

It’s a good day to be thinking about gratitude. I just got the results of my Pediatrics boards and, mercifully, I passed. Like many things in the life of a working mommy, the whole boards process felt fragmented, stuffed into the crevices of an already packed schedule. I studied in stolen hours, early in the morning, late at night, during E’s naps, during quiet moments on call. There existed the dream of reading the textbooks cover-to-cover, mastering the seemingly random landscape of dysmorphisms and eponymous genetic syndromes, committing to memory, not for the first time, the detailed physiology of the nephron. Instead, I did as many practice questions as I could and read all the explanations and made a stack of index cards that I only had time to review once before the test. Studying certainly helped, but what carried me through the process were my patients, the hundreds of people whose stories constitute my fund of knowledge. The symptoms they had, the way their bodies looked and felt under my hands, the labs and images I reviewed in an attempt to understand them, the medicines we prescribed, the way things turned out. All the babies whose birth weight I guessed just before putting them on the scale. All the toddlers who scribbled, babbled, stooped, and recovered during their well-child visits. How do I remember Hurler’s syndrome? I remember A, from my first year as a clinical student, and his mother who carried him everywhere in her arms even at the age of seven, because she could not afford a wheelchair. In the boards review study book, they used phrases like “coarse features” and “macroglossia,” but I just remember his face, whose beauty became more apparent to me over time, and all the grief and tenderness in his mother’s voice as she sang to him, more effective than any medication at calming his agitation. I can only hope that what I have given is somehow proportional to what I have received.

The medical path – and especially the parent-in-medical-training path – has been much harder than I expected and when I reflect on this path I chose, gratitude isn’t always right there on the surface. But when I opened the Boards score report, it was right there. I looked up from the computer and the first thing I saw was my spouse. I thought to myself, “How can a person be so steadfast in the support of another?” I am in awe of it. I was the one who first brought up the idea of having a baby in my last year of medical school, before starting residency. I spelled it out to her over the Formica table in our then-kitchen – how we would have an infant while I was taking 24 hour calls and working long days, how it would be an insane juggle. She said, “That seems like it’s going to be really hard.” But it felt like the right time. We gambled and got a jewel, our daughter E, who is infinite light and delight. But it has been harder than hard. Over the last three years my spouse has done breakfast, drop-off, and pickup almost every day, dinner and bedtime too many days, whole weekends, whole weeks, whole months, sick days, unexpected call-in days, holidays. She gives our daughter what I wish I could be giving her when I’m not there, and so much more. She gracefully bolsters me in my mommy role even though I spend less time with E, when I can imagine a different person laying claim to the “parent-who-knows-more” position. She keeps us well-fed, keeps our household functioning, and through her eyes, I feel beautiful and powerful every day. She does all this while navigating her own full career as an artist and teacher. She has sacrificed some of her own creative and career advancement over the past three years so that I could forge ahead. I know it is painful for her at times – not what she signed up for, even though she did (good love isn’t as simple as they say) – but her loyalty and support just keeps shining and it lights my way and keeps our family warm.

So there are many layers to the gratitude I am feeling on this, the first day of the rest of my professional life. Gratitude to my patients, who are my teachers, who have accepted my inexperience and given me the gift of their trust and allowed me to participate in their lives in a profound way. Gratitude to my spouse, for EVERYTHING. Gratitude to my parents, which is a whole essay in its own right, the YEARS of patient attention and thoughtful decision-making, late night high school research paper crisis management and SOS babysitting saves, self-sacrifice and deep concern for my well-being. Gratitude to my friends, who have stuck with me through long silences. Gratitude to my colleagues and attendings, for saving my ass and helping me find my voice and for caring so much and taking great care of patients and teaching me by example. The African proverb “It takes a village to raise a child” has become so cliché at this point as to have almost lost meaning, but I’m thinking today about the village that raised me, and no words of gratitude are adequate. I will have to thank them by trying every day, with the best of myself, to be of service to the world.