Differential Diagnoses: Worry, No Worry.
There are two possibilities when you, on Monday-morning pre-rounds, in a state of ignorant bliss after a call-free weekend, find that another name plate adorns the door of a patient on your sign-out list. (1) They went home, meaning you've worked your magic and now they are singing your praises (move one space forward! Collect $200!) (2) They were sent to MICU. (i.e. good news: no longer your responsibility; bad news: you probably missed a fatal metabolic disturbance, causing them to code at 5AM Saturday night, and now you are a bad bad person -- Go to Jail!). Fortunately, on consult service there is none (ok, ok, less) of the guilt (I'm on GI! No PE for me!). But the forever inquisitive and studious academician you are, you decide to pop a visit to the good-old MICU.
And so I found her lethargic (which in medicine means something far graver than sitting, stoned, on the couch watching Road Rules) in the glass aquarium that is the Cardiac-ICU unit, family members around, and a panoply of tubes extending out of her. This is not good. I feel badly for her. (who wouldn't?) But I feel worse for the medical resident who was in charge of her care, who did not think her increasing shortness of breath was due to the small effusion in her pericardiac space, because her LV function had been perfect, because despite her horrible cancer history, her heart has never failed her, who did not think it likely that this effusion could have expanded to 500cc and effected a cardiac tamponade with resultant respiratory decompensation that drove her CO2 to the upper 90s and her blood pH to fall below 7.2. I feel for the resident. Because I have been there, with the scarlet insignia of C, (culpable), or of N (negligent), plastered across my chest. And you feel like the whole world is judging you.
It is a terrible feeling.
These are not isolated events. I remember the OB resident who, on the morning before a patient threw a pulmonary embolism, wrote "LE: no edema" without checking her legs, despite the fact that she has had a DVT that caused her legs to balloon up over the course of several days. Or of that time I, myself forgot to check the abdomen of one of my patients that AM before she developed an opening between her gut and her skin, causing her to require a colostomy bag. I could not face her that day. I felt as if I've failed her.
I remember one ER episode, when a man, dressed in a superhero costume, came in complaining of back pain. In real life, these complaints are a dime a dozen. You end up seeing so many cases that turn out to result from things you can't fix (i.e. vertebral compression resulting from an obese body exerting itself upon a skeleton already undergoing osteopenia, long-standing history of sciatica from a prolapsed disk, and worse - narcotic withdrawal from over-medication, and even worse - idiopathic.) that you tend to think yourself silly for thinking of things that you can fix, and really, for life-or-death matter, should (i.e. aortic rupture, as was the case for our Superhero friend, who eventually bled to his death).
As a clinician faced with a patient with a nebulous complaint, you have two choices : (1) Not to worry. (2) Worry. For the most part, I have seen more residents take the former path, and more attendings take that latter. I used to think, and in part still do think, that part of the reason is that the latter path requires one to order a myriad of obscure and costly tests that will not only throw the hospital into greater state of financial duress, but will also invite nasty looks to the poor intern, so often the innocent messenger for the attending, from those (i.e. poor nurses) who must carry out those orders (good example: testing for fecal fat, which requires you to collect 72 hours worth of stool and calculate how many grams of fat were not absorbed). And the attending, always able to walk away after rounds, never needing to explain his or her views on why this test is indicated, is exonerated from abuse.
There is more to this however. I am more inclined to think years of training will expose any physician to experiences akin to that OB patient with the PE or my lady with the fistula. So many that they become fearful, perhaps even petrified, of the small possibility that the one thing that was not checked, that afterthought of a differential at the bottom of the list, becomes the proverbial piece of straw. And I think more nefarious than the threat of suits and unemployment is this guilt that pervades. That you, entrusted with this wealth of knowledge, and the power to help those who cannot help themselves, ultimately fail to do so.
The reality is that you cannot check everything. There is only so much time, resources, patience. But I think in the end, the good doctor's top differential is always to worry, because it is a far nobler crime to oneself to live with the guilt of having done too much. But this is easier said than done, because of much of medicine training is weeding out the false positives. To learn, once again, to look for the zebras among the elephants, is indeed a difficult feat to accomplish.
And so I found her lethargic (which in medicine means something far graver than sitting, stoned, on the couch watching Road Rules) in the glass aquarium that is the Cardiac-ICU unit, family members around, and a panoply of tubes extending out of her. This is not good. I feel badly for her. (who wouldn't?) But I feel worse for the medical resident who was in charge of her care, who did not think her increasing shortness of breath was due to the small effusion in her pericardiac space, because her LV function had been perfect, because despite her horrible cancer history, her heart has never failed her, who did not think it likely that this effusion could have expanded to 500cc and effected a cardiac tamponade with resultant respiratory decompensation that drove her CO2 to the upper 90s and her blood pH to fall below 7.2. I feel for the resident. Because I have been there, with the scarlet insignia of C, (culpable), or of N (negligent), plastered across my chest. And you feel like the whole world is judging you.
It is a terrible feeling.
These are not isolated events. I remember the OB resident who, on the morning before a patient threw a pulmonary embolism, wrote "LE: no edema" without checking her legs, despite the fact that she has had a DVT that caused her legs to balloon up over the course of several days. Or of that time I, myself forgot to check the abdomen of one of my patients that AM before she developed an opening between her gut and her skin, causing her to require a colostomy bag. I could not face her that day. I felt as if I've failed her.
I remember one ER episode, when a man, dressed in a superhero costume, came in complaining of back pain. In real life, these complaints are a dime a dozen. You end up seeing so many cases that turn out to result from things you can't fix (i.e. vertebral compression resulting from an obese body exerting itself upon a skeleton already undergoing osteopenia, long-standing history of sciatica from a prolapsed disk, and worse - narcotic withdrawal from over-medication, and even worse - idiopathic.) that you tend to think yourself silly for thinking of things that you can fix, and really, for life-or-death matter, should (i.e. aortic rupture, as was the case for our Superhero friend, who eventually bled to his death).
As a clinician faced with a patient with a nebulous complaint, you have two choices : (1) Not to worry. (2) Worry. For the most part, I have seen more residents take the former path, and more attendings take that latter. I used to think, and in part still do think, that part of the reason is that the latter path requires one to order a myriad of obscure and costly tests that will not only throw the hospital into greater state of financial duress, but will also invite nasty looks to the poor intern, so often the innocent messenger for the attending, from those (i.e. poor nurses) who must carry out those orders (good example: testing for fecal fat, which requires you to collect 72 hours worth of stool and calculate how many grams of fat were not absorbed). And the attending, always able to walk away after rounds, never needing to explain his or her views on why this test is indicated, is exonerated from abuse.
There is more to this however. I am more inclined to think years of training will expose any physician to experiences akin to that OB patient with the PE or my lady with the fistula. So many that they become fearful, perhaps even petrified, of the small possibility that the one thing that was not checked, that afterthought of a differential at the bottom of the list, becomes the proverbial piece of straw. And I think more nefarious than the threat of suits and unemployment is this guilt that pervades. That you, entrusted with this wealth of knowledge, and the power to help those who cannot help themselves, ultimately fail to do so.
The reality is that you cannot check everything. There is only so much time, resources, patience. But I think in the end, the good doctor's top differential is always to worry, because it is a far nobler crime to oneself to live with the guilt of having done too much. But this is easier said than done, because of much of medicine training is weeding out the false positives. To learn, once again, to look for the zebras among the elephants, is indeed a difficult feat to accomplish.
posted by Maureen @ 6:34 AM
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