Category: Medicine

I meant well. My patient called and had a recurrence of her medical problem.^[1] In the past I had sent her to a specialist. He had made some recommendations if the problem recurred. I could have made her call or go back to the specialist. In hindsight I wish I would have. I wanted to help her and everyone. I meant well. I was trying to make things easier. I looked at the recommendations from the specialist. I prescribed one of the medications that he suggested could help with her problem.

She developed a horrible complication from the medicine.  It was a rare complication. But it had been reported with the medicine I had prescribed.

I acted quickly. I immediately saw her. I called specialists and asked for help. I did whatever I could find to help her recover from the complication.  All the king’s horses and all the king’s men…

She got worse. A lot worse. ICU type worse.

And then every day, sometimes twice per day, I walked to the ICU to see her. I carefully monitored her condition. I looked at everything. I spoke with the ICU team and all the specialists. Together we worked hard to do the best we could to help her get better.

It was hard. It was hardest on her. I wish that I could go back in time. I wish I could do anything possible to prevent her from having the complication. I have replayed the events over and over again in my mind so many times since then. 

It was also really hard to continue to be her physician in the midst of all of this. I had prescribed the medicine. And every day, sometimes twice a day, I would walk down the hall and climb the stairs to go to her room. It felt so heavy. My heart was a lead weight as I climbed the stairs every time. I wouldn’t take the elevator. It didn’t seem right. I climbed the stairs. I would swallow hard and go in to see her. Be the best physician that I could be. She deserved the best. 

I kept doing the walk. Every day. Sometimes 2 or 3 times a day. I had to. She deserved physicians who would do that. 

And I needed to do it. The word that comes up now as I think about it years later is “penance.” It was for me like something that I needed to do. I am sorry. I am really sorry.

I wish I could tell you that everything worked out fine. It didn’t. She survived but ended up with complications. It left her injured. There was nothing that I or anyone could do to fix it. Unlike in childhood when there would seem to be someone to rescue you, in real life there are times when there are no fixes or rescues. She had to learn how to live with the complications. I had to learn to live with the guilt that a decision I made in treating her caused those complications.

I had to learn to go on living and making decisions. I had to learn that this life is not a fairy tale. Sometimes things go wrong. And sometimes you cannot fix them. What do you do when that happens? You must put one foot in front of the other and you keep walking. Even if your heart is heavy and you feel sick inside, you just keep putting one foot in front of the other. 

That is what so many of you have had to do. We all wish that Mom or Dad would come in and clean up the mess. But that is not the way it works in real life. And when you become Mom or Dad you want to be the one who fixes everything for your kids. But you know that in your own life not everything can be fixed. You know that you have to just keep walking. It gets even harder when you begin to worry that you cannot or should not fix everything for your kids too.

The pain has shaped me and molded me and taught me. I am not going to say that I am thankful for it. That would not be honest. To this day I would do whatever necessary to spin time backwards and not to have prescribed that drug. But I did learn.

I learned that bad things happen. I learned to think more whenever I make a decision in medicine. Just because there seems to be a clear action, we have to think again about what “could” go wrong. Even if it is not frequent, we still are obligated to think what could go wrong. 

I learned about sharing the decision making with my patients. The risk was small. But I read about the obligation that doctors have to disclose risks to their patients. This is not always done in medicine. Doctors are trained to balance risks and make the “best” decision. We are told to be objective. We may not want to worry our patients. But we also have an obligation to involve our patients in the decision making as much as possible. Often we don’t go through the discussion with the patient. We should.

I learned about guilt. Penance doesn’t help by the way. It doesn’t make things better. It really doesn’t fix anything. It doesn’t even make you feel better. 

In retrospect I am thankful that I did the walk every day. But it has nothing to do with penance. What is important is to accept the reality and still do the right thing regardless of your feelings of guilt. Do the right thing regardless of whether it is easy or hard. Just do it anyway.

Just keep walking. Everyday. Sometimes 2 or 3 times a day.

This too shall pass. That is the expression. I say it to encourage me and others. This too shall pass. Not completely however.  When things are hard you can keep putting one foot in front of the other. Over time it gets a little bit better. It doesn’t just go away. It didn’t go away for her. I still feel it too. My heart isn’t as heavy now. But it is still with me. I will always think about it. I will always think about her.

Bad things do happen in medicine. Complications are going to occur. When I switched to cardiology and was doing procedures the burden would weigh heavy on me. Every time my pager would go off, I would jump and worry that something bad had happened. Most of the time everything was fine. But sometimes complications would occur. 

Somehow in medicine we have to learn to deal with this. Patients will have bad outcomes even if we do everything perfectly. Patients will have complications from procedures even if we are skillful and careful. Sometimes we will make mistakes. That too is a certainty because we are all human.

So, what do you do when there is a complication?

1. Be the best physician you can be regardless of how you feel. Continue to do the right thing for the patient. Do it even if it is hard.
2. Objectively look to see if there are lessons that you can learn. Was it preventable? If you had it to do all over again would you do anything differently? No fair changing your mind because you know the outcome. You don’t have a crystal ball. Based on what you knew at the time would you still do the same thing again? From a safety perspective there are ALWAYS lessons to learn. What are they? Learn them.
3. This too shall pass – or at least – we can continue to move forward in spite of the complications that have occurred. We owe it to the next patient that needs us. Complications are going to happen. We must learn and go on. Just keep walking.

I see this happen to our surgeons and proceduralists. They all have had to learn how to deal with complications. Some handle it better than others. But if you expect to never have a patient have a complication you will never be able to take care of any patients. You have to keep moving forward. Learn what you can. Be objective. Not about guilt or not guilt. What can you learn? Is there any better way? There may not be. But ask the question. And do the right thing. Even if it is hard. Be objective. Penance doesn’t help by the way. It is not about penance. Just do the right thing. That is what helps. 

What about for those who read this who are not doctors?

1. Life is hard sometimes. You WILL have times that you will not be able to fix things. That is just the way it is.
2. When life is hard, just keep walking forward. One foot in front of the other. Even if your heart is heavy, go ahead and walk. Every day. Sometimes twice a day.
3. This too shall pass. Or sort of. It does get easier with time.
4. Penance doesn’t really help. Even thought you might want to submit yourself to some penance to help with your guilt, it doesn’t really help. Don’t try to hide it. Don’t try to “make up for it.” Stop. Think. Just do the right thing. Even if it is hard. Just do it anyway. In the long run you will be happy that you did.

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^[1] For purposes of patient privacy, I am nondescript intentionally. The exact circumstances don’t matter. They do not change the reality of what I am trying to communicate.

My last patient of the day was an 85-year-old with HFpEF. 

HFpEF (or Heart Failure with a preserved Ejection Fraction) is a condition where the patient’s heart looks normal on the echocardiogram, but they have heart failure anyway. It is very common. It accounts for about 50% of the heart failure that we treat. But it also can be very frustrating. Things can look normal. But the patients get short of breath. Sometimes they can be very short of breath. Often they end up in the hospital.  We do not have good treatments for it. It is one of the big gaps that we have in medicine. 

She was 85. Her chart indicated a history of hospitalization for severe depression, frailty and some other medical problems.  Really? My last patient of the day? 85 years old. Sick. And likely with something that I can’t make better.

Sigh. 

Let’s go back to a few other stories first.

We had a close family friend who was in his 80s. His speech had slowed down. His mind had not. If you would be patient enough to listen to him, it would become abundantly clear that he was very much still “in there.” He was very intelligent with a great wit. There were riches within if you would be patient and wise enough to wait for them.

He was admitted to the hospital. My wife went to visit him and was frustrated at how some of the staff could buzz in and out of his room and not acknowledge him. If he were younger, or faster of his speech, they would never have done this. They would of course greet him, explain what they were doing and ask him if it was ok. But he was slow of speech, and slow to object, and old and quiet. They would just buzz in, do what they needed to do, and buzz out of the room. They wouldn’t truly acknowledge him for the intelligent man that he was. They wouldn’t wait for his permission to do things or to find out what things he needed. They would be gone before he could speak. He would get frustrated by it. But over time he had started to come to expect it.

Is this what it means to live life when you get old?

I was rounding in the hospital. It was a busy day. I had a long list of patients to see. I too “buzzed” into a patient’s room. I had to see him, do a brief exam and confirm what the APP (physician’s assistant or nurse practitioner) had told me about him and his care. When I looked at him, I was reminded of our family friend. That acknowledgement stopped me. I slowed down. I grabbed a chair. I sat down. I asked him how he was doing. I waited. His words came slowly. Much to my surprise however I found that he was very much “in there.” I got a lot more information from that visit than I had suspected. I also got a lot more out of the visit than I had expected. I got to interact with a kind, intelligent, and wise man. There was so much more to him that I wouldn’t have known if I hadn’t made myself slow down. I walked out of the room more satisfied and enjoying my job more than I had when I walked into the room.

People look different when they are in the hospital. They often lose their identity. The certainly lose a lot of control. The activity in the hospital can come and go and buzz in and out and leave little time to let them catch up with what is happening. This is much worse when they are elderly. They become tasks. They lose their humanity. We lose our humanity.

It was another day several years ago. I was going to see a patient in the “ACE” or “Acute Care of the Elderly” unit. I marched into the room where there was an elderly man asleep. His sheet had fallen to one side of him exposing his private parts. His hospital gown was askew. My goals became to get in and out of the room as quickly as feasible. 

And then I looked at his name. He was one of my patients from years before. He was not only one of my patients, but he was a retired physician. He was a brilliant man. In his day he was visionary. He brought new ideas and new techniques to our city. He was loved by hundreds or more likely thousands of patients. 

Once again I was stopped in my tracks. My interaction with him slowed down. I covered him up and straightened his gown before I woke him to talk with him. He was an important man and deserved to be treated with dignity. (Aren’t they all important people deserving of dignity?) Age had pulled at his intellect. He was not all that he used to be. But to me, he was still very much “in there.” I reminded him who I was and how I had been his doctor years before. I reminded him of who he was and how much I valued the things that he had done in the past. He didn’t remember all of it. But I could, and I was going to remember it all for him. 

I was in the office on another day. It was another very elderly man with shortness of breath. His family spoke a lot for him. He was quiet. I stopped in the middle of the visit and directly asked him what his career had been. He started to describe his work. In the process I discovered that he had a PhD in chemistry. He was a brilliant man. His face lit up as he was able to describe where he went to school. We went to the same college. We talked about shared college experiences (even though they were separated by a generation of years.) He was very much “in there.” Suddenly he was a part of the office visit rather than the subject (or victim) of it.

My last patient in clinic was an 85 year old woman with HFpEF. 

I went into the room and saw a frail elderly woman accompanied by her son. It is always so easy to just talk to the son. He of course is younger and has more rapid speech. 

But I forced myself to address her and talk primarily to her. When I did she astounded me with her eloquence. She had a quiet dignity buried within her withered frame. I could imagine what she had been like in her younger years.

She told me how the staff at her assisted living were forcing her to do physical therapy. She told me how every time they tried to stand her it would create great distress for her. She eloquently described her shortness of breath and chest pressure better than I have ever heard it. “When they stand me up, I get the idea that I am going to die.” “My chest fills with pressure. I have to sit back down. I have to wait to let the ‘air go out of the overinflated tires’.”

It was an amazing experience. She was very much “in there.” I learned a lot about her. I was better able to understand and take care of her. I may not have been able to solve all of her problems, but I at least heard her and tried to help her. I also walked out of the room a lot happier and more satisfied with my day. Not that we ever have favorites, but she was my favorite patient that I saw that day.

I tell myself this regularly: “Slow down. Look for the person inside. Look beyond the slow speech. Look beyond the hospital gown or disheveled clothing or uncombed hair. Look beyond the frailty. Look beyond the disease.”

You may be surprised. I suspect you will be rewarded if you do this.

You may discover a wonderful human being. You too may see that “he or she is very much in there.”