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Every Doctor’s Nightmare

Bobak Akhavan ~

I was an intern, doing a rotation in the coronary-care unit (CCU) of a large urban hospital. It was very challenging: The patients had complex medical issues, and my fellow residents and I were given lots of responsibility for their care. Still, I felt I was finally getting the hang of residency.

One of the first patients I saw was Mrs. Smith, a middle-aged woman who had come to the emergency room with chest pain. We admitted her to determine whether she was suffering from coronary-artery disease that might lead to a heart attack.

Mrs. Smith was a kind, soft-spoken woman. Her daughter, Crystal, in her twenties, had inherited her mother’s brown eyes and hair. She lived with her mother, was very involved in her care and made sure that we knew her full medical history.

Mrs. Smith complained of vague, diffuse chest pain, abdominal discomfort, nausea and vomiting. Aside from a surgery several years back to replace her aortic valve, she had no previous cardiac history. She had a mildly elevated heart rate and lower abdominal tenderness. Her cardiac work-up included electrocardiograms, an echocardiogram and blood tests for cardiac enzymes; all were unremarkable. Further tests revealed an elevated white blood cell count and numerous white blood cells in her urine. This led us to suspect a urinary-tract infection, so we treated her with antibiotics. Over the next few days, as we monitored her, the symptoms completely resolved.

Mrs. Smith had few complaints. On rounds, when we’d ask, “Mrs. Smith, how are you feeling this morning?” her typical reply was, “I’m feeling much better, thank you.”

But Crystal remained very worried about her mother. She visited every day, and her visits all went the same way.

“How is my mom today?” she’d say, then ask me to review her mother’s treatment plan and explain why we’d chosen it. Every day, I’d describe how we evaluate for coronary disease and why, in Mrs. Smith’s case, a urinary-tract infection seemed more likely. Sympathizing with Crystal’s anxiety, I spent as much time as I could trying to reassure her. Mostly I felt that she trusted our decisions about her mother’s care–but each time she repeated her questions, I’d feel less certain.

Mrs. Smith’s lab-test results continued to improve, and her vital signs remained stable. After five days, we discharged her home with Crystal and scheduled a follow-up visit.

Ten days later, on early morning rounds, I listened somewhat distractedly while the team presented a patient admitted the previous night. Familiar details caught my attention: A woman we’d discharged after ruling out coronary-artery disease had been found lying on the floor by her daughter, who had called 911 and begun CPR herself. The patient, resuscitated, was whisked to the cardiac-catheterization lab to have a drug-emitting stent placed in her right coronary artery.

My heart raced as the resident said, “She’s not following verbal commands; she’s on life support.” They’d started a hypothermia protocol, lowering her body temperature to reduce damage to the brain.

By now, we’d reached the patient’s room. I walked through the door, not knowing what to expect.

There lay Mrs. Smith, unconscious, with a breathing tube in place and IV lines running from her arms and groin.

And there stood Crystal.

She pointed at me.

“You!” she shouted. “You did this to my mother! You’re killing her!”

My heart seemed to stop; I didn’t know what to say.

“This is your fault!” Crystal went on tearfully. “You sent her home and said she was okay. You’re the reason she’s like this!”

Shame and guilt engulfed me. Amid my confusion, I remembered a senior mentor’s words: “No matter how bad you think your day is, the patient’s day is worse.”

Somehow, I managed not to succumb to my emotions. Instead, I stood there, nodding, as Crystal poured out her upset and anger. On some level, I knew that it was more important for her to express her feelings than it was for me to defend myself. My team, too, stood silently as she berated me.

Finally, my attending stepped in, saying, “This was not his fault. He’s an intern–the final decision to send someone home is not his.”

Crystal turned and began firing questions at him.

“I’ll look into what happened and get back to you with more information,” he said. Quickly, without examining Mrs. Smith, the team left.

I followed them, feeling intensely guilty and wishing that they’d done more to back me up. Crystals’ words had stung deeply. I looked up Mrs. Smith’s chart and my discharge summary, searching for a mistake and thinking, Maybe I’m not as good an intern as I thought.

My team acknowledged that we’d missed Mrs. Smith’s heart condition, but a thorough review of the data from her previous admission showed no hint of heart disease. The lead cardiologist told us that her coronary lesion wasn’t serious enough to have caused cardiac arrest. It was a mystery.

For the rest of the day, I couldn’t free my mind from its painful merry-go-round. I second-guessed every decision and reviewed each treatment plan over and over, for fear of missing something. Anxiety, doubt and guilt were eating me up. I didn’t know what to do: Should I keep this to myself, or talk to someone?

As the day neared its end, the struggle became so painful that I felt I had to confide in my senior resident, Jenny.

I told her how bad I felt about that morning. “Now I feel unsure of myself in everything I’m doing.”

“This was not your fault,” she said firmly but calmly, as if she knew just how I felt. “Do you remember how much time you spent with Mrs. Smith? You wanted to make sure that you got all the right information, and that her treatment plan was the best it could be. And you spent extra time with Crystal, answering her questions. You were Mrs. Smith’s biggest advocate.”

She went on, “We can’t always control a patient’s outcome, even when we do our best. You’ll always be learning in medicine; the most important thing is to stay mindful of yourself, and of the process.” Hearing her quiet, confident words, I felt my guilt ease.

Because Crystal had voiced such outrage, there was concern that she might sue the hospital. Consequently, I was told to avoid having anything to do with Mrs. Smith. Then my rotation ended. Unfortunately, I never learned how things turned out for her.

As guilty as I felt about Mrs. Smith, I still wished my attending and team had defended me more vigorously. In contrast, I will feel forever grateful to Jenny for her reassuring words.

This case stays with me to this day. Looking back, I’ve begun to wonder whether other physicians feel guilt and embarrassment more often than they admit. I see how important it was that I reached out for help, rather than holding those painful feelings inside.

In medicine, as in life, I know that mistakes are inevitable. In striving to become the very best doctor I can be, I know that I’ll continue to need my colleagues’ support and reassurance.

About the author:

Bobak Akhavan grew up in California and did most of his clinical rotations in Brooklyn. “That was where I really began to get a feel for practicing medicine. From there, I went on to do my residency in internal medicine at the University of Texas and stayed an extra year to complete a chief residency. Currently, as a fellow in pulmonary and critical-care medicine, I often see difficult and complex patients whose outcomes aren’t so different from the one described here. I think it’s important for physicians to share their experiences with each other, and also with nonphysicians. We sometimes forget that we, too, are allowed to feel difficult feelings.”

Story editor:

Diane Guernsey


10 thoughts on “Every Doctor’s Nightmare”

  1. Dr. Arkaven, nobody likes to be on the receiving end of any angry outburst, but as you yourself quoted, “No matter how bad you think your day is, the patient’s day is worse.”

    It seems however that your story largely ignored your mentor’s important lesson while focusing mostly on how bad this event was for YOU.

    The advice you received to stay away from a patient/family who were justifiably upset was truly unfortunate, as Dr. Dobie’s comment also confirms. This was a CYA defensive move on the part of hospital administration, not one motivated by compassion for what this family had gone through, as several studies on medical apologies now advise.

  2. Dr. Louis Verardo

    Dr. Akhaven, I think you showed incredible character and professionalism to have the ability to absorb that daughter’s angry comments; I am not sure I would have been able to do likewise during my first year of training. We doctors are obsessive by nature as we evaluate and treat patients, and when unexpected things happen, we tend to think we overlooked something. We have an obligation to be thorough; we also have to accept that sometimes events occur which are beyond our control or expectation. That doesn’t make it easier to deal with, but it should allow us to be a bit more forgiving to ourselves. Please be gentle with yourself.

  3. It was poor advice to stay away. There is lots of evidence that discussing these poor outcomes with family and patients is critical to everyone healing. There should have been a case review with you, the patient, her daughter, and your team, with all the decisions reviewed, for better or for worse. As a physician, I believe this deeply. And when my son died, the hospital did not follow this advice.

  4. If you truly wanted to know the outcome of this poor woman, you could have. Files, Phones, Easy. You don’t need more support from your coworkers. You need to reflect and reflect and never think you did everything right. Think of how you can do better. As your mentor said, don’t think of yourself, think of the patient.

  5. A sad story, indeed. But the intern was given terrible advice by his superiors: He should NOT have stayed away from Crystal; he should have talked to her, gave her a chance to finish venting, and to apologize: they would both have benefitted from this kind of exchange. Perhaps in her daily questioning during her mom’s first hospitalization, she might have shared some observations that would’ve helped with the diagnosis. I’m guessing she lashed out because she was feeling guilty. Avoidance is not a helpful response.

    1. This is a well-written story similar to what I can only imagine is one that similar to one that every doctor and nurse have to tell, hopefully there is an attending and a senior resident or supervisor like the ones that this intern had. The intern did his best–he did a proper cardiac evaluation and attended to Crystal’s questions every day. I really appreciate that the attending physician stepped forward.
      I feel strongly that the advice to stay away from Crystal was wrong–i think it sometimes is better to continue to care for the patient unless the patient or family requests you be removed from the case. Also, it is likely that she was angry at losing her Mom and not really angry at Dr. Akhaven. I think it is great that Dr. Akhaven was a chief resident–i am sure he was so supportive of the interns and residents at his institution, and a great role model. I appreciate his courage in submitting this narrative. I was also that intern….

  6. I have been a doctor for 46 years. I am now a Harvard professor, so I should know better. A lot of my patients have died over the years. I mean this literally, every time one of my patients dies, I ask myself, “What did I do wrong? Could I have have prevented this?” We always need to ask ourselves those questions, but we also have to forgive ourselves when we did the best we could.

    1. carolyn goldstein

      I have been a doctor for 48 years. I am still practicing full time. whenever I have an unexpected outcome I ask myself “what should I have done differently?” sometimes it is hard to forgive myself.

  7. I was ambivalent reading this. An intern can’t be expected to predict what will happen but the daughter was right there with her mother and said repeatedly that more was wrong. She needed to be heard more and the intern less concerned about ‘vigorous backup’. Yes, it feels awful but a public display by more people of support for him may make him feel better but not the daughter.

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