Jennifer Goetz, MD, MassGeneral
As a junior resident, I told a patient that I would come visit her the next day (as I typically do for patients unless it would be contraindicated in their treatment). My supervisor strongly advised against seeing her given a multitude of complexities in the case (splitting and attachment difficulties) that would be worsened if I saw her on the inpatient unit. I didn’t visit and have always regretted not keeping my word, feeling torn between the promise I gave her and what was clincally indicated. I now never promise patients I will come to visit them, but rather tell them I will be in very close contact with their treatment team. If it’s appropriate to visit, I will. I’ve never forgotten how difficult it was for the patient, and for me, to have not kept my word, even if “in her best interest.” Words matter.
Sam Kant, MD, University of Maryland Medical Center
There is always potential for missing things reading and/or using the electronic health record. It is important to have a systematic routine for navigating the EHR to avoid missing anything, and to maximize its use.
What do you think?
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Rachel Salas, MD, Johns Hopkins University School of Medicine
Not speaking up sooner when I saw or experienced bullying in medicine. Now, I try to recognize it, process it, name it, and speak up as soon as possible. This helps me be a better, more supportive team member. Ultimately, it helps our clinical practice.
Panagis Galiatsatos, MD, Johns Hopkins University School of Medicine
A mistake I’ve learned from is the assumption that “shortness of breath” must always be a cardiothoracic issue. One patient had over a dozen hospitalizations for “shortness of breath” and an extensive somatic work-up. Forty-five minutes into our second clinic visit he began crying. Ultimately I diagnosed my patient with depression. Now more than ever, “shortness of breath” always results in a mental health evaluation for my patients. And this great teaching patient has had extensive therapy for his mental health issue over the past year.
Scott Wright, MD, Johns Hopkins University School of Medicine
I was seeing a patient of mine in follow-up after a difficult hospitalization that included many tests and procedures. He had become frail and much weaker since I had last seen him. I had known the patient, who lived alone and was retired, for a number of years, and I thought that I understood his healthcare preferences and goals of care. He would repeatedly refuse ‘routine health maintenance’ offerings including screening tests and immunizations. He also was not agreeable to taking medications with proven efficacy, such as lipid lowering medications, and he admitted to being only moderately compliant with is antihypertensive medications.
At the hospital follow-up visit, I needed to tell him that he had widely metastatic lung cancer. I did so slowly, candidly, and empathically. He heard me, and he understood the gravity of the diagnosis. He teared up, and he thanked me for my honesty and openness.
After telling me that he didn’t know what he should do next and whether he should consider treatment (if any were available), he then asked me what I thought he should do. I thought about it briefly (certainly not long enough) and answered that I thought that he should meet with our palliative care team.
He started to cry and said: “Doc, I feel like you’re giving up on me.”
I made several mistakes. I made assumptions based on my history with the patient. I did not fully appreciate where he was emotionally. I shared information that he was not ready or prepared to hear.
While I could blame the time pressures in the outpatient setting, or other factors, the failure was all mine. I have never forgotten this encounter and I think about it every time that I deliver bad news or am asked, “what do you think I should do?”
Kim Stokes, PA, East Carolina University
The first week I practiced as a I missed a shingles dx. No rash, just “burning and tingling.” My patient came back a couple months later after his cardiologist saw the rash. Now shingles is higher in the ddx!
Shmuel Shoham, MD, Johns Hopkins University School of Medicine
I thought my words were calming. But it turns out that my patient felt that I was ignoring her distress. I learned to ask what it was that scared her. To listen. I think I am getting better at it.
Gordon Caldwell, MD, Lorn and Island Hospitals, Born, Argyll, Scotland
I recall man with chest pain, normal ECG, and troponin. I wouldn’t allow home on Christmas Eve. Angiogram showed 95% stenosis of LAD.
Listen to your patient. They are telling you the diagnosis.
Expertise like that can only come from assessing thousands of patients with chest pain.
Flora Smyth Zhara, Dentist, King's College, London
Being pressured to carry out a procedure against my better judgement, and then dealing with the consequences … NEVER again!
