September 18, 2011


There was this one moment I remember vividly from when I was a third year medical student. I had been working with one specific doctor all week in clinic, and we were talking about an interesting patient we had seen the day before.

"I worried about her all night," the attending said.

I remember reflecting on that line later that night. I remember it so vividly because I didn't worry about her at all. I went home that night, did some reading, mucked around on the internet, and had a blissful night's sleep. And I wondered why. Was it because I didn't understand the complexity of her case? Or was it, I really worried, because I didn't care about my patients enough?

That continued throughout the rest of medical school. I felt like I connected well with patients during the day. Empathized with them. Felt concern for them. But when I went home, I could unplug from that. And always in the background was this vague gnawing feeling tha maybe I didn't care enough.

From the other side, I can see it was because you are so well protected as a student. Sure, you dabble in independence. One night as a fourth year student we were being hammered on call. The resident was busy with our 8th trauma ICU admission of the night and a big case just got out of the operating room. The resident sent me to evaluate the patient and come back and tell me "stable or spiraling" (i.e. is this a patient I need to see now, or in an hour when the traumas are done). I remember the anxiety of that moment standing in the ICU room alone with the patient - looking at monitors, drains, and drips and trying to get the overall gestalt of the situation. But by the end of the night, the resident had come and seen the patient, and had agreed with my assessment. I went home and had a worry-free nights sleep.

In some ways, moving from student to resident is like being a sheltered teenager that suddenly graduates high school and moves away to college, thrown into a crazy world where dangerous things lurk around the corner.

I worry about my patients now.

The patient I just operated on with post-op tachycardia and EKG changes. I do an assessment, order labs, look at her old EKG, and make the determination that her heart rate is secondary to pain and she ends up going home. I worry that she is doing OK, and I didn't miss her heart attack.

The patient whose feeding tube comes out prior to discharge. I place a new one, order the xray, and see it isn't comfortably into the stomach. Go, advance the tube, and re-order the scan. Somehow the patient gets discharged before he follow-up x-ray is taken, and I worry all night that the tube is in the right place.

The patient with shortness of breath after an operation where you SHOULD feel some shortness of breath, and I worry that her symptoms are covering up something more insidious.

There's a few things that I mull over about this newfound worrywort quality of mine:
1. I wonder if it is because I don't want to "get caught" doing something "wrong." I think that may be part of it, because all of us in medicine tend to have a perfectionistic quality. And I recognize that, as a person who didn't really get "into trouble" as a child growing up, I retain some of that quality in adulthood even now as a resident where I don't want to be in "trouble."
2. That being said, most of my focus is on my patients. The worst thoughts I have are of my patient at home, suffering, because of something I did or something I missed. So I think my worry comes from a good place, because my focus is on keeping my patients well.
3. I'm learning that its good to have worry. It keeps you vigilant. But you have to be able to turn it off. You have to be able to trust your colleagues to handle issues for you. You have to be comfortable with uncertainty and trust that if things begin to go downhill, the patient will let you know.
4. I'm also learning that perfection is a noble and good goal but not an attainable reality. You will make mistakes. There are mechanisms in place to pick up on mistakes. And, to use a cheap sports analogy, you have to forget about the botched play and get ready for the next one.

I think back to those days of medical school when I worried that I didn't worry enough and I smile. It's always fun to reflect on your own naïveté.

1 comment:

Christine said...

My, what wonderful new aspects of personal wisdom are revealing themselves. Your discoveries serve us all. Keep writing. Keep going. I am continually amazed by you. ~Christine