Mistakes in Medical School
Thomas Robey -- How many times in medical school have you thought, “Wait a minute, was that right?” Sometimes we students question statements made from classroom podiums. Other times it’s a policy made by school administration. Maybe a classmate’s behavior raises concern. The further along I get in my medical education, the more I notice myself asking that question of my own clinical decisions.
My first week in the county hospital’s emergency room has prompted a spike in moments of post facto doubt that I did the right thing for a patient. Addressing mistakes in medicine is an important skill –- and it’s one that I feel I am not yet prepared for. All I know now is that I’m painfully aware of both the potential for and reality of medical mistakes.
As far as I can gather, this sort of introspection occurs when providers take on new and increased responsibility, are in the process of learning from experiences, and find themselves in a new environment. For me, the longish transits to and from work permit additional opportunities for reflection.
Students on my emergency medicine clerkship are given responsibility unrivaled by any other rotation in our training. We are expected to carry 3-5 charts at a time and take initiative for patients’ care from the moment they are put in a bed until their discharge or admission. There are caveats, of course. This doesn’t apply to trauma patients: students participate in care, but certainly do not call the shots! Also, attending physicians chart a complete note in addition to the student’s record, must co-sign orders and expect to receive regular updates. But the basic decisions are the student’s to make. Due to the busy nature of the ER, and the throughput, a faulty action may not be realized until the patient is out the door.
Take for example the injection drug user I cared for this week. She came in with a deep deltoid abscess in her shoulder. Why so deep? She had run out of veins so was now muscling heroin. I did a thorough exam of her lesion, determined there was no subcutaneous gas and used ultrasound imaging to identify the depth and size of the abscess. I was able to get a little bit of blood for labs and found her white count was 14,000 but her sodium level was normal. (Potentially systemic infection, but probably not necrotizing fasciitis.) Knowing that muscle abscesses cannot be drained in the ER, I referred her to the general surgery service. I was caught up on the logistics of her transfer; for example, no one could get satisfactory venous access, even with ultrasound guidance. I didn’t realize until after she was admitted to the operating room that I’d not listened closely to her heart. Yes, cellulitis can kill people, but the more fatal consequence of IV drug use is endocarditis and septic emboli to the brain. I was so caught up in doing the right thing for her wound that I lost track of the big picture.
It’s a good thing that my attending listened to her heart, and the anesthesiologist, and surgeons and... but in the end I am left with the truth that I let her down. I suppose that’s why experiential learning works. You can bet on my listening to every injection drug user’s heart from this point forward.
Thank you for posting your experience. As someone who is constantly trying to be aware of 'the big picture' and not be so very detail oriented, you've given me a very important motivation to continue working on this. Thanks!
Posted by: Krista | Jul 16, 2008 6:35:39 AM
You learned from it, but I think you did a great job considering the critical thinking involved in managing her care. Without years of experience, I don't think any medical student is expected to know that first hand.
Posted by: Rae | Jul 22, 2008 3:16:52 PM
"You can bet on my listening to every injection drug user’s heart from this point forward."
But what good is that? I question the relevance and ethics of saving a drug user from a heart condition so that they may live another day to shoot up more and continue to be a drain on society and a distraction from real patients with non self induced conditions. Would it not be MOST pertinent to go ahead and do whatever hearts screening necessary, but MOST OF ALL get this person referred to SOMEONE who can help them break their cycle of drug use? There are many resources available, including free ones. NAMI is good. Checking the heart is merely putting another band aid on the problem. So what? Get to the root cause, man.
Posted by: Justin Hamlin | Jul 22, 2008 3:24:05 PM
I will give you the benefit of the doubt and choose to believe that you do not really mean to say that patients with drug addictions are not worthy of thorough physical exams and proper medical care. I also sincerely hope that you do not view a patient with a serious and potentially fatal medical condition as "not a real patient" based on their history of substance abuse. And I'm sure you did not mean to say that it is "unethical" to save the life of a drug abuser, somehow implying that the "ethical" choice is to let her die in your ER! In today's culture of patient centered medical care, where humanism is emphasized as strongly as sound medical knowledge, there is simply no place for such notions. While it is true that this patient is most likely in need of psychiatric counseling, denying her the right to basic medical care is simply appalling.
Posted by: David | Jul 22, 2008 4:27:52 PM
While I do agree that a discussion is warranted on her lifestyle (not for judgment's sake, that's the furthest from our job, but for risk of future abcesses in a patient with poor periphral circulation), I hardly think that what the future Dr. Robey did was putting a bandaid on the problem. The fact of the matter is, as Thomas pointed out, the potential for a severely adverse outcome existed, and that he did the right thing by making sure the acute situation was addressed (the first and formost job of an ER physician). I commend Thomas on posting an article where he is able to reveal the doubt that we all have but are to afraid to voice for fear of others judging us. In addition he's able to admit that he could have gone even further. True that a discussion is probably in the patients best medical interest but who's to say that wasn't done. The fact of the matter is we can all discuss things that we should have done differently or could have done better but Thomas' post is showing that he's doing just that which is what will make him a great doctor.
Posted by: Chris | Jul 22, 2008 4:33:25 PM
I'm going to skip over what the other Justin said (while biting my tongue) and comment on what Thomas originally wrote about. I've been a medic for years now and have had my fair share of situations that during which I made a mistake of some sort. And I agree with Thomas, that I learned the lessons more deeply after someone pointed out that I made a mistake. I can promise I won't ever forget to check/stabilize c-spine...ever again. However, I think we should add something to Thomas' post. While its important to realize, as students, that we will make mistakes, we should also strive to remember that as we pass from the student role into the teaching-role that our students will gain the same benefit we did from their mistakes. And, of course, to be just as critical/caring towards our students as our teachers were towards us.
Posted by: Justin S. (Not the Justin from above!) | Jul 22, 2008 5:53:37 PM
There seems to be an egregious distortion in your ethics and moral framework. Your point is well taken but your position and implication that yet-another-IVDA-person stumbling into the ED is not worthy of your full attention to not only the presenting problem but potential complications is simply wrong.
Another reason why your reply just rubs me the wrong way is that you assume that the patient's addiction was not addressed. I dare say it most probably was. In many institutions, there are protocols in place to get patients 'plugged in' to the system.
All this is besides the point. Thomas' intent here was not to ruminate on the patient's addiction, rather to make a very compelling point on how we all should (and do) learn very dear lessons from our mistakes.
Posted by: Ned | Jul 22, 2008 8:45:19 PM
Thomas, you are and will be a fine doctor. In my 25 years as a practicing RN, I've learned that MDs with "heart" become doctors. Some, like Justin #1, end up as extremely well educated plumbers.
Posted by: christi | Jul 22, 2008 9:16:49 PM
Justin H, My mandible didn't just drop, it fell off. At least I can still type.
I'll try to remember how unethical it is to treat all those faux patients with all those those self-induced lesions. Instead of treating emergent conditions in the ED, let's "get to the root cause." Anger management for GSW, drug rehab for arrhythmias, safe sex counseling for AIDS complications, explosives safety courses for pyrotechnics injuries, etc. Maybe then the presenting conditions will magically disappear.
I hope that no one close to you goes down the same road as Thomas's patient. If they do, I hope that their care is based on training, experience and most of all compassion, not on their doctor's estimation of their worth to society. I also hope you consider--provided you are or ever become an MD--what your patients would think of their doctor if they read your comment.
Thomas, thank you for your post.
Posted by: George | Jul 22, 2008 11:06:32 PM
all i have to say is wow (to the responses). there is not enough grammar in this world (being politically correct) to achieve a sarcastic remark to you people with adverse responses to this article!!! my only hope is that the original intent was directed at the hideous/ignorant banter so as to impress such said person(s) with an irreversible "code of conduct" in the future. I for one, refuse emergency medicine and will probably never get on this website again (obvious reasons), but am thankful for the reassurance afforded by the previous-mentioned. Thanks.
Posted by: chris | Jul 23, 2008 5:00:01 AM
Thomas, I think what you've just written is very important. The first ones who publicly stand by their mistakes are the ones who leave the deepest and most important impression. Your deed is exemplary.
Posted by: Raphael from Switzeralnd | Jul 23, 2008 10:13:03 AM
Although i totally agree with what you wanted to point to us. My concern is that as medical students we are thrown responsibilities at times just like the present situation you mentioned , to take decisions at our disposal based on our 'knowledge' and whatever experience we are. But are the patients justified in receiving such sort of care from a naive resident? When patients come to us the have full faith in the doctor they hand their lives into. Are we doing justice? Is a new resident supposed to learn just like we learn driving by practicing more and more and then becoming good at it. Can at all times the patient afford to take risks for our sake?
Posted by: leena | Jul 23, 2008 10:32:46 AM
I would like to join leena here in her question, also as an IMG whose seeking to find residency in the U.S...
I can't help wonder, will American patients allow a foreign doctor make mistakes and learn through them? What's in it for them?
Where I am from, Egypt, patients frequently complain from the overcrowding on their beds with medical students, and the attendant always reminds them that this is an educational hospital, and that patients are receiving free treatment in return... And I can't help imagining myself in the shoes of those patients, thinking I wouldn't want some junior doctor, especially a foreign one, make mistakes while treating me...
And also somehow patients aren't well educated about medical rankings, they just see a doctor whose treating them, wouldn't young doctors making mistakes, especially if directly infront of the patient, make those patients less trusting of doctors in general?
Posted by: Ramy | Jul 23, 2008 6:28:46 PM
Hi Thomas, im from Mexico and i think that to be a good doctor you have some times to treat the patients in the way we want to be treated, some times we skip treatments or procedures in order to keep life or maybe we see the superficial damage and we get impatient to make a quick healing of the problem that is afecting our patient at the moment but without taking care of the consequences that our procedures will cause. I think that if we do a complete check on our patients and follow our procedures without skiping anything and taking care of them with humanity we will make the best for our patients. SO JUST KEEP UP THE GOOD WORK AND BE SURE OF WHAT ARE YOU DOING BECAUSE ITS WELL SAID THAT A CHEF HIDES HIS MISTAKES WITH SAUCE, THE STUDENT USES AN ERASER, BUT THE MEDIC... THE MEDIC COVERS HIS MISTAKES WITH SOIL.
Posted by: Raul Jimenez | Jul 23, 2008 8:19:27 PM
"Thomas, you are and will be a fine doctor. In my 25 years as a practicing RN, I've learned that MDs with "heart" become doctors. Some, like Justin #1, end up as extremely well educated plumbers."
This is just priceless... :D well said Christi!
I'd like to join in commending Thomas on his introspective method of thought; which I truly believe is, or at least should be, one of the major pillars of modern medicine.
I'd like to acknowledge Ramy's concerns, and a few others on this thread who worry that, maybe medical students should not be given such great responsibilities, which they may or may not be ready for. This is something that I've been dreading as my clinical training gets closer (I'm a Med II student).
That said, I can hardly see a better and more effective method of training for prospective physicians. I truly believe that making mistakes, as well as realizing just how close one was to making a mistake and churning the consequences in one's head is one sure and proven way of learning any thought process, profession, or practice anyone can throw at you.
I know that the stakes are high, but this is only reason for someone worthy of these responsibilities to tread all the more carefully in this profession.
Posted by: Ram | Jul 23, 2008 9:29:37 PM
Hi, i am from Australia and works in Emergency in one of the country hospital. I am totally agree with what Thomas has said that experiential learning works the most. When i was medical student i was very much overwhelmed by this field and i found it very hard in making a proper diagnosis and thorough physical examination. But after i started working in Emergency things started becoming more and more easier. I was making quite silly mistakes in the beginning but i learned a lot from the experience.
Thomas you have done a great job, you will become good doctor.
Posted by: Gaurang | Jul 23, 2008 11:50:04 PM
Hi Tom! We all learn from our experiences in life or as we practice whatever profession we have. In the case of being a health provider, we have learned so much in our years in the medical school, how to get a thorough physical examination of every patient we see and closely correlate our findings with a disease condition. As we move on to practice, we sometimes forget to do a complete physical examination because we limit ourselves to what is presented to us, or merely on the things that we see grossly, or probably we are limited because of the numerous patients we see, or with the workloads we have. But that will never be an excuse in being a doctor... We may feel that we let somebody down because we failed to detect/diagnose a condition that they have, but this will not render us less of what we are--- if we just open ourselves for improvement and work to be more competent, i guess we will not fail more patients in the end... And Tom, the desire we have to serve others as physicians will not be blacken by the not so good experiences we have in the clinics/hospital.. Learn from what you experience, and desire to be better, after all in whatever we do, LIFE is what we make it. Godbless!
Posted by: thinkerbelle | Jul 24, 2008 12:08:53 AM
Hi Thomas,great post,thx for sharing such an important experince...ur exp will teach all of us who read ur post to be careful in examination and look at patient as d "complete picture".....To Justin Hamlin,pls do not become a doctor,the need to get to the root of problem with having a stigma on a patient is a different thing.
Posted by: Kok Soon | Jul 24, 2008 2:10:30 AM
Thts really sweet of u 2 share such experiences with us... now i'll never forget this info... or make d same mistake... thanks...
Posted by: Meenakshi | Jul 24, 2008 6:36:39 AM
hi thomas! very informative post.. think it's modesty that makes a great clinician as he is never ashamed to admit the mistakes he made and thereby learns from them.. u've taught me a clinical point as well as a lesson t build my character.. cheers!
Posted by: Roshini Weerasiri | Jul 24, 2008 10:09:17 PM
your words are worth to understand and to remember .
a thing i notice is, in my college and campus ... many get admitted to medical school without the intention to treat the sufferings and just they would be with intention to make money. I WONDER ,, THAT,, I NEVER KNEW MEDICAL PROFFESSION IS FOR BREAD AND BUTTER.
I GOT STRUCK IN MIDDLE WHAEN ICAME TO KNOW THIS THING,.
you know.. if i dont have that heart to care and understand medicine and to FEEL the PATIENTS ,,, i coundnot be knowing or might not have the EYES to see the mistakes ,that YOU ARE POINTING .
if we care for patients and if we dont THINK MEDICAL PROFESSION IS FOR BREAD AND BUTTER,, then any can see like you.
REALLY ITS NICE OF YOU.
Posted by: ravindra.k | Jul 25, 2008 1:27:07 AM
Thanks for your kind comments, and for engaging a difficult conversations about the balance between experiential learning and patient care and the sensitivity we must have when treating patients who suffer diseases related to cultural taboo or illegal actions. For more of my thoughts about narcotics, consider this post:
Posted by: Thomas Robey | Jul 25, 2008 3:59:48 AM
I am very delighted to read all the comments. It gives me an overview how people see things in different context.
Well, being a medical students, i know it is important sometimes to make mistakes because they help you to become a better doctor in future. Surely, anyone who reads this article will always remember that IV drug users are at great risk of having infective endocarditis and that their heart status needs to reviewed.
From the Gambia Medical School.
Posted by: Lamin F Jarju | Jul 25, 2008 4:11:56 AM
good experience not only for you but also for me.Cause iv drug abusers are not that much commmon in Ethiopia so i might miss the same case,but not after i read ur article.
Posted by: tsegazeab | Jul 25, 2008 11:43:08 AM
thank u for sharing us your experience..point well taken..
No matter how great you are..u will still commit mistake,unintentional that is..for it's simply inevitable..just take the lesson out of it,and dont make the same mistake again..
Posted by: roxanne | Jul 25, 2008 1:02:03 PM
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