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Physician Learns Lessons About Patient Care from Failure


 

“Are you comfortable talking to him about all this stuff?” my attending asked me casually.

“Yeah, of course—sure,” I replied, trying to mimic the same casual tone.

STOP!

Hold on. What did I just agree to do?

More than a decade later, I still feel the nervous tension in my stomach as I think about that day.

It was my first day of internship, and I was in an urgent care clinic. I had just reviewed a patient chart before going in to see him and discovered that he had newly diagnosed hepatitis C and a liver lesion on ultrasound, which made us concerned about hepatocellular carcinoma (HCC). And “all this stuff” that I had just agreed to do involved talking to the second patient I had ever seen in my life as a “full-fledged” doctor about this diagnosis.

A number of thoughts were racing through my mind as I walked toward the room (Now, I’m not sure, isn’t HCC something serious? Does it metastasize? Could the lesion be something else?).

I knocked on the door and reached for the doorknob.

As I entered the room, I noticed his face more than anything else. His face looked tired. Not the type of tired that comes from a night of poor sleep, but the type that comes from a lifetime of having it rough. I sat across from him, trying to make some small talk to break the tension I was feeling.

I had just given him life-changing news and sent him out into the world without any support. I picked up the white pages and started calling the numbers that matched his name. I searched the system for some connection. No luck.

I told him the news quickly, in a rather matter-of-fact way. As I mentioned the words “cancer of the liver,” I watched him turn a little pale, somewhat shocked. He had lots of questions, but all I could really tell him was that he needed additional work-up and that it was critical that he follow up with a gastroenterologist as soon as possible. What did I know? It was my first day of internship. I remember telling him multiple times, “It’s really, really important that you see your gastroenterologist soon.” The word “really” was the only therapeutic intervention I could offer.

He left the office, but I knew he was in bad shape. My attending didn’t even ask me how the conversation went.

Post-Meeting Blues

I was absolutely devastated. What had I just done? I had told someone that he might have cancer and then sent him out. This felt wrong in so many ways that I could not articulate that day but felt in my heart.

As soon as I got home, I went online and read everything I could about hepatitis C and HCC. Its presentation, progression, and sequelae. I became an expert. I barely slept that night, thinking about how I had left him. My mind raced:

I should have asked him if he had family.

I should have asked him who his gastroenterologist was.

I should have called his gastroenterologist.

I should have put a hand on his shoulder and told him we would figure this out together.

I should have told him he wasn’t alone.

I couldn’t wait to rush into the urgent care clinic in the morning, look up his number, and call him to deliver on some of the shoulds from the day before.

I went in early and dialed his number. To my great disappointment, a recording notified me that the number had been disconnected. Disconnected? I had just given him life-changing news and sent him out into the world without any support. I picked up the white pages and started calling the numbers that matched his name. I searched the system for some connection. No luck. Every day for three weeks, I looked for him in the urgent care waiting room and on the roster of scheduled patients.

I’m So Glad To See You

Then one day, as I hopelessly glanced out into the waiting room, I saw him. He was sitting in a chair, looking much like I remembered him. I ran over to him with excitement, told him I was so happy to see him, and that I would get him a room right away so we could talk.

Here’s the killer: I had been a disappointment to my patient, my profession, and myself, and do you know what my patient said to me? Thank you! He said thank you for being honest with him and for giving him all the information I had. He told me he had made some major lifestyle changes, and he wanted to seek treatment.

I got him the earliest available appointment for gastroenterology. I then called the clinic and spoke with the physician who was scheduled to see him. I ordered a series of additional tests based on my reading and her recommendations. And, lastly, I updated his number in our system.

Before he left, I gave him a hug and told him he was going to be OK, because even though we didn’t have many answers today and this was a serious condition, we were going to figure this out together. He was not alone.

To me, that day was the day I joined the medical profession.

I called him several times over the following year. He was able to get treatment and, the last time we spoke, he was doing quite well.

Lessons Learned

To this day, that episode is still my greatest failure as a physician. I carry a part of it with me every day, in every patient encounter. I’m grateful for that.

There are three lessons that I’ll never forget in my practice of hospital medicine:

Humility. As a resident on my first day of internship, I felt that I had so much to prove—mainly demonstrating that I could handle a tough situation. Now I realize that while I handled the situation, I failed to take care of my patient.

If I had looked around, I would have realized that I had an entire team of experts—attendings, nurses, case managers, and social workers—willing and able to help my patient. Despite our many years of medical training, it is our responsibility to humbly engage our entire team and ask for help and insights, for the purpose of healing and supporting our patients.

Respect the hierarchy. Hierarchy in medicine is an interesting entity—sometimes visible, but often an invisible veil that governs our behaviors. When my attending asked me casually if I was OK with communicating critical information with our patient, I felt pressured to be casual about the gravity of the situation. He set the tone for that interaction without realizing it. We do this often as hospitalists. Our tone and body language with our team members or trainees, while respectful, can keep them from feeling comfortable about reaching out to us at critical moments.

Above all, advocate for your patient. Ultimately, my biggest failure was that I did not advocate for my patient. Sadly, this is not a rare occurrence in our profession. With mounting pressures to deliver on many fronts—among them, quality, cost, and experience—advocating and supporting our patients sometimes falls to the side. The increasing numbers of handoffs often lead to a culture of passing on problems. At times, we use labels like “noncompliant” or “not engaged” without deeply understanding the underlying challenges our patients face. Advocating for our patients is one of our core professional values in medicine; it should not be compromised.

Medicine is a profession of sharing stories and learning from each other. I am grateful that I was able to share my story with you.


Dr. Afsar is associate chief medical officer at UCLA Hospitals in Los Angeles. She is also assistant clinical professor and executive director of quality and safety in the department of medicine and neurosurgery at UCLA Hospitals. She is an SHM board member. Contact her at nafsarmanesh@mednet.ucla.edu.

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