There is a contradiction in medicine that has always interested me – the need to form a complete psycho-social picture of each individual patient (aiding empathy) versus the need to depersonalise, categorise and store their medical story (thus adding to experience). When things go wrong, this tension results in a paradoxical lack of humanity.
Example: a junior doctor, two years qualified, makes a mistake. She writes the wrong antibiotic up on a Friday afternoon, having failed to check the result of cultures that were taken three days before. The bacteria causing the infection is not sensitive to the antibiotic that she prescribes. The patient deteriorates. The doctor recognises and regrets her error, watches the patient and his family, learns all that there is to know about his life and background. He dies two weeks later (his death the result of mutiple diseases, not just her action). She is devastated. For days and weeks she reflects on her mistake. A vivid image of the family keeps entering her mind, as do their words, when they asked how a simple urine infection could make someone this ill. Moreover she checks the computer assiduously before prescribing antibotics from then on.
Twelve years later she is asked to deliver an induction lecture to new doctors. She emphasises how important it is that they check each result for themselves, take nothing for granted…watch the details. She is a very careful doctor, always was really, except for that one slip which happened early on. She drives home…and casts her mind back to the moment she learned that her patient had grown worse over the weekend, due, in part, to her brief incompetence. She finds that she cannot remember his name. She cannot form a picture of his face in her mind’s eye. The family…how many were there? The man has gone…only the error, and the lesson that grew out that error, remains. The individual has been subsumed by history, by a thousand other patients with a thousand different problems.
We cannot be expected to remember every patient, of course. But those who made the greatest impressions on us might, you would think, linger on in our memories. Indeed they do, but mainly in the form of salient facts – the features and factors that made them special, be they medical, situational, or personal. Their memory survives as a construct that exists only in relation to the effect it had on you, the doctor, rather than the self-contained, individual and tragic story that the patient’s demise truly signified in their world…a world that you, as their doctor, were never really a party to.
It is a subtle and rather esoteric observation, I admit it, but for me it feeds into a larger question. How do doctors ‘process’ the memories of patients who once presented a great medical or personal challenge?
A mature doctor will have been buffeted and battered by numerous ‘bad outcomes’. That cold phrase describes unexpected injury, suffering or death of patients related to decisions or treatments ministered by us, their doctors. Those outcomes may have been inevitable, but the fact that they occured after we saw them and gave advice forms a link in our mind. Was it something I did? Should I have made a different decision? Was I wrong? And if I was wrong, what will I do differently next time? A lesson is learnt, and each little shock, each piece of bad news, adds to the pattern of experience that forms the value of a good doctor. We carry those lessons around with us, making sure that next time we encounter a similar situation we do not make the same mistake. We get better, and feel more confident. The price – a series of personal tragedies that become smaller and smaller in our memory as time passes. All but the most harrowing (or perhaps those that resulted in sharp criticism or proessional censure) lose their emotional edge. We recall the events in abstract – ‘I did this, this happened, he died, I felt awful…oh yes, I don’t recommend it, don’t ever do that…’ – but we are no longer visibly damaged. In fact we are wiser and stronger, and at some level perhaps we are grateful for having been through it.
My point is that the lifelong process of learning that is a medical career requires us to find a way to live through these setbacks and make something positive out of them. To do this doctors must strip those memories of the very qualities that made them so powerful in the first place…the patients’ suffering and the impact this had on those around them. The lesson learnt is usually one of process, data interpretation, practical technique or communication…whatever it is it is something to do with the doctor. It is the doctor who is the constant, whereas the patient, even though their specific needs and problems formed the basis of the risk, is one of many who will cross that doctor’s path.
So is all this a problem? It is if we become too good at the process of assimilation and are tempted to put each mistake ‘down to experience’ too soon. It is if we do not dwell sufficiently on the impact of mistakes that, from a medical point of view, were purely ‘technical’. It is if we immediately compartmentalise those errors, surrounding (or hiding) them in hastily erected walls of rationalisation, forensic examination and (instinctive) defensiveness, thereby underplaying their social significance. I wonder if such post-hoc failures of imagination and empathy that can lead to a lack of candour. When errors are immediately assessed in relation to the system that caused them rather than the social unit, the family, that was most directly affected by them, we are in effect turning away from the pain and settling our gaze on our own concerns. That has to happen of course, if weaknesses in the system are to be adressed, but the timing and the emphasis have to be right.
Personally, as a doctor who has been blown off course as frequently as any other, I think depersonalisation and abstraction are vital. They are not particularly warm or human traits, but they are understandable. The process of learning from experience must be the same for doctors as it is for any other professional, and the same need to filter, discard and retain the ‘essence’ of each incident applies. The difference, for doctors, is that the extraneous matter is often deep emotion and human pain.