The Art of Constructive Worrying

Posted on: 2018-11-22 07:53:18

Some nights I lie awake and think about patients from the past. Mistakes play back like a movie reel in my mind. Some details are now lost to me, as many of these mistakes hark back to when I was a resident. But the sick sensation of realizing an error comes back as vividly as if it were happening now. Why didn't I immediately transfer the patient with a suspected gastrointestinal bleed to the intensive care unit? Shouldn't I have made a diagnosis of sepsis earlier in the patient who had low blood pressure but no fever? Why did I question the need for a bronchoscopy in the patient who had a solid organ transplant a year earlier and ended up having pneumocystis pneumonia? The mistakes haunt me, as they should any conscientious physician. We carry deep within us the cardinal rule of medicine: first, do no harm. And yet all of us will make errors, and therefore do harm.

Aiming for perfection generates a toxic by-product: we avoid admitting mistakes. If we confess to error or to lack of experience with a problem, fellow colleagues or trainees may see us as lesser, especially if we are the only ones confessing that we sometimes fail. So instead errors are treated as something that shouldn't be discussed, and trainees learn that the ideal is to know everything, and to not make mistakes, although no physician can accomplish either part of this false standard. When we make mistakes, we feel terrible about them yet often can't talk about them because we feel the shame of the error will only be magnified if we let others know about it.

We need to work toward a different culture, one in which we openly acknowledge our own mistakes and acknowledge that avoiding them completely is impossible. Doing so is critical to staying mentally healthy in the high-pressure world of medicine, particularly during the intense residency years. And the culture shift must start with the attending physicians. If we don't own up to our mistakes, how can we expect residents to take ownership of theirs?

When my patient had a bronchoscopy despite my saying it was not likely to be useful, and that bronchoscopy revealed pneumocystis infection, as suspected by the pulmonologists, I was embarrassed. I reviewed the case again. I realized that, by my third week of seeing the patient every day, I had stopped looking in detail at every vital sign, focusing only on the ongoing fever. I had missed the intermittent elevations of the respiratory rate-a clue to the sometimes slowly developing pneumonia caused by pneumocystis. I had personally reviewed the computed tomography (CT) scan, a test I had requested, but I had not seen the radiologist's reading that mentioned the diffuse changes could be due to pneumocystis. The data were there, picked up by the pulmonologists who saw the patient with fresh eyes, and fortunately proceeded with the bronchoscopy.

It wasn't pleasant to admit that I had neglected to thoroughly review the vital signs and subsequent CT reading. I felt I had to discuss with both teams what I'd missed and why, in the hopes that it would teach all of us, the residents, the students, and me what not to miss next time. I thanked the primary team and the pulmonologists for being on the ball when I was not, and I was grateful, as I often am, that patients are taken care of by a team. My status as a stellar clinician suffered a bit. Although the patient eventually recovered on appropriate treatment, recovery would have been sooner and faster if I had been paying better attention to the signs and symptoms.

That mistake and others taught me to worry about missing key details of a patient's clinical picture. But since worry alone is destructive, I've had to learn what I call constructive worrying-thinking and worrying about the factors that matter most and making plans based on this worrying. I've trained myself to pay more attention to specific aspects of the history or physical examination (was neck stiffness assessed in the child with fever and altered mental status?); to check how individual laboratory assays were done (which of many histoplasma test results were positive in the patient "positive for histoplasma"?); and to ask again about details when the story is not clear to me (exactly how many days did the child have fever?). If I don't remember those details while rounding, my mind is jogged when I write the progress note or talk to a colleague or read an article, and I follow up. Constructive worrying uses the compassion and concern I have for my patient, and lessons I've learned from past mistakes and successes, to focus on what's most important.

I've previously viewed worrying as a sign of inadequacy on my part, perhaps because I know how harmful it can be when it's not constructive-when it overwhelms to the point of making a physician indecisive. I became aware of the value of constructive worrying only recently. Now that I'm a colleague to heroes from my medical school and residency days, we discuss how we stay sharp as clinicians. A legendary doctor in my field confided in me that she feels stressed when she starts a week of patient service. She constantly checks on clinical details in the Red Book, the bible of pediatric infectious disease, and a book she has contributed to generously. "It's at my bedside," she said. Another outstanding clinician, the guy we all turn to when we're stumped about a case, told me he likes to get patient sign-out early in the day, so he can read up about the illnesses before rounding. He seems to have facts effortlessly at his fingertips, but that is, of course, because he's constantly reading. It turns out the great ones may, in fact, be great because they check more thoroughly and worry more constructively than the rest of us. So in fact, it's not just OK to worry, it's good to worry, if you turn that worry into constructive habits: check the patient, check the laboratories, check the literature.

Dedication to constructive worry has another benefit: over time the frequency and magnitude of your errors tend to become smaller. You read more and ask better questions. You learn to better distinguish normal from abnormal. You focus on the critical factors you should never miss. You make mistakes but catch them earlier. And you and your colleagues, also on constant alert, provide a safety net for each other.

The learning plan I've made from constructive worrying goes something like this: Learn carefully and well from those you work with. Try to avoid errors through constructive worrying. Make an error anyway (this is inevitable). Acknowledge the error. Apologize to your patient and their family for making it. Forgive yourself. Learn from the error. Teach others about it. Model vulnerability. And then repeat, starting at the first step.

Physicians aim at perfection of "do no harm," but we can't achieve perfection. The goal we can achieve is to do as little harm, and as much good, as is humanly possible. Worrying the right way can help bring us closer to that goal.






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