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Marc D. Wager

When I was in medical school, more than thirty years ago, I felt I received pretty good training on how to communicate clearly and effectively with patients and families. I even remember the name of the fictitious character we had to practice telling about his wife's demise: "Mr. Gottrocks, I'm afraid that your wife has taken a turn for the worse; I think you should come to the ICU right now." As a pediatrician, more recently, I've been trained to discuss vaccines in a nonjudgmental way with parents who, contrary to my wishes, decide not to vaccinate their children.

Despite all of this training, though, and despite many articles on the merits of doctors admitting their wrongdoing, nobody ever taught me how to say, "I'm sorry, I think I screwed up."

Recently, I had to say that to the mother of one of my patients. And it was one of the hardest things I've ever done.

First, a little background: for more than twenty-five years, I've worked in a group practice in New Rochelle, just north of New York City. The day in question was busy, with lots of checkups, lots of flu shots and a few sick visits. At the end, I was scheduled to see a set of eight-month-old twins for routine vaccines, including flu shots.

Their mother, Mrs. Hart, a lovely, soft-spoken woman who works as a school social worker, had also brought her two older children, eight-year-old Gabriella and five-year-old Judah.

She pulled me aside and asked, "Can you please give them flu shots as well?" Although they weren't on the schedule, I readily agreed.

I vaccinated the twins as their older siblings watched, clueless that they were next. After a little crying, the infants quieted down.

Then I turned to Gabi and her brother.

"Now it's your turn!" I said with my usual enthusiasm.

As I turned and reached for the syringes, Gabi and Judah screamed. I heard the door open, then the sound of pattering footsteps as they raced away down the hall. Panicked that they might actually escape, I sprinted after them and managed to reach the exit before they did. I turned and stood in the doorway, panting.

"Gabi, Judah, c'mon back," their mother called calmly.

Gabriella slowed, stopped, then turned and trudged slowly back into my office. Judah, still screaming, refused to budge.

Patiently, Mrs. Hart came up, took him by the hand and led him back.

I think Gabi realized that she had no choice. While she was available and somewhat cooperative, I gave her the shot.

"Oh, that wasn't so bad!" she exclaimed. (I hear that all the time.)

I needed to save the label from her syringe to log it in her chart, so I did something that I never do: I recapped the needle (doing this is a common cause of needle-stick injuries) and put it aside.

Meanwhile, Judah was still screaming. At this point, his mother was gripping his torso, the babysitter was holding his arm, my medical assistant was holding his legs--yet he continued yelling and thrashing about. Even his mother was showing signs of annoyance, and there was no doubt that I felt pretty aggravated myself.

I grabbed the syringe and jabbed it into his left deltoid muscle--then saw that there was no fluid in the syringe.

All of his screaming has got me flustered, I thought.

I removed the needle and stepped away, intending to recap it. Then I spotted another syringe, still filled with liquid, sitting on the desk.

I must have used Gabi's syringe on Judah, I thought in horror. What do I do?

With Judah so uncooperative, and myself so ruffled and exasperated, I couldn't imagine trying to give him another shot.

I can't say anything now, I concluded. I've got to think about how to handle this.

I said goodbye to Mrs. Hart and the children and went home.

That night, I couldn't sleep. As I tossed and turned, thoughts raced through my mind: What if I simply don't tell her? Maybe I imagined it...Maybe he'll be protected by herd immunity.

In the end, there was no escaping it: I knew that I had to tell Mrs. Hart. The prospect made me miserable.

Will she hate me? I fretted. Will she be furious? Will she think I was incompetent? Which upsets me more--the harm I've done, or the potential damage to my reputation?

The next morning, I built up my courage and prepared to call Mrs. Hart.

She's a social worker; they're always nice, understanding people! I comforted myself, then dialed her number.

"Mrs. Hart, I have something to tell you: I made a mistake in the office yesterday, and I need to let you know what happened. I'm very sorry about this, and I want to correct the mistake as soon as possible. I'm pretty sure that I vaccinated Judah with the same syringe I'd used to vaccinate Gabi. I realized it when I went to inject him and the syringe was empty--and then, afterwards, I saw an unused syringe, filled with liquid, sitting on the desk."

"Are you sure?"

"Yes, because there was a vaccine left over."

(A few seconds of silence.)

"I'm really sorry," I said. "I feel terrible. I want to correct this as soon as you think Judah has recuperated from yesterday's trauma."

"What if he did get the vaccine, and then you revaccinate him? Would that be dangerous?"

"I thought about that. Children under the age of eight routinely get two doses during the first year they're vaccinated against influenza, so this is not all that different. I think it's better to take the risk of vaccinating him twice than not at all...but I'm pretty sure he didn't get vaccinated. In order not to inconvenience you, and to minimize the trauma to Judah, I'd be happy to vaccinate him anytime, either in my office or at your house."

"Thank you for being up front with me. I appreciate your candor."

"Again, I'm really sorry. And I thank you for being understanding."

Fast forward a month: Mr. Hart, a big, strong guy who seems like he tolerates no nonsense, brought Judah in for his flu shot, which I gave with no problem.

I slept so much better that night!

Fast forward a few months: It's almost the end of the influenza season. We've seen a lot of flu in our patients, even in some we'd vaccinated--but none of these four kids got it.

Looking back, I think of all the lessons I learned: First, here's one more reason not to recap needles. Second, my mother was right: Honesty is the best policy!

Finally, I think about the misery I felt at making--and having to admit--an error. And this was a mistake with relatively few consequences. How would I react if I ever made a really serious mistake?

I hope I never have to find out.


About the author:

Marc Wager practices pediatrics with the Pediatric Group of New Rochelle. He graduated from Lehigh University and the Albert Einstein College of Medicine and did his pediatric training at Jacobi Medical Center and his adolescent-medicine fellowship at Montefiore Medical Center. In addition to practicing pediatrics, he plays French horn with local orchestras, chamber ensembles, operas and musical-theater productions (his favorite genre). "I owe my love of reading and writing to my favorite teacher, Jeff Laffel, who taught me in sixth grade and in twelfth-grade English. I wrote this essay to reflect on one of the difficult things I had to deal with in my career." He has had short pieces published in the New York Times "Metropolitan Diary" and on girlology.com.

Story editor:

Diane Guernsey

Comments   

# nicola murray 2017-05-12 22:32
Hi Marc, I did similar when I was a GP trainee, gave a very complaining and hard to vaccinate 4 year old the wrong vaccine (extra Dpta instead of MMR). I totally empathize with all you felt. I went through it all. I spoke to my supervisor who suggested I phone up the mum and tell her that little jimmy needed another immunization, which wasn't as honest as you, but did mean that the child was correctly immunized. I still feel bad about such a relatively small mistake to this day! The mother again was totally pleased to be recalled as she really wanted her child to be protected by vaccination.
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# Martin Lederman,MD 2017-05-12 21:55
Marc, this episode so reminds me of why I went into medicine and why I'm so glad to share patients with you. Your honesty, your ethics and your excellence as a physician shines through. Thank you for sharing your experience.
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# Charlene Edgar 2017-05-12 21:02
Yes, Doctors are humans too. Your Honesty, reveals just
what kind of Doctor, you are.
You are the Doctor I would want for my PCP.
Thank You for sharing!
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# Maggie Mahar 2017-05-12 19:29
A truly wonderful story.

While reading it, I was afraid that the story would have a
tragic ending. (The boy becomes very sick or infects
another child .)

I am. most impressed that the Dr couldn't sleep, not because he knew he had hared a children, but because. he
realized he Might Have.

Thiis is exactly what we need in the medical profession: physicians who have the conscience, and the moral integrity to let patients know about mistakes.

This could greatly reduce malpractice suits:
full disclosure, by doctors and hospitals (Some hospitals have tried this and it's working.)
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# Pris Campbell 2017-05-12 19:12
Thank you for sharing this. I wish more doctors could be open about their mistakes.
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