The stat cardiac-arrest page came through on my beeper at exactly the same moment as the hospital-wide PA system announced, “Code 411, cardiac arrest, MICU.” The operator chanted the mantra over and over with studied deliberativeness, as though there were even a snowball’s chance in hell that I hadn’t heard it. The repetitive droning of her voice echoing throughout the twenty-three floors of the hospital and the persistent buzzing of the beeper at my waist were like rising tides of terror pressing in on both sides of me.
This was it—the first code I was in charge of.
After two years of racing to codes as a first- and second-year resident, buoyed by the excitement of dramatic action, thrilled to be part of a team, grateful to be assigned one of the many minute tasks required to save a life, secure in the knowledge that the medical consult would be directing the show—now suddenly, the code was mine. I was the medical consult. I was the one to call the shots, to direct the care, to assign the jobs, to make the decisions.
I had been on the medical-consult service for less than a week. I’d been privately counting on thirty days elapsing with every last coronary artery in the hospital capaciously wide open, every lung alveolus buoyant with oxygen, every blood clot obediently self-dissolving, but this strategy was evidently not working as I’d hoped. Here it was: my first code.
Shit!
I slapped my hands against the overloaded pockets of my white coat to keep the tools and cards and pocket guides from spilling out while I raced to the medical intensive care unit. I burst into the MICU breathless, throat parched to Saharan levels, pulse pounding powerfully enough to detonate the collar of my shirt, and glanced wildly about the unit.
There was the crowd, huddled around bed 5. I loped over and pressed through the bodies, angling toward the head of the bed. “I’m med consult,” I announced, gamely smoothing out the jitteriness in my voice.
And then my brain splintered into complete and utter blackness.
A resident began feeding me the facts—seventy-two-year-old guy, diabetes, coronary disease, stroke last year, admitted with pneumonia, developed allergic reaction to his antibiotics, subsequent renal insufficiency, transferred to the MICU three days ago for congestive heart failure, spiked a fever last night, a bit delirious but still talking, now unresponsive, BP 70 over palp, thready pulse.
Or something like that. The truth was, I couldn’t have told you the details twenty seconds after he finished relaying them to me, much less twenty years later. Everything he said sloshed into the primordial neuronal soup that was now the condition of my gray matter.
Say something, I implored myself. Anything. “Chest compressions,” I forced out. “Keep bagging the oxygen. Get a line in. EKG.”
Any idiot knows the basics for keeping someone alive! But what next? My brain remained jammed up with panic. I couldn’t seem to remember a damn thing from those ACLS training courses. All the protocols had seemed so logical then, so ridiculously simple on those ever-forgiving mannequins.
But now there was someone real, someone alive—though perhaps not for much longer with me at the helm—and I couldn’t unknot a single protocol.
Did you shock first or give epinephrine first? Or was epi only for the asystole algorithm? Should I be following the pulseless electrical activity algorithm? Or the pulseless ventricular tachycardia algorithm?
Someone pressed an EKG into my hand. The presence of something actual in my hands brought a brief mollifying reprieve of emotion. These would be my tablets handed down from the Mount; the talismanic markings would allow me to divine the answer and jump-start my fear-stricken brain.
I stared at the electrocardiogram. And stared. And stared. I squinted at the zigs and the zags, but they seemed to melt into a Sanskrit-like jumble. Think, I demanded. Think! All those exhortations from my teachers about approaching the EKG methodically, about systematically examining the rhythm, the rate, the axis, the P waves, the QRS complexes, the T waves—these lessons evaporated in the cold shudder of reality.
Think, I screamed to myself.
Okay, the T waves. Maybe they looked a little peaked. Peaked T waves were indicative of elevated potassium levels, except when they weren’t. And except when they looked peaked but weren’t actually peaked.
They did look sort of peaked, I thought to myself, but maybe they were just hyperacute T waves, or maybe they were enlarged from early repolarization. Or maybe they were just big. I was too terrified to trust myself on anything. I could order the treatment for hyperkalemia—if those peaked T waves were real—but I was too scared that I might be wrong. What if I injected intravenous calcium for hyperkalemia that wasn’t actually there, then really fucked things up?
“Who’s in charge here, anyway?” barked a new voice. My body seized up tighter, if that was even possible. A cardiology fellow blustered his way into the crowd, clearly seeing the mess for what it was. I looked up and made a vague indication that I was running the code.
There was an embarrassing moment as the fellow and I instantly recognized each other—Mitchell had been in my medical-school class. We’d spent the first two years of school together, even traveled in the same circle of friends. But because of the years I’d taken to do my PhD, he’d completed his training before me and was now a senior cardiology fellow while I was a third-year medical resident.
It was evident that if he hadn’t known me from med-school days he would have dressed down the medical consult for not running the code more aggressively. He bit back his comment, sidled over to me, and leaned in to look at the EKG. “Peaked T waves, hyperkalemia,” he announced clearly, though not derisively—an act of humanity that allowed me a modicum of dignity. “Let’s get some calcium,” he said, “an amp of bicarb, D50 and insulin.”
The patient did all right in the end, or at least survived the code, which was pretty much what we considered success in the MICU. I slunk off after the patient stabilized, hoping to disappear myself in the sea of white coats shuffling off to conference or rounds or the ER. I was furious at myself for getting so paralyzed by fear that I could barely run the code. What had happened to all my training? All the codes I’d participated in? All the lectures and books I’d been learning from?
What made me the angriest at myself, though, was that I’d actually gotten it right. It was hyperkalemia. The T waves absolutely had been peaked. I could have called it on the spot and been the model of a take-charge resident, as a medical consult running a code is supposed to be. But I couldn’t get beyond my gripping fear—of the situation, of getting it wrong, of killing the patient, of looking like an idiot.
The amygdala is ground zero for the processing of fear in human beings.1 I remember the first time I laid eyes on an actual amygdala, after slicing through a brain with a repurposed kitchen knife in neuroanatomy class. That’s it? I thought. That nickel-size splotch tucked below the temporal lobes was the seat of my fears? It was monumentally underwhelming and even lacked the poetic almond shape that its Latin name connotes.
The amygdala acts as the ringleader of the limbic system—the emotional guts of our brain. Weaving together the hippocampus, thalamus, amygdala, and some ancient parts of the cerebral cortex, the limbic system calibrates the nitty-gritty of who we are—our fears, our attractions, our memories, not to mention the cornerstone imperatives of food, sex, and anger. If psychoanalysis had a neuroanatomical substrate, it would be the limbic system. And if it wanted a laser-like focus, especially when it comes to fear, it would train its sights on the amygdala.
I read of a patient with a rare condition that damaged the amygdala on both sides of her brain. Though her other emotions appeared normal, she neither felt nor expressed fear. Researchers did what they could to frighten her—brought in live snakes, set spiders loose, showed scary movies.2 They even took her on a haunted-house tour. She didn’t so much as flinch. It wasn’t that she had nerves of steel; she simply did not experience fear.
As a medical student and intern, I longed to be her. I desperately desired an emotional shield that would block out the paralyzing fear that seemed to track my every step. If I could only corral my amygdala and limbic system, being a doctor would be effortless.
Fear is a primal emotion in medicine. Every doctor can tell you of times when she or he was terrified; most can list more episodes than you might wish to hear. This fear of making a mistake and causing harm never goes away, even with decades of experience. It may be most palpable and expressible in neophyte students and interns, but that is merely the first link in a chain that wends its way throughout the life of a doctor. It may be sublimated at times, it may wax and wane, but the fear of harming your patients never departs; it is inextricably linked to the practice of medicine.
I sometimes compare career notes with friends who are in the business world, and I’ve asked what their worst fear is. It’s usually something along the lines of making a financial blunder, screwing up a major project, having an investment fall apart, losing a job, disappointing the boss or family, losing money. I have to restrain myself from saying, That’s it? That’s all you are afraid of?
That, of course, is the basic fear in medicine, that we will kill someone, or cause palpable bodily harm. I vividly remember my first reading of Ernest Becker’s classic existential treatise The Denial of Death.3 Becker posited that humans are terrified of their own mortality, and that every action we take, on an individual or societal level, is directed (usually unconsciously) by the necessary denial of imminent death.
This precisely captured my fear as a doctor-in-training, except that the fear was entirely conscious. I was terrified of causing death, and every action I took was an obeisance to that fear. Medical students, for all of their competence and competitiveness, are a pretty fearful bunch, more so than the general population and even more than their age-matched peers pursuing other professions.4 Some of this is not surprising. You really should possess some fear as you begin to jab sharp objects into other people’s bodies, prescribe potentially lethal medicines, or initiate treatments that put lives at risk. Any medical student without fear is a cavalier cowboy better suited to a desk job.
But the fears can easily spiral out of control and overwhelm students and interns. If this happened only rarely, to only those few who entered the medical field with their own preexisting mental-health conditions, that would be one thing. But the truth is that the fear overwhelms even the most psychologically sound and well-adjusted trainee. At some point it happens to nearly every single person who travels through the medical training process. If you don’t believe me, just ask any doctor you know.
Curtis Climer has traveled extensively, but at heart he is a rooted person. He practices medicine in the very same rural Oregon hospital in which he was born. His family has lived in Oregon since the early 1800s. His grandmother was one of ten siblings, but in the vast extended family that descended from her, there was only one other cousin beside Curtis who even attended college. Curtis is the first physician in the family.
Medical school was a shock for him. Coming from a tiny college, where asking questions in class was encouraged and quirky humor was comfortably tolerated, Curtis didn’t blend in with the conservative students from big universities. Nobody laughed at his jokes. They rolled their eyes derisively every time he raised his hand in class, and he was awarded the prize for Most Ridiculous Question of the Year at the school’s annual awards ceremony. The bushy lumberjack beard didn’t help.
But by the second year, things improved. Spending the summer in the fresh air at a summer camp teaching gymnastics (he’d been a gymnast all through college) gave a lift to his spirits. When he reentered the lecture halls with a new attitude and a new clean-shaven look, many of his classmates didn’t even know who he was. Gradually he came to know them, and they turned out not to be so awful. The feeling was mutual. “You know, I thought you were so weird,” one of his classmates said in the backhanded-compliment style of a twenty-something, “but you’re actually pretty ordinary.”
When internship arrived, Curtis flourished. He loved the specificity of clinical medicine. In the classroom, he’d had to memorize reams of diseases, all of which had equal emphasis. But on the wards, a patient’s symptoms narrowed this list, made certain diseases more likely, and often pointed to one specific disease, something you could actually hang your hat on, something you could focus on treating. The day-to-day work, however, was exhausting and he never seemed to be able to catch up on sleep. The endless paging and constant multitasking made him feel like a battery that was always draining, never recharging.
That January morning was like all others, the start of another thirty-six-hour call day—ten sick patients on his hands, plus four new admissions already waiting for him. It was the dark days of winter, and Curtis couldn’t remember the last time he’d seen an actual ray of sunshine. Before he’d even had his first yawn of the morning, a gastric ulcer in one of his patients chose that moment to begin hemorrhaging. Curtis dropped everything and sprinted down the hall, his mind spinning through his mental list—check vitals, two large-bore IVs, fluids wide open, stat hematocrit, call blood bank for two units of blood on standby, rectal exam to see if there was blood in the stool, nasogastric tube to lavage stomach, page GI if patient crashing.
While he was stabilizing the GI bleeder, at the other end of the ward a blood clot was casually flicked out of the heart of another of Curtis’s patients. Shortly thereafter, the patient couldn’t move the left side of his body. Curtis shifted gears and flew to stanch that fire, his brain now flipping to the protocol for acute stroke—check vitals, quick neuro exam, stat head CT, page neuro. The four new admissions were still waiting in the emergency room, of course. And there was still the daily litany of morning report, attending rounds, noon conference. It really wasn’t different than any other day.
The day wore on into evening. The calls from nurses for various emergencies large and small continued unabated. By nightfall, the calls shifted to tasks that his colleagues had neglected to do before they’d left—medication renewals, IV replacements, sundry forms and orders. At 10:30 that night, Curtis remembers getting annoyed at his compatriots for not being more assiduous at clearing up their scut lists.
He was sitting at a desk on Unit 4C writing a progress note in a chart when his pager went off for the umpteenth time. He dialed the phone automatically, still penning his note, and a nurse requested an order for Tylenol. A Tylenol order for an intern requires even less thought than flicking on a light switch. It’s a task that barely registers on the horizon of consciousness.
But at this moment, Curtis suddenly had no idea what to say. He couldn’t remember the first thing about Tylenol—how much, how often. “Somewhere inside of me,” he recalls, “I could feel myself falling backward off a cliff. I was in free fall and could actually feel the wind blowing by me. I could see the edge of the cliff growing smaller as I fell deeper and deeper into some ill-defined chasm. And I had no idea where bottom was.”
He stammered incomprehensibly on the phone. The nonplussed nurse prompted him, feeding him the details of 650 mg PO, q4H, prn, and he mumbled his assent as tears began to fill his eyes. He hung up the phone and simply sat there, stunned, weeping.
“I had no idea what had happened,” he says now. “All I knew was that it felt like I could not make another decision.” When his pager went off again, it was for a simple sleeping medication, one that he had prescribed dozens of times in the past month. But he couldn’t dredge up any information about it. He stumbled through the conversation somehow, then he called his resident, Mike.
“What do you need?” Mike asked briskly. A good resident was always on the prowl to lift an item or two off his intern’s scut list.
“I’m not sure, Mike,” Curtis said hesitantly. “Something is wrong.”
“What’s the matter?” Mike asked, his voice beginning to register the gravity of the situation.
“I . . . I don’t know,” Curtis replied, and the tears began to flow again.
“Stay where you are,” Mike said. “I’ll be right over. Don’t move.”
Curtis hunched over his shoulders and sat in the doctors’ station, crying, waiting, praying that his pager would not go off. Mike arrived at 4C promptly and didn’t seem fazed by a sobbing intern. He seemed to know what was happening.
“Give me your scut list,” he said calmly to Curtis. “I’ll take care of this. You get over to the call room and get as much sleep as you can.” Curtis raised himself shakily to his feet. His physical body seemed to work, but everything inside had shut down.
“Tomorrow morning,” Mike ordered, “skip any work or meetings that are not absolutely critical. By whatever means possible, you need to be out of the hospital by noon. I’ll pick up whatever is left over to do.”
Curtis shuffled off to the call room, only vaguely able to process the compassion of his resident. The beds were rumpled and old; the sheets probably hadn’t been changed from the last four interns, but he didn’t care. He dropped off into a dense and dreamless sleep. When he awoke, he was still standing on the cliff, but now he was four feet inland from the edge. Four feet of safety but still four feet from the chasm. He could easily topple over again.
He worked cautiously through his morning tasks, not sure if the oddness inside him was visible to the outside world. But just after attending rounds, Kathryn, the other intern on the team, leaned over and said, “Curtis, what’s happening to you?”
Curtis explained to her about the Tylenol and the cliff and the black, bottomless abyss. She listened carefully, and then very softly she said, “That’s your first time, right?”
He stared back at her, too amazed to speak.
“For most of us,” she continued, “it’s already happened several times. For some it started within the first month of internship.”
Curtis was stunned. One experience like this was terrifying; he could not imagine going through it repeatedly. With Mike’s help, he managed to escape the hospital by noon. Once home, he took a steaming bath and then crashed on his bed, not stirring for the next seventeen hours. When he awoke the next day he was twenty feet back from the cliff edge. He felt better, more like his regular self. He probably would not fall off from that twenty-foot distance, but he knew now that he could, and that disquieting knowledge could not be unlearned.
Curtis experienced an acute stress reaction, a psychological term that encompasses a spectrum of responses. The common thread is an intense reaction to a shocking or traumatic event. The sympathetic nervous system shifts into overdrive, and tides of hormones and neuronal firings can alter the state of being, sometimes profoundly. Gravely injured patients can be in a state of shock so profound that they sense no pain whatsoever.
Different people exhibit different reactions to the same stressor—sometimes diametric opposites. Witnessing a person keel over unconscious can induce such overwhelming panic and anxiety in a bystander that he or she freezes, unable to do anything. For the next person over, this stressor can sharpen their focus and nerve, allowing them to jump in and begin CPR.
What Curtis experienced is termed a dissociative reaction. He felt utterly removed from himself, wicked away from the events around him. There is a sense of the surreal, as the real world waxes and wanes.
Anecdotally, many doctors and nurses will tell you about their “moments,” as they are often called, that moment when the medical world overwhelmed them and they were unable to function for some period. But there is little research in the field. What has been published shows that for health professionals, acute stress worsens performance on tasks that require divided attention—that is, tasks that require integrating information from various sources.5 In contrast, concrete tasks that require selective attention—placing an IV, for example—may be improved by a modest amount of stress.
But complex tasks requiring attention to disparate things suffer notably under stress conditions. Multitasking and juggling is the daily bread of medicine—treating a patient who has stomach pain but also a rash and also missed three days of medications; taking a phone call from an anxious family member or irate insurance company while documenting the details of a physical exam; reacting to a dangerously low sodium level but remembering that the treatment is different depending on the patient’s overall fluid status while also remembering to check whether the low sodium is merely an artifact related to concomitant hyperglycemia.
Curtis’s acute stress reaction was not uncommon, as his fellow intern noted. For him, it was a reaction to the composite of his situation. The Tylenol request was simply the trigger that nudged him over the edge, almost literally. His reaction—and the signal that something needed to be done—was loud and clear, and luckily Curtis had a resident who recognized the situation immediately. Very often, however, these signs are missed.
Some medical schools and residency programs are taking note of the fact that fear, stress, and feelings of being overwhelmed are nearly universal in their trainees, and are beginning to take steps to address this. This is crucial, because research from the field of psychology suggests that people who are fearful are more pessimistic in their outlook and may overestimate the risk of bad outcome.6 As a result, their choices of action may lean toward the risk-averse.
As I stood in front of my first coding patient, I “chose” what seemed to be the most risk-averse action—doing nothing—even though it turned out that I’d made the correct diagnosis of elevated potassium. At that moment, doing nothing seemed the least risky path, but it wasn’t. If the cardiology fellow hadn’t come along in time, my patient would have died promptly from a hyperkalemic cardiac arrest.
What exactly is going on? Why does overwhelming anxiety so brutally impair our decision-making? The amygdala and the limbic system figure prominently here,7 as a welter of emotions distracts us, and we misread important cues. There is a tendency to overemphasize the unimportant issues while downgrading the important ones. I can remember the swell of stimuli—people shouting, machines beeping, equipment flying—and how it seemed to cave in on my thought process, making it impossible to concentrate on the critical tasks at hand.
Some residency programs offer stress-management workshops, support groups and mindfulness meditation.8 Other suggestions for reducing stress range from identifying and treating trainees who exhibit “at-risk” behavior to increasing “interdisciplinary teamwork” to rejiggering call schedules to chewing gum9 (yes, gum does seem to reduce stress, at least in undergrads). But in the end, most residents are simply too busy to incorporate yet another thing, no matter how beneficial, into their day,10 or maybe it’s just too difficult for doctors to practice medicine and chew gum at the same time.
A surgery residency in Greece taught half of its residents simple stress-reduction techniques, such as muscle relaxation and deep breathing, over the course of two months. Compared to their colleagues who didn’t undergo this training, these surgical residents experienced a significant decrease in their stress levels and a concomitant increase in their decision-making abilities.11
Though these programs seek to reduce stress—in the global sense of all things awful about medical training—none really focuses on the fear, the panic really, that grips us during various points in our careers. There are many who argue that doctors should never lose the fear of doing harm, that it is a healthy existential fear that maintains a necessary awe and humility in a field where lives are indeed at stake. But for those in the profession, we need to be alert for when we or our colleagues become overwhelmed by this fear; our patients’ lives are at stake.
Over the years of practice, as I gained confidence, I found that my overriding fear receded in intensity, though it never completely vanished. Studies have corroborated that stress generally decreases as one moves along in training.12 My fear became, perhaps more in parallel with Ernest Becker’s theory, an unconscious, or maybe semiconscious, modulator of my actions. The moments of utter panic were fewer, but the fear was never absent.
Hao Zhong was a thirty-two-year-old man who had swallowed a bottle of pills and then followed this by slitting his wrists with a carving knife. “He’s stable,” my resident told me—I was the attending in charge of the ward for that month—“but his family wants him transferred to Mount Sinai.”
This is a frequent occurrence with upper-middle-class patients who accidentally end up in a public hospital. The ambulance brings them to the closest facility that can handle the particular emergency. (For Mr. Zhong, with his dramatic suicide attempt, that facility was, of course, Bellevue Hospital.) Then, when they realize where they are, they start clamoring—sometimes demanding—a transfer to a private hospital.
When they become aware that they will have to pay out of pocket for the transfer, however, many change their minds and settle in. More often than not, they find themselves pleasantly surprised by the clean, spacious hospital and doctors quite similar to their private physicians. However, I never press anyone to stay at Bellevue (unless his medical condition would make leaving unsafe). My feeling is that if someone prefers to be at a private hospital and is able to make the arrangements, then he should go where he is most comfortable.
Mr. Zhong didn’t care one way or another, but his family wanted him uptown in the swankier setting that Mount Sinai offered. The resident told me that the arrangements were in progress. Psych had seen the patient in the ER but wanted him monitored on the medical ward because of the pills he’d swallowed. I called hospital administration, because I always forget the precise details of interhospital transfer. “If they want to arrange an ambulance and can pay for it, they are free to go,” an administrator told me. “But it’s not our responsibility to take care of the arrangements. It’s the family’s.”
I was listening with only half an ear. I had started on the wards just the day before and was supervising two teams of residents, each with eighteen to twenty patients. The day wasn’t more than half over, but I was already behind the eight ball, still trying to get a handle on the old patients while a steady stream of new admissions was coming in, including Mr. Zhong.
I scanned my spreadsheet with thirty-nine typed names, plus several more handwritten at the bottom, each scribbled in as a new admission arrived. Starting on the wards was always harrowing. It seemed impossible to familiarize myself with every patient, but I had to be sure that I leafed through every chart and at least stopped in at every patient’s room for a brief visit, since I was ultimately responsible for every single patient on our ward. Even that minimal amount of attention, though, took hours. I worried incessantly that something would slip under the radar.
I plowed my way through 16-West, checking in with each patient on my list to be sure everything was okay, at least for the moment. I told myself that I would review each case in depth on the following day. Though tomorrow the other team under my supervision would be admitting, so there would be another influx of new patients. The residents and interns were scurrying about with today’s new admissions, while I scurried about getting familiar with the old patients. Whenever our paths crossed, we would confer briefly over the latest lab results, pending X-rays, or minor crises that arose. It wasn’t humanly possible for me to check every lab on every patient; I relied on my residents.
Mr. Zhong was resting comfortably in his bed when I popped into his room. He was wearing a white undershirt and old sweatpants, but his hyper-trendy European eyeglasses gave away his socioeconomic status. As did his high-end laptop, upon which he was typing furiously. “IPO’s in a few days,” he said, by way of explanation. “Still ironing out kinks in the security codes.”
When I peeled back the bandages on his wrists, I could see that the cuts he’d made were superficial. They didn’t even require stitches, only surgical adhesive strips. “I was pretty stupid, eh?” he said, pursing his lips in a self-deprecatory manner.
“Well,” I said, leaning against the wall near his bed since the visitors’ chair had apparently been requisitioned elsewhere, “it depends on how you look at it. You certainly sent a clear message to your family and to your doctors that something serious is going on in your life.”
“It’s not like I want to die or anything—” he replied, then cut himself off midsentence. “That’s sounds pretty ridiculous, doesn’t it? I mean, here I am sitting in Bellevue, for God’s sake.” He gave an eye roll but also smiled wryly. “I mean, how stupid can I get? Just because at three in the morning I couldn’t think of a better way to cut the stress. And now my partner’s gonna kick my butt if I don’t get the last bug out of the system. Maybe I ought to slit the wrists of my computer.” He shot an exaggerated glare at the laptop.
Because of the overdose, the ER had lavaged his stomach and administered a dose of charcoal to absorb whatever the lavage might have missed. This apparently worked, because his body seemed to have suffered few ill effects. His labs and EKG were normal. Mr. Zhong said he was feeling fine and was mostly sheepish about his suicide attempt. “I gotta go back to my old shrink—you don’t need to tell me that.” But of course I did tell him that, and we discussed the importance of ongoing treatment.
When I pressed him about further thoughts of suicide or concrete plans, he shook his head. “If I kill myself and botch the IPO, my partner will kill me.” He stopped and his face took on a mock-perplexed look. “No, wait, that won’t work, will it.”
Onward through the ward I soldiered. Mrs. Everett’s fever was down. Mr. Liang was getting his chemo. Mr. Chowdury was waiting to be called down for his stress test. Mrs. Jimenez had been accepted by a nursing home, but the bed wasn’t ready yet. Mr. Selwin was in the GI suite getting his endoscopy. Ms. Soto’s bone scan hadn’t been read yet. Mr. Hastings would be discharged after ophthalmology saw him. Mr. Sabatini was refusing an IV. Mrs. Abaza had been at dialysis since 8:00 a.m. Mr. Riyad needed only two more days of antibiotics. Cardiology would be taking Mr. Vladic to the cath suite any minute now.
By late afternoon I’d gotten through most of my list, though the new admissions continued to pile up. The stable ones—pyelonephritis and noncardiac chest pain—I’d put off till later. The GI bleeder I checked on right away.
The only thing that made it possible for an attending to be in charge of forty patients was that the interns and residents were actually the primary doctors for the patients and did the direct work. I functioned more as the supervisor and consultant to my two house-staff teams. I of course had to check on every patient myself, but they did the grunt work.
The sun was edging down into the East River as I sank into one of the seen-better-days office chairs in the doctors’ station with six charts open in front of me, consulting my patient list and making notes. The resident popped in. “The ambulance is here to transfer Mr. Zhong to Sinai.”
I looked up and saw medics wearing sporty blue parkas standing with a stretcher in front of the nurses’ station. “All his labs okay?” I asked the resident.
“Yep,” he said. “It’s been twenty-four hours since ingestion now, and no change.”
“Seen by psych?”
“Evaluated in the ER.”
“Someone’s called his private psychiatrist?”
“Yep.”
“There’s an accepting doctor at Mount Sinai?”
“Yep.”
“Family took care of papers, transfer issues, ambulance?”
“Yep.”
“Okay,” I said. “Wish him well. Did Sanders get the head CT yet?”
“Med students are wheeling her down now. I’ll call you when the results are back.” The resident was already out the door with three scut lists in his hand.
I watched Mr. Zhong climb onto the stretcher, surrounded by his family. When he saw me through the window he pointed to the laptop under his arm and made a scissors-snipping motion at it. I couldn’t help but smile. The medics tucked the sheets around him and then buckled the orange safety belts that prevented the patient from slipping off while the stretcher was in motion. Papers were signed, and he was off. I waved and then turned back to my charts; the chair creaked its annoyance at my movements.
Mr. Lambert had spiked a new fever. Ms. Hestina needed an ENT consultation, but that could wait until tomorrow. The surgeons wanted medical clearance in order to take Mr. Kinsawa to the OR, so we’d need to take care of that now. That antibiotic for Mr. Demir was nonformulary, so needed a special approval form. Mrs. Jennings was refusing her meds.
The phone rang, and I answered while scanning my list. It was the hospital administrator I’d spoken to earlier. “That patient of yours who wanted to go to Mount Sinai,” he said. “I was just looking at his record and I see that he was admitted for a suicide attempt. Did psych clear him?”
“They saw him in the ER,” I replied, pulling over a nonformulary medication form and filling in Mr. Demir’s details.
“Yes, but that was just the emergency consultation in the ER. Did the regular psych team evaluate him once he was up on 16-West?”
A sudden iron tension burrowed in my spine. “On 16-West?” I stammered, my mind now beginning to shift gears. “Umm, I know they saw him in the ER, but I don’t know if they were here on the ward. We were told the patient was cleared in the ER.” I shoved the form away and started scrambling through the charts on my desk to see if Mr. Zhong’s was there, which of course it wasn’t.
“Dr. Ofri.” The administrator’s tone turned stern. “You sent a potentially suicidal patient out of the hospital?”
“He went in an ambulance, with medics.” I could hear my voice trying to shore up the situation with whatever hard facts I had at hand.
“He went in the care of his family in a private ambulance. They could take him anywhere they want. They could take him home. They could leave him on the street.” The administrator continued to lecture me, but my nerves were already jangling with anxiety and it was difficult to focus. “If something happens to him, if he attempts suicide again, we are entirely responsible! You can’t let a patient like this out of the hospital.”
I raced to the nurses’ station, pulled out Mr. Zhong’s chart from the discharge bin, and began flipping madly through the pages. I finally found the original ER sheet and scanned through twenty-four hours of handwritten notes. Scrawled at the bottom was the psych note: Patient with strong supports and family network. Not currently voicing interest in repeat suicide attempt, but nevertheless remains at risk. Would keep on 1:1 observation until re-evaluated by regular psych consult team.
The regular psych consult team! How could we have missed that? Now we had gone and discharged a patient whose last psych evaluation said to keep on 1:1 observation for suicide precaution. If anything happened to Mr. Zhong . . . I could hardly bring myself to think it. I dropped the chart on the desk and haltingly drew both hands to my mouth as the gravity of what I might have done began to sink in. What if my oversight caused the death of this young man? And, of course, on the legal side of things, I wouldn’t have so much as a toothpick to stand on.
Back in the doctors’ station I threw myself into the chair, ignoring the angry hissing of the cushion. I grabbed the phone and snapped at the operator for Mount Sinai’s phone number. I had visions of Mr. Zhong bolting out of the ambulance and streaking down Third Avenue, disappearing into the night, swallowed up by the anonymous city. Would he fling himself on the subway tracks? Dodge in front of a careening taxi? Clean out the Tylenol shelf at CVS and swallow his way to fulminant liver failure?
I wended through layers of phone tree at Mount Sinai, trying to ascertain whether Hao Zhong had arrived there. I kept getting low-level administrators who curtly declined my request for information, citing HIPAA privacy regulations. I slammed the phone down and gritted my teeth. How could I have been so stupid!
I saw my resident walking briskly down the hall with the rest of the team. They all clutched charts and scut lists and were talking and writing as they walked. I could hardly blame them for this mess. Too much was happening at once. They’d gotten a verbal report from someone in the ER that “psych had cleared the patient,” and they gave the same report to me. No one had taken the time—or had the time—to read the actual note to see that further monitoring was recommended, that the patient was still considered suicidal.
Seeing the resident walk by, though, shot an idea into my head. I called Mount Sinai back and asked for the page operator. “This is Dr. Ofri,” I said, corralling some authoritative heft into my voice. “Please page the admitting medical resident for me.” The operator didn’t say a word or even ask if I was a Mount Sinai doctor; she simply patched through what must have been her 1,357th page of the day.
Thirty seconds later a young voice was on the line. I quickly explained that I was a medical attending at Bellevue and that we’d transferred a patient to Mount Sinai this evening. I just needed to confirm that he’d arrived. The resident paused and I could hear clicking on a keyboard. I imagined her scrolling down lists of patients, her mind running down her own scut list, annoyed at this extra task some outside doc had thrust upon her. My foot tapped a jerky syncopation on the floor, and my fingers twisted around themselves in the phone cord. I tried not to think of subway tracks or drugstore shelves.
The resident came back on the line. “How do you spell his name again?”
“Z-H-O-N-G,” I said, grabbing clumps of hair in my fist. “First name H-A-O.”
“Hmmm, not in the medical department.” She paused again. “Computer’s really slow tonight,” she said, with an edging tone of pleading, clearly hoping I’d thank her for trying and then hang up.
Mr. Zhong’s funeral spooled through my head, his grieving family split-screen with a prosecuting attorney in a courtroom. I’d really done it now—let a suicidal patient leave the hospital. How could I be so . . . so . . . stupid? Idiotic? Negligent? Pathetic? Disgraceful? My brain was a veritable thesaurus of culpability.
“Umm, that might be him.” The resident interrupted my thoughts. “Did you say Z-H-O-N-G or Z-H-A-N-G?”
“O-N-G,” I barked hoarsely into the phone. “Z-H-O-N-G.” The stiff, cracked vinyl of the chair chafed my thighs. The doctors’ station was filled with castoffs from the nurses’ station; this one was probably from two renovations ago.
“Wait, here he is,” the resident said, a minor note of victory in her otherwise tired voice. “Zhong, Hao. Still in the ER, awaiting a bed on psych.”
“But he’s there, right?” I said, needing to hear it again before I could register the thought.
“Yeah, he’s in the computer system. I can see that he’s been admitted to psych already. He’s here.”
I slumped back in my seat, and the wobbly back of the chair sagged perilously. But I didn’t care. The tide of relief insulated me from the usual vertigo that accompanied a recline in the loose-jointed chairs.
We’d avoided the abyss—Mr. Zhong and I—but just narrowly. I whispered an apology aloud. I had endangered his life. It was inexcusable. But the truth was, something like this was inevitable.
The abiding principle on the wards was that since attendings didn’t have the time-consuming scut that residents and interns had (drawing blood, placing IVs, chasing down consults, running to radiology), one attending could supervise two teams.
With forty-odd patients and dozens of data points for each patient, there was no possible way I could personally verify every single lab, X-ray, consultation report, physical-exam finding, or progress note for each patient. I relied on verbal reports from my residents for a large percentage of the data. I tried to prioritize and then check on what I thought was the most critical, but the truth was that anything could turn out to be critical. When the resident said, “Labs were fine,” there could be an unexpectedly low bicarb level within the thirty individual lab values that his statement encompassed. The possibilities for harm seemed endless.
And then there was the time needed to actually evaluate the patients, to talk to them, examine them, read the charts, write my notes. Ten minutes in each patient’s room, and then another ten minutes reviewing the chart seemed like a bare minimum. But altogether, that was more than twelve hours right there. And that didn’t include rounds, teaching, conferences, let alone grabbing a sandwich or going to the bathroom. Residency regulations limited the number of patients that residents could be in charge of. No such regulations applied to attendings.
Having something slip under the radar was my fear from day one as an attending, and now it had happened. I’m sure many other things slipped under the radar too, but luckily most were benign. Mr. Zhong’s episode was a biggie, though it would fall into the near-miss category, since—thankfully—nothing harmful actually transpired. But still, the error was the same, irrespective of the outcome.
A few days later, I related the incident to my colleagues at our weekly meeting, and there were commiserative murmurs all around. The saving grace was that, by and large, all our residents were extremely conscientious—a good thing, since our reliance on them was absolute. Woe to the attending who was assigned to the less compulsive resident.
But I was practicing substandard medicine, and I knew it. The fact that only one major thing had flown under the radar so far was of little comfort. I felt like one of those plate-spinning Chinese acrobats: one plate after another was tossed onto my poles, and I had to keep them all balanced and spinning. If the acrobat dropped one, it was just shattered china to sweep up. If I dropped one, someone could die.
For the rest of the month, I walked around the wards with a film of nervous tension on my skin. What would drop next? I felt as overwhelmed as I had as an intern. Except that as an intern, I always had my resident to turn to. As an attending, there was no one else to pick up my slack. The buck was supposed to stop with me.
A little less than a year after Mr. Zhong slipped from my grasp, things began to change. It became clear that the ratio of one attending to two resident teams was unsustainable and patently unsafe. There needed to be one attending for each resident team. The sticking point was, of course, money. Hiring twice as many attendings was no small budgetary endeavor.
The hospital responded by shifting more doctors from the clinics to the inpatient wards. This helped staff the inpatient side but left the outpatient clinic struggling. Patients had to wait months for appointments, and every one of our sessions in clinic was crammed with overbooked patients. My fear of something flying under the radar simply shifted from my ward months to my clinic months. My amygdala puttered along, unperturbed, steadily feeding my underlying anxieties and fears.
Fears can range from the abject panic of thinking you might have killed your patient through your actions to the low-level worming anxiety that you might be missing something in the everyday care of patients. Some time ago I reviewed a book written by a patient who had a debilitating disease that no doctor could diagnose.13 The book was part of a series entitled How Patients Think, a complement to (or retaliation for, depending on your perspective) Jerome Groopman’s book How Doctors Think.
The author wrote of her years of mysterious symptoms that did not fit easily into a simple diagnostic category. Her ailments were labeled psychosomatic (and the author was labeled a “difficult patient”); it took two decades before a correct diagnosis was made. The author turned out to have a rare illness—myasthenia gravis—and this was compounded by the fact that her symptoms were exceedingly atypical for myasthenia. It was a needle in the haystack, and the needle didn’t look very much like a needle. This near-impossibility of diagnosis notwithstanding, the patient suffered greatly in the process due to both misdiagnosis and overall poor treatment. Her fury at the medical establishment was palpable.
I read the book attempting to keep the steady, dispassionate eye of a literary reviewer. But it was hard to hold back the bubbling fear of the clinician, of the primary care doctor who sees hundreds of patients with vague, multifaceted, seemingly unrelated symptoms. As I progressed through the pages, I realized that if this patient had come to my office, I surely would have missed the diagnosis too. I would be another in the line of clinicians she writes off—justifiably or not—for blundering her care.
This type of patient is the daily bread of the general practitioners—internists, family doctors, nurse clinicians, physician assistants. In contrast to specialists who have their diseases cut out for them—cardiologists get patients with heart problems, pulmonologists get patients with lung problems—the general practitioner has the far more challenging task of sifting out serious illness from the vast sea of aches and pains that afflict the human race. And this is what we fear, that one of these hundreds of patients will indeed harbor some grave illness and that we will miss it.
Not long ago I wrote an article about one such patient.14 I described Beverly Wilton as the classic worried-well type of patient—a healthy, fifty-year-old educated white woman with a long litany of nonspecific, unrelated complaints. She was thin and anxious, with tight worry lines carved into her face. When she unfolded a sheet of paper on that Thursday morning with a brisk snap, my heart sank as I saw thirty lines of hand-printed concerns. Ms. Wilton, like Mrs. Alvarez, is the type of patient who can overwhelm a doctor, quickly siphoning off reserves of time, clinical reasoning, and empathy.
Ms. Wilton told me that she had recently started smoking again after her elderly mother became ill, and she was up to a pack a day now. She had headaches, eye pain, abdominal pain, pounding in her ears, shortness of breath, and dizziness. She experienced dryness when she swallowed, needling sensations in her chest, tightness in her gut. She couldn’t fall asleep at night. And she really, really wanted a cigarette, she told me, nervously eyeing the door.
This is the patient who makes me feel as though I’m drowning. I avoid asking the comprehensive review-of-systems questions because I know I’ll get a yes to everything.
When I teach residents and medical students, I always ask them to place a patient’s symptoms within a physiologic paradigm. Most diseases have specific symptoms, related to the particular pathology at hand. There are certainly illnesses with global symptoms—many endocrine and rheumatologic diseases, for example—but even these diseases usually have recognizable patterns.
For most patients, if they truly have significant organic pathology of the renal, neurologic, gastrointestinal, pulmonary, and cardiac systems simultaneously, they are devastatingly ill and not hard to miss.
But the overwhelming majority of patients who come to an outpatient medical clinic with multitudes of symptoms are like the patient who sat before me on this day—healthy-appearing, with a good exercise capacity, stable weight, and a perfectly normal physical exam. Ms. Wilton even had a normal EKG and cardiac stress test done within the past year. It would be exceedingly unlikely for a serious illness affecting multiple organs to be present in this sort of patient.
The metaphor of drowning is not only apt; it’s diagnostic. It is a clue that something else may be going on, that the doctor needs to probe for other issues, such as stress, depression, domestic violence, eating disorders. When I administered a questionnaire for anxiety and depression, Ms. Wilton selected the highest value for every question.
I told her that her symptoms were most likely from anxiety and Ms. Wilton seemed relieved. “My mother is impossible,” she said. “I try to be there for her while she’s sick, but she is just as crabby as always. In fact, that’s the first time I ever got chest pains—when I visited her after her surgery last month. The same thing happened with I visited her at rehab last week.”
She brought her fingers to her temples and squeezed a cage around her face. “Every time I take off from work to get her to the doctor, I get flak from my boss. And my son, he’s twenty-eight, but he still can’t support himself. No wonder I’m smoking like a chimney.”
I could envision the vise-like tension pressing in from every facet of her life. I explained how stress could cause physical symptoms, and though we couldn’t change the facts of her life, we could try to ease the pain by treating some of the symptoms of stress. Ms. Wilton welcomed this approach, and I felt a sense of satisfaction that I might actually be helping my patient where she really needed it.
Fourteen hours later, in the dead of night, my pager went off: extension 3015. The emergency room. Never a good sign. I called in and got the news from an intern. Ms. Wilton had been admitted to the hospital with a pulmonary embolus—a blood clot in the lung.
A pulmonary embolus, a leading cause of sudden death—it was hard to get much worse than that. I sank down onto a chair, clenching my eyes against the stinging ray of guilt. My worst fear had come true: a patient with vague and seemingly unrelated symptoms turned out to have a life-threatening illness. As the intern spoke, my mind raked back over my encounter with Ms. Wilton, all the symptoms she had listed for me.
There they were—chest pain and shortness of breath—buried in her sea of anxiety, job worries, family concerns. A potentially fatal condition was right smack in front of me as I prescribed her sleeping pills and a visit to a psychiatrist.
“Oh, and it was bilateral,” the intern added. I sank my chin against my chest, too traumatized to reply. The presence of blood clots in both lungs meant that she’d be sentenced to a lifetime of blood thinners to prevent future clots. No one wants to take a chance with bilateral pulmonary emboli.
Ms. Wilton had fit the stereotype of the worried well so perfectly. Her expansive and multifaceted list of complaints was classic for a person suffering from emotional stress. Occam’s razor—the law of diagnostic parsimony—tells us that the simpler explanation, the single condition, usually underlies the patient’s symptoms.
However, there is the counterargument, Hickam’s dictum, which states, in essence, that patients can have as many diseases as they damn well please. Ms. Wilton did indeed suffer from emotional stress and had many symptoms resulting from that. But at the moment she sat in my office, she also had a handful of blood clots growing inside her.
It’s Hickam’s dictum that terrifies doctors: even when you think you’ve made the most reasonable diagnosis, there could be something else lurking, something horrific. If you make that sort of error while picking stocks for investment, or filling out a 1040, you might lose a little money. Or a lot of money. Or a lot of clients. But you won’t kill someone. This fear is the inner lining of a doctor’s daily life.
After reading Jerome Groopman’s book How Doctors Think15—which filled me with plenty more fears of the myriad errors I could be making—I tried to analyze the cognitive errors that led to my misdiagnosis. For Ms. Wilton, her shortness of breath blended into the greater landscape of her many symptoms. This symptom did not stand out in terms of severity or time course. Plus, it seemed to occur only when she visited her mother. This blending of symptoms was mirrored in my mind as well. Not to mention my attribution bias, which my judgment solidified around my stereotype of a healthy-appearing, educated white female with an extensively prepared list of complaints.
How might I have picked up on the pulmonary embolism? The brute-force approach might have dug the needle from the haystack. If I had taken every symptom in isolation and asked—as every medical student is taught to do—about duration, severity, provoking and relieving factors, associated symptoms, I might have found the shortness of breath to be the key symptom.
The truth is, any one of her symptoms might have masked a life-threatening illness and could have justified a full medical investigation: Headaches could have been a cerebral aneurysm. Abdominal pain could have been a bleeding ulcer. Needling sensations in the chest could have been angina.
Dissecting each symptom in isolation with textbook-perfect detail would have taken easily an hour or more. This technique works heroically well in books, movies, and clinical legends, but in real life there is a waiting room full of patients, all of whom could rightfully complain that their doctor was arrogantly ignoring them and taking their time for granted. And of course, in this era of accountability and quality measures, I would have been dinged for being inefficient and not meeting “productivity goals.”
In the real world, I had twenty minutes allotted to evaluate, treat, and document Ms. Wilton’s myriad symptoms. I performed my history and my physical exam, and then I relied on my instinct that it was extremely unlikely that Ms. Wilton had a cerebral aneurysm and a bleeding ulcer and angina and a pulmonary embolus. She couldn’t have all that and look as well as she did.
I relied on my experience, my clinical judgment, as well as my stereotyping, and chalked it all up to stress. And I was wrong. My fears about harming patients, fears that had been tamped down somewhat with my years of experience—and perhaps simple good fortune—reignited with a vengeance.
When I wrote the article about her case, my original intent had been to examine the role of stereotyping in medicine, pointing out that I’d even managed to stereotype myself—white, educated, female, neurotic. What I wasn’t prepared for were the scathing reader comments that were posted online. How could you be so incompetent? Doctors never listen to their patients! Those arrogant doctors never take the time to hear the full story! Those money-grubbing doctors are just milking the system!
It was dispiriting, to say the least, especially because I thought I had taken the time to listen to Ms. Wilton’s story, to tease out the context of her life that might have affected her illness. I realized that I would probably make the same mistake again, that I would likely miss a pulmonary embolism, just like I would have no doubt missed the myasthenia gravis of the patient who wrote the book I had reviewed. Just as I might miss a serious problem in Mrs. Alvarez next time she appears with her host of “worst-ever” symptoms.
Despite my years of experience, despite my training, despite my diligence, there is no doubt that I will make more mistakes in the future, that I might harm a patient, that I could easily get battered in a lawsuit. Maybe—and here, perhaps, is the deepest existential fear—I simply am not good enough to be a doctor. Maybe I need to take down my shingle and let my patients be cared for by more competent hands.
But as I look around at my colleagues, I think that I fall within the acceptable range of capability, that I’m probably not much worse or much better than they. When I started speaking to them, I realized that they all carried around this same fear—fear of harming patients, fear of not being good enough. One of my colleagues summed it up only half jokingly, saying, “Every day is an opportunity to lose our license.”
She recalled a time when her mind wandered for a brief moment while an intern plodded through a case presentation. It was one of twenty such cases she’d been listening to all afternoon, each one presented in a droning monotone. The day was growing late, and she was thinking that she could use another cup of coffee. Nevertheless, she jogged herself back into focus, just as the intern was saying something about a patient’s foot looking a little dusky so he was going to give the patient a podiatry appointment for two weeks hence. That was when her own inner caffeine jolted her upright.
A dusky foot is one of those heart‐stopping terms in medicine, because it can mean a limb is losing blood flow. For these patients—who usually have diabetes and severe vascular disease—that limb might need emergency surgical treatment to restore blood flow. Or, if the lack of blood has already done too much damage, then the limb might have to be amputated promptly to avoid deadly gangrene. This kind of patient needs to see a vascular surgeon immediately to gauge the severity of the situation, not a podiatrist in two weeks. A dusky foot could certainly turn out to be nothing more than discolored skin, but it’s not something you take a chance with.
The intern hadn’t understood the gravity of the situation and so was doing what he thought was reasonable. But for the attending, her momentary lapse of attention was terrifying. A few seconds longer and that patient’s dusky foot would have disappeared into the haze of vaccinations, mammograms, and other nonurgent matters. If the blood supply had indeed been compromised, the patient could have lost his leg, or his life.
I visited Ms. Wilton in the hospital the following day. Her breathing was better, thanks to the timely treatment she’d received in the ER. We talked about the gravity of a pulmonary embolus and the need for her to take blood thinners for the rest of her life to prevent recurrence. However, too high a dose of blood thinners could cause bleeding; too low could allow another blood clot. From this day onward, Ms. Wilton would have to live in the precariously narrow canyon between clotting and bleeding, teetering forever between the risks of pulmonary embolism and the risks of bleeding ulcers or strokes, all of which could be deadly. I had to own up.
“I need to offer you an apology,” I said, my voice slackening. “I missed this diagnosis. You told me about your shortness of breath and your chest pain. But given all your other symptoms, I didn’t think of a blood clot in your lungs.” The mere articulation of these words was agonizing. The concise summary seemed only to concretize the fact that my actions could very well have killed Ms. Wilton. Sudden death is frequently, in fact, one of the first symptoms of pulmonary embolism. “I . . . I’m sorry.”
Ms. Wilton waved her hand dismissively. “The truth is,” she said, “I didn’t think anything of the chest pains either. I’d had this appointment scheduled with you for months—way before the chest pains started—so I guess it was just random chance that this blood clot happened now.”
I appreciated her forgiveness. The random timing of the embolus offered some comfort, as did the knowledge that pulmonary embolism is known to be a notoriously difficult disease to diagnose. But I realized that not only did I need to keep tuning my skills as a doctor, I also had to figure out a way to live with the uncertainty of medicine and its attendant anxiety. As sure as the sun will rise, as sure as the next ambulance will roll into the ER, as sure as the next patient will walk into a doctor’s office with a list of vague symptoms, mistakes will happen. From autopsies, it is estimated that 10 to 15 percent of diagnoses are incorrect.16 There is an entire academic field devoted to studying diagnostic reasoning and how to decrease errors in our thought processes.17 But this research doesn’t address the issue of how individual doctors incorporate the ongoing prickly thrum of discomfort inherent in this imperfect science of medicine.
After Ms. Wilton, I reconsidered my approach to the patient with a sea of complaints. When a patient presents with so many complaints that it’s not possible to cover them all in depth, I now openly acknowledge to her that impossibility. But then I say, “Today, we are going to review three of your concerns: you pick two, and I’ll pick one.” This allows the patient to select the two most concerning issues, and allows me to home in on the one I think might conceal a serious illness. And then after I reach a conclusion, I remind myself to go back and ask, “Could it be anything else? Is there something I might have missed?”
This approach may improve my diagnostic accuracy, but it doesn’t curtail the fear that percolates in the background of every encounter, keeping me on edge, never allowing me to feel perfectly at ease with being a doctor. In Ernest Becker’s view, humans use denial to erase the palpability of death in such a way that we don’t even realize that we are reacting to this existential fear. But in medicine, that layer of denial is curled back just enough to let us be consciously aware of it.
For that, I can only take a deep breath and acknowledge to myself that this is not an aberration, but an integral part of clinical medicine. Being a doctor means living with that fear, incorporating it into one’s daily life. It is like stepping onto a moving carousel and feeling your stomach drop, yet needing to continue forward despite the queasiness.
There’s no easy answer about how to proceed onward in daily medical life with that ongoing churn of anxiety and fear, and certainly no research to guide us. Each doctor has to come to terms with it and negotiate an individual emotional armistice. We need to keep it nestled in a recess contained enough to permit us to function. But if we wall it off too hermetically, we will lose a fundamental layer in the polyphonic texture of being a doctor. This fear and anxiety, in a modest amount, maintains the reverential and vigilant stratum required in caring for other human beings. We physicians need to tuck it away but also keep it alive.
When I was a patient—giving birth to one of my children—I had a doctor known for his warm bedside manner. Everybody loved him. He was covering for my regular OB that day, but I was comfortable with that since I’d met him before. He was cheerful and warm and I felt that I was in good hands. Things were moving along swimmingly until suddenly they weren’t. The fetal heart monitor showed concerning late decelerations, and the pH wasn’t where it should have been.
I remember distinctly how his manner changed. The pleasant cheer melted away and a tense focus replaced it. Small talk vanished. It didn’t feel like his prior congeniality had been fake, but now I had a sense of his concern and fear coming through as he checked a second pH, and then a third when the first two conflicted. I was anxious, to be sure, terrified, but in an odd way, something about sensing the doctor’s fear reassured me. He was taking nothing for granted. When he called in a second doctor for assistance, I could feel his growing anxiety.
As a patient, I wanted my doctor to be scared, just a bit, just enough to ground him in the profound weight of what he was doing. I obviously didn’t want him to be overwhelmed, but at that moment, I had no way of controlling the outcome. I was ceding the fate of my child to this doctor and I wanted him to feel the fearful awe—in the truest sense of the word—for the life-and-death side of medicine.
Fear, like all emotions, is neither good nor bad; it is simply one of the normal states of being. Overwhelming fear can be incapacitating, as I learned during my first code. But appropriate fear, as I witnessed in my obstetrician, can be crucial for good medical care, especially during critical situations. All eventually worked out well for me and my baby, but I gained an appreciation for how fear in the right dose might serve the doctor—and the patient—well. Being aware of our fear and figuring out how to titrate it appropriately is a vital skill for a doctor. Our patients’ lives may depend on it.