Artist unknown, photo taken in Covent Garden market 14.12.13
Justifiably or not, young doctors are inspired and motivated by the thought that they might, one day, save somebody’s life. Opportunities come rarely, but spend long enough in a hospital and one day you will find yourself in a situation where a single action (be it a procedure, a prescription or a revelatory, previously un-thought of diagnosis) will stop a patient from dying in front of you. You cannot help but walk away immensely pleased, brimming with adrenaline enhanced satisfaction.
Some would say the temptation to wallow in a bath of warm aggrandisement is self-centred. It may encourage a too narrow perception of the clinical encounter, diminishing the suffering or fear felt by the patient and magnifying the importance of the doctor. For after all, who really matters here, you or the person who’s life has been saved? But I would defend the doctor who excitedly recounts such an episode to a friends or partner by inserting themselves in the lead role, because to suppress that pleasure, and take the puritanical view that ‘it’s just my job, it means nothing’ would be to deny doctors access to a very important source of job satisfaction. However, experience has told me that there is a quid pro quo, one that is revealed when things go badly. We must ask ourselves – how happy are we to take the lead role when our actions or omissions contributed to suffering…or even death?
My SHO and I (a registrar at the time) were called to see a patient with cirrhosis who had started to vomit blood. We resuscitated him, decided it was safe to take him down for an endoscopy, and within half an hour we were watching the varix spurting blood across the field of view on the monitor. I fired two bands, the bleeding stopped, and the drama was over. My SHO looked across, still squeezing the second bag of blood and clearly impressed, and said,
“You just saved his life.” What impressed him, I think, was not my specific role in this, but the fact that a procedure could so swiftly stabilise a patient. The experience would prove a clincher for him…he had been thinking about choosing this specialty and the opportunity to perform heroics, like this, was just what he needed to witness.
But as we walked back to the ward I began to explain,
“It’s not me, or us, who saved him. If we weren’t here today there would be another registrar, and another SHO, who would have found him and ‘scoped him. The chances are they would have done just as good a job.”
“But it was you. You made the diagnosis and sorted everything out.”
“But those were not exceptional actions. They are just what you do in those circumstances.”
“You may as well give yourself a bit of a pat on the back.”
“I am, internally, because I’m glad we made all the right decisions. But what we did was normal. We are working in a system that is designed to allow us to find patients who need us to apply our training and skills, so really it’s the system that saved the patient. Not us personally.”
“So you don’t get any fundamental satisfaction from that?”
“I do, but I have to put it into perspective. So do you. Try this. Imagine we had got the patient down here…no…imagine YOU were the registrar and had got the patient down here. And imagine you were doing the endoscopy, found the varix, but messed up somehow. You didn’t set up the banding kit properly, or you chose the wrong place to band. And he kept bleeding. Then he vomited blood and aspirated, then had a respiratory arrest and died in front of you. How would you feel?”
“And would you blame yourself?”
“Of course I would, if I messed up.”
“Up to a point. But I think I know what your mind would do. Everybody does the same. You feel bad, you go home, you think on it, you talk to your mates…then you rationalise. — He was in a high risk group — The endoscopy nurse should have told me the banding kit was not set up correctly — In fact she should have set it up anyway — There wasn’t time to arrange anaesthetic support — The varices must have been under high pressure — These patients, what do they expect when they drink all their lives? –…”
“I would never think that.”
“The mind can go to some dark places when you feel under threat.”
“I wouldn’t just rationalise it away.”
“Perhaps, to some extent, just to keep yourself functional. My point is, whenever you are tempted to congratulate yourself on a job well done, imagine how prominently placed you would want to see yourself in the scene if things hadn’t gone well.”
“It sounds very joyless.”
“A bit. My advice is, enjoy the satisfaction, but don’t talk about it. Because fate has a way of arranging things so that after every example of brilliance or skill, something comes along to bring you straight back down to earth.”
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