There exist, in truth, three simple words that strike dread into the hearts of every physician:
Do. You. Remember.
This phrase was introduced to me in the middle of first year. I was spending time in my medical student lounge when a link popped up on my newsfeed to a TED talk by Dr. Brian Goldman, an emergency physician from Toronto who hosts the radio show White Coat Black Art and who has also authored the book “The Night Shift.” In the video, Dr. Goldman reaches out to the audience about changing the medical culture of silence around making mistakes (check it out if you haven’t seen it yet, it’s worth the break).
When I watched the video of Dr. Goldman speak, it was clear that he was haunted by the encounters that left him remembering specific patients.
Fast forward two years. I’m in a family medicine clinic, trying to learn the ropes of ambulatory medicine. A lot of the exposure here is the “bread and butter” cases: sore throats, fevers, rashes, well baby checks, immunizations—all good for honing in on a consistent approach. The work done by clerks involves history and physicals, contributing to an assessment and management plan, as well as conducting basic procedures. To assure patient safety, we’re supervised and things are double- and triple-checked by residents, nurses and the attending physicians. I assumed it was a pretty safe system.
Yet one Wednesday morning when I was just arriving to the clinic, Angie, the team nurse pulled me aside. She had a phone in her hand.
“Hey Jim, do you remember Greg Foster?” Her voice was hushed, almost solemn. “He came in yesterday with the sore throat.”
Yes, Mr. Foster, 45-years-old; he had a two-week long sore throat and a cough that worsened over the course. He stated that the cough did not bring up much sputum, but did produce a sparse, thin and white mucus. No fever, no shortness of breath, no chest pain. No nocturnal symptoms, but he did feel his voice was hoarse. He was not travelling recently and never smoked. On examination he appeared well, not dyspneic, with an occasional dry sounding cough. His heart sounds were present and normal, and his lung fields sounded clear. Pretty much unremarkable up to his pharynx which did look red and irritated but without any swollen glands or petechiae. All vital signs stable. As per the protocol at our clinic I brought in the attending who conducted his own exam. Satisfied, he suggested I perform a rapid strep test but predicted, correctly, that it would be negative.
“It’s good for you to practice doing these things.” He said, as Mr. Foster was amenable to the idea with a trainee practicing on him.
In the end we thought he had a case of viral pharyngitis and he would soon recover with some more rest and symptomatic management. Mr. Foster seemed reassured and left, and I logged the case, which the resident also reviewed and signed off on. Later my attending reviewed some clinical pearls for sore throats: the group A Streptococcus pharyngitis guidelines, red flags for more serious conditions, and which diagnoses you want to make sure are ruled out (such as peritonsillar abscesses, cancer and epiglottitis). This is pretty typical on how the cases went for me: straightforward.
So why was Angie asking if I remembered Mr. Foster? A low rumble of dread swelled in the back of my head. What did I miss?
“Yes, I remember him. He was here yesterday with a sore throat.”
“Yeah, it’s his wife calling, she’s very upset because he was rushed to the emergency room last night, unable to breathe. He had to be intubated at the hospital and he’s stabilized now, but it was dicey for a time. The docs at the ER said that it’s epiglottitis, and that we should have caught it earlier.”
My heart sank. My mind raced. Thoughts exploding out at once. Many of them expletives.
Frantically I tried to go over the whole encounter in my head again, and analyze it again from another angle. Maybe I could recall what was missed.
Was it the hoarse voice? It had to be an early sign, how could I have overlooked that! Stupid stupid STUPID.
My attending came and settled the issue by stating that this “miss” was not something we could have predicted yesterday. Furthermore, I need not think of this as my fault, as there was a whole team of people that were also involved in Mr. Foster’s care. Yet for the rest of the day, I was shaken.
I think I understand why physicians hate that phrase. It triggers the mind to become obsessively masochistic. It opens Pandora’s Box: doubts in one’s abilities, anxiety for the subsequent consequences, and fears for the patients. Once opened they can run rampant. The demands of expecting perfection and being immaculate adds to the stress of facing errors. Phrases like “we should have caught it earlier” implicitly throw the blame on other physicians, and perpetuates the ideation that mistakes happen only for “bad” doctors.
At the same time, it’s irresponsible to shrug off mistakes nonchalantly by assuming that these incidents are inevitable. By doing so, especially at the trainee level, we not only lose out at a valuable moment to learn but more so, fail to appreciate the outcomes of our actions on the patients. Working as a clinical clerk is not a sterile bubble for us to just learn and “play doctor,” but puts us in an environment to start to learn how the consequences of medical decisions can unfold.
It takes experience to find balance within these moments, where we are reminded of our fallibility, to remain assured in our abilities, yet still humbled by the incident to learn. As a student, I have to accept that mistakes and errors will happen and I should not become paralyzed by my fear of making them.
Do you remember?
Before, I wondered when I would first hear this question, and questioned how I’d react to hearing it.
Now, I guess I’m wondering how many more times I’ll hear it before I graduate.
Author’s note: Names and dates are edited to preserve anonymity.
The clerkship experience can be the definition of tumultuous. As we’re suddenly tossed into the wards, it’s easy to become caught up in the shuffle as we move through our service rotation. These posts try to take a step back and become “a fly on the wall” observing and reflecting on the overall movement through clerkships.