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Mistakes in Medical School

Thomasrobey72x721Thomas 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.

July 15, 2008 in Thomas Robey | Permalink

Comments

you know..
i am also a medical student.
but unfortunately,a victim of medical malpractice. though this had happened to me, i still preferred to stay as a medical student.
so im very aware of that. just be careful always on your decisions. i think you're good because you still value what we say as the "code of ethics". here in my country some of those new doctors here discriminate patients who seemed to be in the lower status. and because of that, a lot of them commit mistakes(ending up to case) because they are not focused on their work. they don't mind what the patients feel. not to mention that those patients, who seemed to be in the lower status, still pays them. i dont think this is the right way to treat patients. --good thing you still have your heart that cares & your passion in your profession is still there. just be responsible always, stay focused & value your patients. just keep up the good work!

Posted by: mouhnie | Jul 26, 2008 6:29:01 PM

Leena, Ramy and others with the same concern. As much as it seems unfair for the patient, you have to know that its exactly how the system works. The patient comes to the hospital seeking the best healthcare. You do your part by doing your very best. Not giving the patient your best is what would be unfair. Any unethical step from your side would be letting down your patient. But you treating your patient to the best of your abilities is after all the best you can do.

As for being seen by medical students, there is no easy way out of this. You want to learn? You have to be there first hand.

And I'm pretty sure you're not the only one to see the patients. Like Thomas mentioned above - the patient was seen by several of his seniors.

And as for making mistakes - happens all the time. You think your seniors are flawless and perfect? Look again. They learnt from their mistakes. Isnt that how life works as a whole. Not just medicine.

Posted by: | Jul 27, 2008 2:06:33 AM

Oh and just to add to my above post - nice post Thomas. :)

Its easy to make mistakes. Everyone does and will. Its only the better of the lot that admit to it and learn from it.

Posted by: Kareema | Jul 27, 2008 2:08:15 AM

Hello there,
Just wanted to say, I hope you will listen to every patient's heart.. and examine every patient's CVS and RESP and ABD and examine every other system... that's the only way we won't miss the silent presenters... It's important to think of the patient as a whole and not systems of pathology... or so they like to say at my school!

All the best!

Posted by: Robertha | Jul 27, 2008 6:46:26 AM

Hello,
I am a bit surprised to read a comment from ramy, the doctor from egypt. Medicine is both a science and an art. I believe it is more of the latter and as students, we really need the patients to become good doctors. We should respect them etc but i seriously doubt that there can be a "good" medical sch without practical training

Posted by: sallar | Jul 28, 2008 7:44:48 AM

Hi Im a student in Africa and the whole drug thing aint that big hee so i wont join the debate but say life is life and as long as we aint giving it wee have to save is.

Posted by: Mumbi | Jul 31, 2008 5:15:51 AM

Thank you Thomas for sharing your experience. I am a medical student at Manchetser, UK. Having had a very good clinical experience at A&E as well as other settings, I absolutely agree with my colleagues posts above that clinical and bedside learning is of immense value to our learning as medical students. It is likely however to make a mistake in the first time, having not applied our knowledge in practical situations before. But this IS real learning as long as lessons are learned.

There is actually a very wise saying by Sir William Osler regarding the importance of exeperiencial learning;'To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to see at all'

Posted by: A Dakson | Aug 3, 2008 8:31:52 AM

Am a medical student in Uganda, Africa. the first medical course unit we do in medical school is medical ethics. without a doubt Thomas is a good professional who accepts and learns from his mistakes. on the other hand I find it quite disturbing that there are people who still think like Justin in this noble profession. To think that any of our lives could one day be in their hands!!!!!!!!!!!!!

Posted by: shirley | Aug 4, 2008 12:46:21 AM

Thanks Thomas, for sharing your experience. I have personally come to realise that I learn better from previous mistakes as a medical student. To be brutally frank I don't think i will ever again forget to check for the presence of other congenital malformations in an infant with spinal bifida. To colleagues like Justin Hamlin, i say i admire the passion with which you hate drug abuse. But i would not hesitate to mention that in trying to help people in this situation, our hatred should not take the better part of us. I know u will be a great medical doctor one day Justin.

Posted by: Raymond Papenfuss | Aug 9, 2008 10:35:40 AM

hello doc.
ya its true we do make mistakes.i appretiate ur article.

Posted by: irmpy | Aug 15, 2008 4:10:21 AM

Thank you for sharing your experience with us, Thomas. I must say that I admire your honesty. I'm still in medical school (undergraduate) and I have worked with several people (senior to me) who could not acknowledge that they erred. As a result, there has not been much improvement on their part (my opinion). Bravo...

Posted by: Pitsi Eric M | Aug 21, 2008 5:36:52 AM

True that there is a margin of error, but to admit it means that your willing to learn. Thanks for the article. It was very interesting.

Posted by: Ajlouny | Oct 11, 2008 9:46:23 PM

Many of these mistakes occur in what AdmissionsConsultants’ medical school experts call the three most problematic steps of the application process.
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Posted by: Brian2008 | Nov 17, 2008 11:14:55 PM

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.

James Ferris

Posted by: disinfection cap | Jun 23, 2010 6:15:27 AM

Without years of experience, I don't think any medical student is expected to know that first hand.

Posted by: Medical Negligence Solicitor | Nov 2, 2010 7:06:07 AM

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