Walking in Beauty

The 11,306-foot summit of Mount Taylor in northwestern New Mexico was my destination one sunny autumn morning. But what I sought that day was something else: understanding and forgiveness.

I had recently committed a medical error that had harmed a patient badly: I had discharged her from the hospital on way too much insulin. It was a major mistake, and I felt terrible about it. In more than three decades of practice in primary care and geriatrics, I had committed medical errors before, but the fault had never seemed so clear-cut, nor the harm so severe.

The circumstances and contributing factors were clear. My team had admitted Sylvia Wilson, a cheerful seventy-eight-year-old diabetic woman suffering from hypoglycemia and confusion. We noted (perhaps too superciliously) how her outpatient physician had failed to recognize that a recent rise in her creatinine (indicating declining kidney function) called for a reduction in insulin. We thought ourselves good doctors as we adjusted her insulin dose downward; and her confusion promptly resolved. We asked our case manager to arrange for Mrs. Wilson’s transfer to a skilled nursing unit for a few days of rehabilitation before returning home.

Her transfer occurred abruptly, and earlier than planned. My residents were off that afternoon, so I was paged to prepare the transfer orders. The case manager urged me to be quick: The transport team was waiting as I finalized the paperwork. I’d always found our electronic discharge process cumbersome and time-consuming; that day, not only was I not speedy enough, I also wasn’t careful enough.

I pride myself on thoroughness and attention to detail—but for some reason still incomprehensible to me, I wrongfully wrote transfer orders for twice the insulin dose that we’d prescribed in the hospital. The next day, at the skilled nursing facility, Mrs. Wilson’s blood sugar plummeted to 20 (normal is about 100). She suffered a seizure and was brought by ambulance back to our hospital.

The severe hypoglycemia caused by the excessive insulin permanently injured her brain. One month later, she remained on our service, poorly responsive—and a daily reminder of my shame and guilt. Now I was second-guessing every decision I made, and every order I wrote. I had lost the quiet confidence that is an essential part of every healer’s art.

As a senior physician, I had counseled physicians-in-training and junior colleagues about useful steps to take in these situations: honest disclosure to the patient and family; participation in an objective review and analysis of cause; advocacy for system change to prevent similar errors in the future; and confidential discussion with a colleague about your emotions. I’d completed all of these—but still I did not feel at peace.

Was I so focused on getting Mrs. Wilson discharged quickly that I compromised her safety? Why was I inefficient at using the electronic health system? Would I have made this error when I was younger? Am I getting too old for this doctoring business?

These thoughts tormented me as I slipped into my backpack at the Mount Taylor trailhead. In 1849, a cartographer named this prominent peak for then-president Zachary Taylor, unaware that for centuries the Diné had gendered it female and called it Tsoodzil, Blue Bead Mountain. To the Diné it was a sacred mountain, stabbed by a stone knife to fasten it to the earth. It marked the southern boundary of the Dinétah, the traditional Navajo homeland.

Just last week, a sympathetic friend had told me a story about her grandfather. Plagued by years of addiction, he had finally found comfort and healing after experiencing the harmony of nature in such a sacred place. She shared with me Hozho naasah, “Walking in Beauty,” a Navajo prayer that celebrates walking in nature and how this leads to happiness and a loving path. Thus I’d decided to come here, a naïve white man in Native American territory, hoping that, somehow, a hike in this special place might ease my anxiety and guilt.

Still preoccupied with thoughts of my medical error, I set off up the trail. An hour later, I walked through a large grove of quaking aspens and ascended a steady slope to a seemingly endless meadow. Here I stopped for several minutes to soak up an unexpectedly soothing sound–the gentle wafting of wind in the trees. Warmed by the morning sun, I began to feel a sense of attunement with the rhythms of nature all around me. My troubled thoughts eased, and my anxiety subsided.

Further up, the way grew steeper, with several switchbacks. Pausing to catch my breath, I looked down to see a crop of blue spruce shining against a black rock formation created by volcanic eruptions 3 million years ago. The trees’ majesty and beauty were arresting. Contemplating my small place in a fantastically complex and ancient universe, I realized why the Diné might come here seeking the divine and hoping to gain a greater understanding of their role in the world.

My legs ached as the last switchback led me breathlessly to the summit. It was a remarkably clear day. Looking east to the horizon, I could just make out Albuquerque, the place where I work as a physician—and where I had made a horrible mistake, despite trying to do my best.

I paused again to hear the music of the wind and feel the warmth of the sun. In that moment, I felt the special comfort that sacred encounters offer to imperfect humans like me. Walking amid the beauty of Tsoodzil had helped me to understand that creation, though imperfect, is also beautiful; that errors are an inevitable part of life as a doctor; and that what’s most important is not being perfect but rather celebrating the joyful path of being a physician.

And I finally found forgiveness. Not from my patient’s family or my colleagues–that had already been given–but from myself.