Fourth year of medical school is exhilarating. Time is spent pursuing electives of interest, interviewing for residency, attending conferences and savoring the last moments with friends before graduation. Throughout my time on the interview trail, several interviewers asked me the same question: “What is the biggest challenge you have come across while taking care of patients?” My mind jumped to the same patient every time. My response was always, “Coming to terms with being wrong.”
As a hopeful future cardiologist, I was eager to start my cardiac care unit rotation. One of my first patients on the service was a lovely and vibrant woman in her seventies. Her past medical history was unremarkable aside from a recent COVID-19 infection that she “never fully recovered from.” She was otherwise active and in good shape. She presented with intermittent palpitations and a syncopal episode. On arrival to our hospital, she suffered a cardiac arrest and was resuscitated after one minute of CPR. Left heart catheterization was unremarkable. An echocardiogram showed segmental wall motion abnormalities with an ejection fraction of 50-55%. Electrocardiogram revealed a sinus third-degree block with concern for idioventricular rhythm without escape.
Because I was following this patient, I saw her several times each day. She took a liking to me because I reminded her of her grandson, telling me daily how proud my parents must be of me. I got to know her, her life story, her values and her spouse and family members. She was a pleasant and energetic woman who was convinced she had lived her life the right way by raising a loving family and taking care of her health perfectly.
Checking in with her several times each day, we became close during her time in the hospital. She often asked for my medical opinion, and I always told her, “Hey, I am just the med student.” But she wanted it anyway, saying she respected my opinion. Everything fit so perfectly, it was practically a slam dunk. The answer was in the history, where it often lies. I was sure this was COVID-19 myocarditis. Perhaps it could be another type of viral myocarditis or idiopathic, but COVID-19 myocarditis fits so well. I was cautiously optimistic this would resolve in time, and I told her that. I never strayed from the attending’s impression, but I did tell her several times that I was convinced she would recover… because I was.
The patient’s third-degree heart block did not resolve, and the electrophysiology team opted to place a permanent pacemaker. She recovered well and was discharged home for outpatient follow-up. Part of me was sad to see her go, because I looked forward to speaking with her each day, as did the whole team; she made everyone on the unit feel appreciated.
As a medical student, you are not usually on an inpatient service long enough to see patients a second time. I was shocked to see her back on our list just two weeks later. She presented again with acute decompensated heart failure. Repeat echocardiogram showed an ejection fraction of 25-30% with global hypokinesis. She was admitted to our service.
During her first admission, I enjoyed seeing her every morning. But now during her second admission, I felt nervous. I vividly remember coming in every day at 5 a.m. and opening her chart, hoping for good news. Each day, I was disappointed. Every echocardiogram, every set of labs, every physical exam, was worse than the day before. With diagnosis and prognosis both guarded, the patient was sent for an endocardial biopsy.
Two days following the endocardial biopsy, I returned to the CCU in the morning at my usual early time. I opened her chart immediately and saw that the pathology report was back. It was not COVID-19 myocarditis. Instantly, I felt an overwhelming wave of dread.
Giant cell myocarditis.
How do you tell a patient they are going to die when just a couple of days ago you were certain they would be fine? Perhaps I missed that lecture.
I started off with an apology. I explained that my initial impressions of her disease were wrong. It hurt to say, and I felt a sense of responsibility. I disclosed the diagnosis and told her about the limited treatment available. She was open to a transplant but confided in me that she was not sure something so invasive would be worth it.
Over the coming days, she continued to decline, and we began treatment for cardiogenic shock. She was sedated, intubated and started on ECMO. She was unstable on ECMO and, given the limited chance of recovery, her family opted for comfort measures only. Her last echocardiogram was the closest I have ever seen to a still heart, barely contracting with a device pumping essentially all of her cardiac output. She passed a couple of hours later, surrounded by her loved ones.
In medical school and perhaps medicine in general, there is an inherent fear of being wrong in all of us. In class, we are surrounded by our gifted colleagues; coming across as wrong or misguided is embarrassing. However, in the clinic, misjudgment can harm a patient who trusted you with their life. Being wrong is more than embarrassing; it is terrifying because the patient is subject to the consequences.
Medicine so often demands the pursuit of perfection. Yet, it is folly. Even after years of schooling and clinical experience, there will be times throughout our career when our differential was not broad enough, our interpretation of the data off the mark and our impression simply incorrect. Being wrong is inevitable and happens to the best of clinicians. Medical education does not teach us how to be wrong; to swallow our pride, come to terms with the truth, reevaluate efficiently and ultimately come forward humbly and honestly when we are wrong. Therefore, we must teach ourselves, for the sake of our patients and for ourselves as clinicians, to find acceptance and learn from being wrong.
Upon reflection, my actions and feelings in caring for this patient reveal how truly afraid I was to be wrong; not necessarily about the diagnosis, but rather about whether the patient would be okay. Maybe coming in daily and opening her chart for good news was just me hoping that my initial impression was still right instead of coming to terms with the fact I was very wrong. Maybe I was afraid to admit I had been overconfident and not checked all my boxes. Maybe I was afraid of losing the first patient I truly invested myself in. Maybe I could not bear to look her in the eyes and tell her she was going to die.
This patient’s story remains at the forefront of my mind as I wrap up my medical school training and head to internal medicine residency this summer. This case forced me to be honest with myself about my shortcomings and where I can improve as a provider. Missing a diagnosis is nothing new for a medical student. However, watching a patient that you were sure was going to be okay eventually decompensate and pass was a hard lesson for which I was not prepared. To be so wrong about where this case was going was both shocking and humbling. The guilt I felt following stemmed directly from failing to accept and learn from my failure.
My biggest regret is being unable to tell the patient how much caring for her changed me as a clinician and as a person. Perfection is something to aim for, but real progress is striving to be better than the person you were yesterday. In caring for this patient, I have become more honest with myself and with my patients. I am more calculated and cautious every time I work up a patient. I approach each patient as a challenge to build as broad a differential and as comprehensive a care plan as possible. Even when I am sure of a diagnosis, I actively try to prove myself wrong just to make sure I am not missing anything. I still have a healthy fear of being wrong, but I am less embarrassed by it. I can swallow my pride. I am quicker to come to terms with mistakes and can reevaluate.
Most importantly, I have been kinder to myself. I am no longer sitting with guilt or compulsively ruminating over cases that I missed the mark on. Instead, I am doing my best to find acceptance, thoroughly reflect, learn and take what I can away to better approach the next clinical challenge. It is a work in progress, to say the least, but I feel that finding acceptance in and learning from my failures is the best way to do right by my patient. Even though “M.D.” will be after my name in a few short weeks, I am far from the “perfect” clinician I have worked so hard to become.
And that is okay.
Image credit: “Heart” (CC BY-NC-ND 2.0) by Polly Pereguinn